| About the Authors |
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xvii | (2) |
| Contributors |
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xix | (4) |
| Introduction: Risk Management via a Strategic Approach |
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xxiii | |
| SECTION 1 Introduction to Risk Management Strategy |
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1 | (106) |
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CHAPTER 1 Risk Management Dynamics |
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3 | (23) |
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3 | (1) |
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Progressive Steps in the Risk Management Process |
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4 | (3) |
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5 | (1) |
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5 | (1) |
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5 | (2) |
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7 | (1) |
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Risk Management Activities |
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7 | (1) |
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Classification of Risk Liabilities |
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8 | (2) |
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10 | (1) |
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10 | (2) |
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10 | (1) |
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11 | (1) |
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12 | (1) |
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12 | (1) |
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Risk Management/Quality Assurance Functions and Activities |
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13 | (1) |
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13 | (1) |
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Administration of Risk Management Programs |
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14 | (3) |
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Goals and Prime Objectives |
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14 | (1) |
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Responsibilities of a Risk Management Committee and/or Coordinator |
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15 | (1) |
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Risk Management Committee |
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16 | (1) |
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Responsibility of the Governing Body |
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16 | (1) |
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Specific Risk Management Functions |
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17 | (7) |
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Incident Identification, Reporting, and Tracking |
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17 | (1) |
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State Mandated Incident Reporting |
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18 | (1) |
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Incident Review and Evaluation |
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19 | (1) |
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Actions to Prevent Recurrence of Incidents |
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19 | (1) |
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19 | (1) |
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Credentialing and Privileging |
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20 | (1) |
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Patient Complaint Program |
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20 | (1) |
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Risk Management Education |
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21 | (1) |
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Insurance Companies and Risk Management |
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21 | (1) |
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Do's and Don'ts of Risk Management: A Claims Perspective |
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22 | (2) |
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Computer Use in Risk Management |
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24 | (1) |
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24 | (2) |
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CHAPTER 2 Regulatory Environment: Standards and Risk Management |
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26 | (21) |
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26 | (1) |
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Promulgation and Implementation of Standards |
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27 | (1) |
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27 | (1) |
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27 | (7) |
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Occupational Safety and Health |
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28 | (4) |
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Emergency Medical Treatment and Labor Act of 1986 |
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32 | (1) |
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Mammography Quality Standards Act of 1992 |
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32 | (1) |
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Safe Medical Devices Act of 1990 |
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32 | (1) |
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Medical Waste Tracking Act (MWTA) of 1988 |
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33 | (1) |
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33 | (1) |
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Environmental Protection Agency (EPA) |
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34 | (1) |
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Regulatory Implementation Mandates |
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34 | (1) |
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State Legislation and Regulations |
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34 | (2) |
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Licensure and Registration of Professional Institutions |
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35 | (1) |
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35 | (1) |
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36 | (1) |
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State Mandated Risk Management Legislation |
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36 | (4) |
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Risk Management Responsibility |
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36 | (1) |
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Governing Body Involvement |
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36 | (1) |
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37 | (1) |
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37 | (1) |
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Risk Management Education |
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38 | (1) |
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38 | (1) |
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Patient Grievance Procedures |
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39 | (1) |
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Immunity and Confidentiality for Providers of Risk Management Information |
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39 | (1) |
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Risk Management Follow-up Procedures |
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39 | (1) |
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Local City and County Legislation Controls |
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40 | (1) |
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Reimbursement Requirements |
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41 | (1) |
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42 | (2) |
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What If Practice Guidelines Are Not Met? |
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43 | (1) |
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Ignorance of the Law Is No Excuse |
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44 | (3) |
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CHAPTER 3 Identifying and Controlling Risks in the Workplace |
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47 | (24) |
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Wrongful Dismissal or Discharge |
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47 | (2) |
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Arbitration in Wrongful Dismissal |
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48 | (1) |
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Due Process in Wrongful Dismissal |
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49 | (1) |
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49 | (3) |
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Three Primary Discrimination Theories |
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51 | (1) |
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51 | (1) |
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Proof and Discrimination Suits |
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52 | (1) |
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52 | (1) |
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Voluntary Affirmative Action |
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53 | (1) |
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53 | (1) |
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53 | (2) |
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Two Categories of Sexual Harassment |
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54 | (1) |
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AIDS and the Health Care Workplace |
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55 | (2) |
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57 | (4) |
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Preventing Accidents and Injuries |
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58 | (1) |
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59 | (1) |
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Monitoring Treatment and Administrative Costs |
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60 | (1) |
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Reducing Costs through Managed Care |
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60 | (1) |
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Fraud in Workers' Compensation |
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61 | (1) |
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Employee Assistance Programs |
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61 | (1) |
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Americans with Disabilities Act |
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62 | (5) |
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62 | (1) |
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Psychological Stress as a Disability |
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63 | (1) |
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Exclusions and Other Conditions |
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64 | (1) |
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64 | (1) |
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65 | (1) |
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66 | (1) |
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Suggestions for ADA Compliance |
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66 | (1) |
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67 | (4) |
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CHAPTER 4 Patient/Consumer Communications to Reduce Risk |
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71 | (20) |
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71 | (1) |
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Why Do Patients/Customers Sue? |
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72 | (1) |
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Observe, Listen, and Communicate |
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73 | (3) |
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74 | (1) |
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74 | (1) |
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74 | (1) |
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75 | (1) |
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Communication Skills and Malpractice History |
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75 | (1) |
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Consent, Informed or Otherwise |
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76 | (2) |
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Informed Consent in Experimental Research |
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77 | (1) |
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Types of Informed Consent |
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78 | (1) |
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Managing Risk through Patient Education |
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78 | (2) |
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Consumer Information Strategy |
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79 | (1) |
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80 | (1) |
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Satisfying the Patient Stops the Suits |
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80 | (1) |
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Patient Expectations and Patient Satisfaction |
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81 | (3) |
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Satisfaction as a Risk Management Tool |
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82 | (2) |
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Grading Health Care for Consumer Report Cards |
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84 | (3) |
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87 | (4) |
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CHAPTER 5 Financing of Risk and Insurance |
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91 | (16) |
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Options in Implementing a Plan |
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92 | (1) |
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Insurance Options Based on Premium Size |
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93 | (2) |
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Captive Insurance Companies |
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93 | (2) |
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95 | (1) |
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Pools, or Self-Insured Groups |
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95 | (1) |
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Large Deductible Insurance Policies |
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95 | (1) |
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Retrospectively Rated Dividend Plans |
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95 | (1) |
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Considerations in Choosing an Alternative Insurance Program |
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95 | (1) |
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95 | (1) |
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96 | (1) |
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96 | (1) |
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Choosing a Third-Party Administrator |
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96 | (1) |
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Structure of Risk Exposure Management |
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96 | (8) |
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97 | (2) |
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99 | (2) |
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101 | (1) |
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101 | (1) |
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Employee/Volunteer Injury and Illness |
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102 | (1) |
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Directors and Officers Liability |
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102 | (2) |
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104 | (1) |
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104 | (1) |
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104 | (1) |
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Protection for a Rainy Day |
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104 | (3) |
| SECTION 2 General Risk Management Strategies |
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107 | (72) |
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CHAPTER 6 Total Quality Management, Continuous Quality Improvement, and Evaluation of the Risk Management Program |
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109 | (21) |
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Medical Injuries Are Neither New Nor Uncommon |
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109 | (1) |
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110 | (1) |
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The Challenge of Prediction |
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110 | (1) |
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Statistical Predictive Models |
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110 | (1) |
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111 | (1) |
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Effectiveness of Risk Management |
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111 | (1) |
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111 | (1) |
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112 | (1) |
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113 | (1) |
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113 | (1) |
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Assessment of TQM Activities |
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114 | (1) |
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Continuous Quality Improvement |
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114 | (3) |
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115 | (1) |
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115 | (2) |
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An Organization's Mission Statement |
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117 | (1) |
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A Focus on the Customer Is Vital |
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117 | (1) |
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A Sampling of Potential Risk Management CQI Projects |
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118 | (1) |
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QIT Risk Management Examples |
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119 | (1) |
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119 | (1) |
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120 | (1) |
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Community Quality Management |
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120 | (1) |
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Program Evaluation Issues and Methods |
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121 | (1) |
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121 | (1) |
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122 | (1) |
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122 | (1) |
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122 | (3) |
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122 | (1) |
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Evaluation by Insurers/Underwriters |
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122 | (2) |
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124 | (1) |
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124 | (1) |
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125 | (1) |
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Risk Management Self-Assessment Manual |
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125 | (1) |
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126 | (1) |
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Evaluation Is an Appraisal |
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126 | (4) |
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CHAPTER 7 Ethical Issues for Risk Managers |
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130 | (20) |
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Ethical Guidelines for Risk Managers |
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130 | (1) |
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130 | (1) |
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131 | (1) |
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131 | (1) |
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131 | (2) |
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132 | (1) |
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132 | (1) |
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133 | (1) |
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Confidentiality and Ethics |
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133 | (1) |
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133 | (1) |
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Decisional Capacity to Weigh Risks |
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134 | (1) |
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Clinical Applications of Ethics |
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135 | (9) |
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Decision Making for Adults with Capacity |
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135 | (1) |
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Surrogate Decision Making |
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136 | (1) |
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137 | (2) |
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139 | (1) |
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140 | (1) |
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141 | (1) |
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142 | (1) |
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142 | (2) |
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Research on Human Subjects |
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144 | (2) |
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Abuse during Research Studies |
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144 | (1) |
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Clinical Trials versus Treatment |
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145 | (1) |
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Institutional Review Boards |
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145 | (1) |
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146 | (1) |
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Role, Responsibilities, and Authority |
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146 | (1) |
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Composition of the Ethics Committee |
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147 | (1) |
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Relationship to Risk Management |
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147 | (1) |
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Ethics Are Not Just Values |
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147 | (3) |
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CHAPTER 8 Assuring Safety and Security in Health Care Institutions |
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150 | (29) |
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152 | (2) |
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153 | (1) |
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Infectious Waste Management Plan |
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153 | (1) |
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154 | (1) |
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154 | (2) |
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156 | (1) |
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Employee Health Intervention Strategies |
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157 | (1) |
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157 | (1) |
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Preplacement Physicals and Continuous Monitoring of Employee Health |
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157 | (1) |
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158 | (1) |
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Emergency Preparedness and Disaster Planning |
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158 | (1) |
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159 | (2) |
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159 | (2) |
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Security and Health Care Organizations |
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161 | (1) |
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161 | (6) |
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Vulnerability to Violence |
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162 | (1) |
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Parking Areas Are High Risk |
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162 | (2) |
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164 | (1) |
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Intervening with Violent Patients |
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165 | (2) |
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Protecting Patient Valuables |
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167 | (1) |
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168 | (2) |
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168 | (2) |
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170 | (1) |
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Securing Information Systems |
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170 | (2) |
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Proactive Security Departments |
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172 | (1) |
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Technology Enhanced Security |
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173 | (2) |
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Additional Security Measures |
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174 | (1) |
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Safety and Security in Ounces and Pounds |
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175 | (4) |
| SECTION 3 Specific Strategies for Specific Risk Areas |
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179 | (172) |
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CHAPTER 9 A Primer on Medical Malpractice |
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181 | (22) |
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181 | (1) |
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Medical Malpractice Law--In Brief |
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182 | (1) |
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183 | (2) |
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185 | (1) |
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Physician-Patient Relationship |
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185 | (1) |
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Duty to Perform Professionally |
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186 | (1) |
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Sources of Professional Standards |
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187 | (1) |
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Additional Theories of Liability |
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187 | (1) |
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187 | (1) |
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187 | (1) |
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188 | (1) |
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188 | (1) |
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Hospital Liability for Medical Malpractice |
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188 | (4) |
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191 | (1) |
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191 | (1) |
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Liability Theories Apart from Medical Negligence |
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192 | (1) |
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Intentional Tort or Conduct |
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192 | (1) |
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192 | (1) |
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192 | (1) |
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192 | (1) |
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192 | (1) |
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193 | (1) |
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The Most Common and Most Expensive Malpractice Allegations |
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193 | (5) |
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Breast, Colon, and Lung Cancer Risk Applications |
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194 | (1) |
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195 | (3) |
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198 | (1) |
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Risk Management Issues in Professional Liability Litigation |
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199 | (4) |
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Unrealistic Patient Expectations |
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199 | (1) |
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No Response to Complaints |
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199 | (1) |
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Illegible Medical Records |
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200 | (1) |
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Insufficient Information in Medical Records |
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200 | (1) |
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No Follow-up on Abnormal Tests |
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200 | (1) |
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Professional Miscommunication |
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200 | (3) |
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CHAPTER 10 Strategies to Reduce Liability: Managing Physicians and Litigation Alternatives |
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203 | (22) |
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Professional Practice Acts |
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203 | (4) |
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204 | (2) |
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206 | (1) |
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Federation of State Medical Boards |
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207 | (1) |
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National Practitioner Data Bank |
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207 | (2) |
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209 | (1) |
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Clinical Practice Guidelines |
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209 | (5) |
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Guidelines by Professional Groups |
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209 | (1) |
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210 | (1) |
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Guidelines for Workers' Compensation |
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212 | (1) |
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Mandates of Insurance Companies |
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212 | (1) |
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Legal Implications of Practice Guidelines |
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212 | (1) |
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Physician Attitudes toward Guidelines |
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213 | (1) |
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Guidelines to Measure Outcomes Are Needed |
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214 | (1) |
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214 | (1) |
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Components of Peer Review |
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214 | (1) |
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Liability Alternatives: Tort Reform and Nonjudicial Proposals |
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215 | (3) |
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Limiting the Number of Lawsuits |
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216 | (1) |
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Controlling the Size of Awards |
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217 | (1) |
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Limiting the Access of Plaintiffs to the System |
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218 | (1) |
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Removing Malpractice Litigation from Judicial Systems |
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218 | (1) |
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219 | (1) |
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Alternative Dispute Resolution: Mediation and Arbitration |
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219 | (1) |
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219 | (1) |
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Accelerated Compensation Events |
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220 | (1) |
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220 | (1) |
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221 | (1) |
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Proactive Liability Reduction |
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221 | (4) |
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CHAPTER 11 Risk Management in Psychiatry |
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225 | (20) |
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225 | (1) |
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Informed Consent and Research |
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226 | (1) |
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226 | (2) |
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Right to the Least Restrictive Alternative |
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227 | (1) |
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Right to Treatment and the Closure of Psychiatric Facilities |
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227 | (1) |
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Right to Treatment: Involuntary Outpatient Treatment |
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227 | (1) |
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Right to Treatment and "Medical Necessity" |
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228 | (1) |
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Right to Refuse Treatment |
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228 | (1) |
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Right to Refuse Psychotropic Medications |
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228 | (1) |
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Right to Refuse Involuntary Hospitalization |
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229 | (1) |
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Clinical Risks in Psychiatry |
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229 | (7) |
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Psychopharmacology and Side Effects |
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229 | (1) |
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Electroconvulsive Therapy |
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230 | (1) |
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231 | (1) |
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231 | (2) |
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233 | (1) |
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Discharge and Aftercare Planning |
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234 | (1) |
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Child and Adolescent Psychiatry |
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235 | (1) |
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Confidentiality and Stigma |
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236 | (1) |
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236 | (1) |
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237 | (1) |
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237 | (4) |
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Violence and Mental Illness |
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237 | (1) |
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Violence in the Institution |
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238 | (1) |
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Availability of Illicit Substances |
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239 | (1) |
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Sexual Conduct and Misconduct |
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239 | (1) |
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Staff-Patient Sexual Misconduct |
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240 | (1) |
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241 | (1) |
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Psychiatric Patients Are Everywhere |
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242 | (3) |
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CHAPTER 12 Identifying and Controlling Risks in Long Term Care: Nursing Homes and Home Health Care |
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245 | (24) |
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Demographics of Long Term Care |
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245 | (1) |
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246 | (1) |
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Long Term Care Regulations |
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246 | (1) |
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247 | (1) |
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A Portrait of Physiological Aging |
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248 | (7) |
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Accidents: Falls and Nonfalls |
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248 | (1) |
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249 | (1) |
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250 | (1) |
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Risks in Caring for Patients with Dementia |
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251 | (1) |
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Restraints Are a Controversial Issue |
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251 | (1) |
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252 | (2) |
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Risks in Related Institutional Services |
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254 | (1) |
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Disaster Planning and Fire Safety |
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255 | (1) |
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255 | (1) |
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256 | (2) |
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257 | (1) |
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Identifying and Controlling Risks in Home Health Care |
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258 | (1) |
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What Are Home Health Care and Hospice Care? |
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258 | (1) |
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Regulation of Home Health Care |
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259 | (1) |
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Who Receives Home Health Care? |
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260 | (1) |
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260 | (3) |
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260 | (1) |
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261 | (1) |
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261 | (1) |
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Falls in the Home Health Care Population |
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262 | (1) |
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High Technology Home Health Care: Product and Equipment Failure |
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262 | (1) |
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263 | (1) |
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Home Health Care Employees |
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263 | (2) |
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Negligence Related to Failure to Instruct |
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265 | (1) |
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Independent Contractor versus Employee |
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265 | (1) |
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265 | (1) |
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Growing Industry, Growing Risks |
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265 | (4) |
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CHAPTER 13 Risk Management in Selected High Risk Hospital Departments |
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269 | (37) |
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270 | (7) |
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270 | (1) |
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271 | (1) |
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271 | (2) |
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273 | (1) |
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Patient-Physician Relationship |
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274 | (1) |
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Documentation and Consents |
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275 | (1) |
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275 | (1) |
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Departures, Discharges, and Transfers |
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276 | (1) |
|
Risk Management Opportunities |
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276 | (1) |
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OBSTETRICS AND NEONATOLOGY |
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277 | (16) |
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Obstetrics and Neonatology Liability Risks |
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277 | (2) |
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279 | (1) |
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279 | (1) |
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Levels of Care: Institutional Capabilities |
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279 | (1) |
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Prenatal and Perinatal Care |
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280 | (3) |
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Genetic Counseling and Testing |
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281 | (1) |
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Antepartum Fetal Surveillance |
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282 | (1) |
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283 | (2) |
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284 | (1) |
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Fetal Heart Rate Monitoring |
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284 | (1) |
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284 | (1) |
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Induction and Augmentation of Labor |
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284 | (1) |
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285 | (2) |
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Pain Management and Obstetric Anesthesia |
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285 | (1) |
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286 | (1) |
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286 | (1) |
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Vaginal Birth after Cesarean (VBAC) |
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286 | (1) |
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Infant Resuscitation and Management |
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287 | (1) |
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287 | (1) |
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287 | (1) |
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Umbilical Cord Blood Acid-Base Assessment |
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287 | (1) |
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288 | (1) |
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Maternal Examination Post Delivery |
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288 | (1) |
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Family Attendance and Videotaping of Birth |
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288 | (1) |
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Medical Record Documentation |
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289 | (1) |
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290 | (1) |
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291 | (1) |
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292 | (1) |
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292 | (1) |
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293 | (13) |
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Negligence and Malpractice |
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293 | (1) |
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294 | (1) |
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Preoperative Assessment and Treatment |
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295 | (1) |
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Intraoperative Risk Issues |
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295 | (5) |
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296 | (1) |
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Perioperative Blood Contact |
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297 | (1) |
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298 | (1) |
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298 | (1) |
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Patient Burns and Pressure Injuries |
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299 | (1) |
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299 | (1) |
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Postoperative Recovery Care |
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300 | (1) |
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300 | (1) |
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Medical Record Documentation |
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301 | (1) |
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301 | (5) |
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CHAPTER 14 Risk Management in Managed Care Organizations |
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306 | (32) |
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306 | (1) |
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Public Perception of MCOs and Litigation |
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307 | (1) |
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MCO Structure and Liability |
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307 | (1) |
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308 | (1) |
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308 | (1) |
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308 | (1) |
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308 | (1) |
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Hybrids, New Models, and Networks |
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309 | (1) |
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Statutes and Administrative Regulations |
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309 | (3) |
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310 | (1) |
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310 | (1) |
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State Administrative Regulations |
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310 | (1) |
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MCO Practice of Medicine under State Law |
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311 | (1) |
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Corporate Laws, Both General and Special |
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312 | (1) |
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Theories of MCO Liability Other Than Negligence |
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312 | (4) |
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312 | (1) |
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313 | (1) |
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Fraudulent Misrepresentation |
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313 | (1) |
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Deceptive Trade Practices |
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314 | (1) |
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314 | (1) |
|
Unfair Insurance Practices |
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314 | (1) |
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314 | (1) |
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Intentional Infliction of Emotional Distress |
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315 | (1) |
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316 | (3) |
|
Statutory Liability under EMTALA: Antidumping Law |
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316 | (1) |
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Statutory Liability under ERISA |
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316 | (1) |
|
Statutory Liability under ADA |
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317 | (1) |
|
Statutory Liability under RICO |
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318 | (1) |
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319 | (6) |
|
Selection, Rejection, and Termination of Providers |
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319 | (4) |
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323 | (1) |
|
Negligent or Abusive Cost Containment Procedures |
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324 | (1) |
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325 | (4) |
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325 | (2) |
|
Ostensible/Apparent Agency |
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327 | (2) |
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329 | (5) |
|
Independent Contractor Status of Physicians |
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329 | (1) |
|
Exhaustion of Contractual Remedies |
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329 | (1) |
|
Exhaustion of Administrative Remedies |
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330 | (1) |
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330 | (4) |
|
Federal Employees Health Benefits Act (FEHBA) |
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|
334 | (1) |
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334 | (4) |
|
CHAPTER 15 Integrated Health Care Delivery Systems: Risk Management Issues, Challenges, and Solutions |
|
|
338 | (13) |
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|
Overview of Integrated Networks |
|
|
338 | (2) |
|
Physician-Hospital Organizations |
|
|
339 | (1) |
|
Management Services Organizations |
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339 | (1) |
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339 | (1) |
|
Group Practices without Walls |
|
|
339 | (1) |
|
Risk Management Issues, Challenges, and Solutions |
|
|
340 | (4) |
|
Culture Clashes among Integrated Health Care Network Components |
|
|
340 | (1) |
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341 | (1) |
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|
|
342 | (1) |
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|
|
342 | (1) |
|
Financial Forecasting or Budgeting |
|
|
342 | (1) |
|
Assumption of Liabilities |
|
|
343 | (1) |
|
Incident Reporting Systems |
|
|
343 | (1) |
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|
343 | (1) |
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|
|
344 | (1) |
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|
|
344 | (1) |
|
Areas of Liability Exposure |
|
|
345 | (1) |
|
System Liability as It Relates to Provider Selection and Services |
|
|
345 | (1) |
|
Liability and the System's Services |
|
|
346 | (1) |
|
|
|
346 | (3) |
|
|
|
347 | (1) |
|
Confidentiality of Patient's Medical Information |
|
|
347 | (1) |
|
Underwriting Considerations |
|
|
347 | (1) |
|
Insurance Program Structure |
|
|
347 | (2) |
|
Afloat in Uncharted Waters |
|
|
349 | (2) |
| Index |
|
351 | |
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