PSRS - Risk Management

Enterprise Risk Management Program Assessment

Risk Management Structure	Risk Management Process and Outcome	Quality Improvement/ Medical Staff/ Risk Integration	Patient Safety	Claims Prevention	High Risk Clinical Areas
Leadership/ management survey— organizational culture towards risk management	Risk identification process	Quality improvement plan	Patient safety plan and goals	Claims trends	Clinical systems and operations
Staff survey	Risk analysis methods	Quality indicators and outcomes in relation to risk management integration	FMEA process	Prevention methods	Leadership
Occurrence tracking	Risk treatment methods	Patient satisfaction results and patient relations program	Safety goals audit and effectiveness	Complaint management	High risk areas – chest pain, stroke, pediatric fever, AMA, abdominal pain, ED
Data collection	Risk evaluation for effectiveness	Data dissemination	National patient safety initiatives	Benchmark comparisons	Environment and Security
Staffing and resources, training and orientation	Data use, predictive modeling	Regulatory related – restraints, grievance procedure, EMTALA, SMDA, recalls. Research, MSDS, hazardous waste, equipment management	CMS-never events	Claims management process	OB—shoulder dystocia, operative delivery, induction, VBAC
Organizational visibility	RCA process and outcomes/sentinel event review	Peer review process and outcomes	Clinical audits	Litigation guide	Technology use
Risk management indicators	Organizational wide educational plan	Medical staff indicator tracking	Communication and teamwork	Reserve trending	Peer review and performance improvement
RM staff job functions and dept structure within organizational goals	Ethics	RCA process	Handoffs	Critical event analysis	Medical record documentation effectiveness
RM dept procedures	Document retention	Committee structure and involvement	Just Culture	Critical event investigation	Case review indicators
RM plan	Environment of care	Medical staff risk control	Accountability models		Patient satisfaction
Committee involvement	Infection control plan	Informed consent			Throughput and flow
		Chain of command

Resource Analysis and Benchmarking

Evaluation of staffing related to responsibilities and risks
Skill mix requirements for position
Comparison staffing

Program Development and Coaching

Risk management assessment and strategic planning
Coaching for execution

Strategic Planning

Facilitator approach for leadership planning
Identify the top risks and priorities at each facility
Complete a SWOT related to risk management functions
Complete goals and objectives for the risks/needs identified along with treatment methods
Develop a master plan and opportunity grid

Critical Event Investigation Education and Support

Differentiate between a critical event, sentinel event & serious event
Understanding critical event response using the risk management process and checklist
- Identify the problem
- Conduct investigation
- Gather and secure information, data, equipment
- Interview tips
- Environment/site visit
- Prepare for media and regulatory involvement/ reporting
- Determine accountability within a Just Culture
- Human factors and contributing causes
- Patient/ family involvement/disclosure
- Prepare for RCA if applicable
- Immediate actions to prevent further harm
- Mitigate loss and prepare for claims management
Discuss the steps to defining different levels of investigations
Review human factors in relation to error
Discuss strategies for critical event debriefing
- Key factors of a debriefing model
Understand how critical event findings are managed through the RCA & peer review process, and in anticipation of litigation
Simulated case scenario practice—group exercises and discussion

Event and Claims Analysis

A risk management expert will review current claim allegations and defense issues
Assist facilities in risk reduction measures and performance improvement
Support is given to help track improvement efforts, integrate risk issues into the quality improvement process, and use best practice information to reduce risk
A retrospective claims and risk reduction analysis is also performed
A comparative review and benchmarking report will be provided

Disruptive Behavior Process Control

The risk management support program will focus on physician behavior management and behavior expectations, with a specific focus on disruptive behavior
Review existing policies and procedures of the medical staff with respect to behavior expectations and disruptive behavior management
Suggest new or additional policies and written documentation that will be necessary to manage disruptive behavior
Inform and train the Board, Medical Executive Committee (MEC), and department medical directors in the issue of disruptive behavior, why it is a threat to patient safety, and how to best intervene to stop this behavior
Inform nursing leadership, nursing management and medical staff of the hospital’s approach to physician behavior management
Allow time for specific one-on-one counseling for medical staff and nursing leaders who wish to gain expertise in dealing with this behavior

Step One – Structure Development

Review and assist with drafting policies on code of conduct, physician behavioral management, disciplinary actions and a behavioral agreement for all physicians seeking credentialing/recredentialing
Review of reporting process and management of physician behavioral issues
Interviews of select staff/physicians

Step Two – Process Implementation Support

Coaching for COO/VPMA in implementing the code of conduct and behavioral agreement
Coaching for medical staff department leaders on specific physician behavior issues and handling

Step Three – Education

Board program on disruptive physician behavior, behavior management and the link to patient safety
Medical staff leadership program
General medical staff
Nursing leaders

Medical Staff Risk Control

Credentialing and privileging process review
Peer review evaluation
Medical specialty QI plans and indicators

Newsletter Articles

Developed at your request