Risk Management and Medical Liability AND The Definition of Risk Management in Health Care.

In any industry, risk management addresses liability, both proactively and reactively. Risk management in health care considers patient safety, quality assurance and patients' rights. The potential for risk permeates all aspects of health care, including medical mistakes, electronic record keeping, provider organizations and facility management.

• What is Risk?

According to the Insurance Bureau of Canada, "Risk, in insurance terms, is the possibility of a loss or other adverse event that has the potential to interfere with an organization's ability to fulfill its mandate."Examples of adverse events in health care are unexpected death, failure to diagnose or treat disease, surgical mistakes or accidents. All of those can interfere with a provider's delivery of medical care. Some can result in litigation.

• Kinds of Risk Management:

The Joint Commission, which accredits and certifies more than 17,000 health care organizations and programs in the United States, defines risk management in health care as "(c)linical and administrative activities undertaken to identify, evaluate, and reduce the risk of injury to patients, staff, and visitors and the risk of loss to the organization itself."Risk management is proactive or reactive. Proactive is avoiding/preventing risk. Reactive is minimizing loss or damage after an adverse/bad event. Medical care delivery is art based in science. Good results cannot be guaranteed.

Every surgery has the potential for an undesirable outcome. Sometimes, regardless of medical intervention, patients die.

Applying common sense can prevent bad results or accidents. For example, slippery floors in high traffic areas can cause accidents. Washing floors at low traffic times and diverting traffic away from wet floors until dry is a proactive means of risk avoidance.

• Measuring Risk:

Potential for some adverse events can be mathematically measured.Treatment choices for a particular patient with a particular disease depend on the reliability of available options, the nature of the disease, whether the patient is hospitalized, the ease of care delivery, side-effects, cure rates and other factors.

Statistical data, regarding the effectiveness of medications, as well as the kinds and rates of potential side-effects, helps physicians decide what to prescribe.

• Managing Risk:

After the potential for adverse events is identified and measured, a plan is designed and implemented to avoid risk(s) and/or minimize damage and loss. Risk management does not have recipes.Occasionally, a plan to prevent risk can create new risks. For example, the introduction of electronic medical records (EMRs) can make more efficient use of providers' time and ease access to information about patients' prescriptions and medical histories. At the same time EMRs can invade patients' privacy or cause physicians and nurses to rely too much on technology, instead of customizing diagnosis and treatment. Breaches of privacy and diagnostic or treatment mistakes can result in litigation.

• Management Plan:

Risk management must be designed for each organization. An organization's purpose, mandate, size, facility construction, nature of business, location, patient populations, demographics, and other factors must be considered.Health care risk management can benefit from already available practice guidelines and principles. National standards for delivered care also help to prevent medical mistakes.

Making quality of delivered medical care a top priority can avoid unnecessary treatments, undesirable side-effects and unfortunate outcomes.

• Section One: Health Care Risk Management:

Risk management refers to strategies that reduce the possibility of a specific loss. The systematic gathering and utilization of data are essential to this concept and practice. Risk management programs consist of both proactive and reactive components. Proactive components include activities to prevent adverse occurrences (i.e., “losses”), and reactive components include actions in response to adverse occurrences. In both cases, the risk management process comprises:

§  Diagnosis—Identification of risk or potential risk.

§  Assessment—Calculation of the probability of adverse effect from the risk situation.

§  Prognosis—Estimation of the impact of the adverse effect.

§  Management—Control of the risk.

All organizations need to address their particular risks. In this Manual, we will discuss risk management as it relates to medical care and medical malpractice tort claims within the federal system. On the proactive side, risk management techniques will help improve the quality of patient care and reduce the probability of an adverse outcome turning into a medical malpractice claim. With reactive risk management, it is important to analyze the tort claims that have occurred for system issues that require intervention. The overall goal in healthcare risk management in both situations is to minimize the risk of:

§  harm to our patients.

§  liability exposure of our health care providers.

§  financial loss to the Agency.

Malpractice tort claims are a fact of medical practice. Studies have shown, however, that most cases of iatrogenic complications or negligence never enter the tort system, and many tort allegations of negligence have no merit. Additionally, there is little evidence that the malpractice litigation process identifies bad doctors or deters malpractice. Therefore, efforts need to be directed toward quality improvement programs and risk management rather than disciplinary measures.

Risk management (RM) program activities are addressed at both the service unit and Agency level. For the service unit, a RM or quality assurance committee often serves as the focal point for the overall program, and receives and acts upon information provided through personal contacts and reports. The following elements are generally found within a local RM Program, although other activities may be included as deemed necessary:

§  Incident identification and reporting.

§  Methods of identifying and addressing potential tort claims, including the sequestering of medical records, and the investigation of medical accidents and near accidents.

§  Review of patient complaints concerning quality of care issues.

§  Review and documentation of sentinel events using a root cause analysis or other recognized method.

§  Methods by which a patient may be dismissed from care or refuse care.

§  Review of requests for medical records from outside attorneys representing patients.

§  Mechanisms for dealing with inquiries from governmental agencies, media, and advocate groups.

§  Ensuring the initial and ongoing competency of staff.

§  Compliance with applicable government regulations, healthcare accreditation standards, and all contractual agreements.

§  Occurrence reporting and data management.

§  Developing RM recommendations for local intervention.

§  Evaluation and feedback.

Risk Management Program has primarily evolved from the analysis and review of malpractice tort claims that have been filed against the Federal Government involving medical care provided at IHS or tribally operated facilities.1 In this regard, the Agency’s RM Program is by nature predominantly reactive in scope. The program’s responsibilities include but are not limited to:

§  Coordinating the processing of tort claims through the Agency, including the solicitation of peer reviews and site reviews.

§  Communicating with the healthcare practitioners who provided the care in question.

§  Examining issues related to the determination of “standards of care.”

§  Working directly with federal attorneys who are evaluating and/or litigating the tort claims or subsequent suits.

§  Claims are presented for review by the Medical Claims Review Panel charted by the Department of Health and Human Services (Department).

§  Maintaining case files and a database of all malpractice claims filed against the IHS since 1986, and providing compilations and analyses of the data for the Agency, the Department, and Congress, when requested.

§  Providing case summaries, peer review, outcome information, and feedback of risk management recommendations to the local IHS and Tribal facilities and Area Chief Medical Officers.

§  Disseminating information about the review process within group settings or meetings.

§  Assisting providers to submit appeals to the Medical Claims Review Panel Submitting payment reports to the National Practitioner Data Bank.