Homework answers / question archive / on a proposal regarding A proposed framework for ERM in Healthcare Organization in the UAE as well as Exploring factors that affect the implementation of ERM in Healthcare Organization in the UAE

on a proposal regarding A proposed framework for ERM in Healthcare Organization in the UAE as well as Exploring factors that affect the implementation of ERM in Healthcare Organization in the UAE

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on a proposal regarding A proposed framework for ERM in Healthcare Organization in the UAE as well as Exploring factors that affect the implementation of ERM in Healthcare Organization in the UAE.

UAE is the United Arab Emirates.

The proposal should include the following elements.1) introduction 2) background(current situation in UAE) 3) existing gap 4)motivation and justification 5)research questions and hypothesis 6) Conceptual Framework, relevant literature and opertionalization. 7) Methodology (which will be questionnaires and interviews made with decision takers and policy makers in the healthcare organizations in the 7 emirates) so this section should include information on sampling, research design and models/variables 8) Potential contributions and implications.

The research questions and hypothesis is really important as it should include at least 3-4 questions.

For section 6, I need a summary table in the end that gives an overview of the main studies allocated based on the main themes would be very helpful, and the arrangements of these papers should mirror the research questions and hypotheses

I have attached a few papers that may help, they include great resources in their references list as well.

I will also attach the framework model that I am proposing to use.(it is also found in the paper titles "E2RM..."

ftoc.indd xii 3/3/09 3:02:30 PM RISK MANAGEMENT HANDBOOK for Health Care Organizations student edition R O B E R TA L . C A R R O L L EDITOR ffirs.indd i 3/2/09 1:55:27 PM Copyright © 2009 by American Society for Healthcare Risk Management (ASHRM). All rights reserved. Published by Jossey-Bass A Wiley Imprint 989 Market Street, San Francisco, CA 94103-1741—www.josseybass.com No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, or on the Web at www.copyright.com. Requests to the publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, 201-748-6011, fax 201-748-6008, or online at www.wiley.com/go/permissions. Readers should be aware that Internet Web sites offered as citations and/or sources for further information may have changed or disappeared between the time this was written and when it is read. Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation. You should consult with a professional where appropriate. Neither the publisher nor author shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. Jossey-Bass books and products are available through most bookstores. To contact Jossey-Bass directly call our Customer Care Department within the U.S. at 800-956-7739, outside the U.S. at 317-572-3986, or fax 317-572-4002. Jossey-Bass also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Library of Congress Cataloging-in-Publication Data Risk management handbook for health care organizations / [edited by] Roberta L. Carroll. — Student ed. p. ; cm. Includes bibliographical references and index. ISBN 978-0-470-30017-6 (pbk.) 1. Health facilities—Risk management. I. Carroll, Roberta. [DNLM: 1. Health Facilities—organization & administration. 2. Risk Management. WX 157 R59533 2009] RA971.38.R58 2009 362.11068—dc22 2008055679 Printed in the United States of America STUDENT EDITION HB Printing ffirs.indd ii 10 9 8 7 6 5 4 3 2 1 3/2/09 1:55:28 PM CONTENTS Exhibits, Figures, Tables, and, Photos The Contributors Preface About the Book ix xiii xxvii xxix ONE DEVELOPMENT OF A RISK MANAGEMENT PROGRAM Learning Objectives Risk Management Program Development Key Structural Elements of the Risk Management Program Scope of the Risk Management Program The Risk Management Process Evolution of the Risk Management Program Selecting an Appropriate Risk Management Program Structure Assessing Areas of the Organization That Need Risk Management Key Components for Getting Started Writing a Risk Management Program Plan Achieving Program Acceptance 1 1 3 4 8 13 21 22 23 26 27 27 TWO THE HEALTH CARE RISK MANAGEMENT PROFESSIONAL Learning Objectives The Risk Manager’s Job: Functional Areas of Responsibility Health Care Risk Management Across a Spectrum of Settings Required Skills for the Successful Health Care Risk Management Professional Risk Management Ethics 31 31 33 53 76 77 iii ftoc.indd iii 3/3/09 3:02:26 PM iv Contents A Profile of the Health Care Risk Management Professional 78 Education and Professional Recognition Programs 78 THREE PATIENT SAFETY AND THE RISK MANAGEMENT PROFESSIONAL Learning Objectives The Scope of Medical Errors Seeking Solutions: What Are the Causes of Medical Errors? 87 87 89 91 FOUR HEALTH CARE LEGAL CONCEPTS Learning Objectives Legal Issues Common to All Health Care Providers Legal Issues Related to Specific Health Care Providers 115 115 116 134 FIVE GOVERNANCE OF THE HEALTH CARE ORGANIZATION Learning Objectives Essential Responsibilities of the Hospital Board Basic Legal Duties of Health Care Trustees Lessons from the Panel on the Nonprofit Sector Federal Sentencing Guidelines for Organizations The Sarbanes-Oxley Act of 2002 The Volunteer Protection Act of 1997 Risk Management and the Board The Medical Staff, Risk Management, and the Board 157 157 159 160 162 165 167 169 170 175 SIX EARLY WARNING SYSTEMS FOR THE IDENTIFICATION OF ORGANIZATIONAL RISKS Learning Objectives Early Identification of Exposure to Loss Food and Drug Administration Institute for Safe Medication Practices, United States Pharmacopeia, and National Coordinating Council for Medication Error Reporting and Prevention Medical Event Reporting System—Transfusion Medicine Intensive Care Unit Safety Reporting System ftoc.indd iv 181 181 182 206 208 212 212 3/3/09 3:02:27 PM Contents v Pittsburgh Regional Healthcare Initiative 212 Other Voluntary Programs 212 Standardizing a Patient Safety Taxonomy: The National Quality Forum 213 Protecting Sensitive Information 213 SEVEN THE RISK MANAGEMENT PROFESSIONAL AND MEDICATION SAFETY Learning Objectives Latent and Active Failures Systems Thinking Risk Management: A Prioritizing Approach ftoc.indd v 219 219 220 221 252 EIGHT ETHICS IN PATIENT CARE Learning Objectives Ethical Principles and Moral Obligations Research Institutional Review Boards Patient Self-Determination Act “Do Not Resuscitate”: Withholding or Withdrawing Treatment 261 261 263 263 266 275 277 NINE DOCUMENTATION AND THE MEDICAL RECORD Learning Objectives Documentation Record Retention Release of Records Ownership of Medical Records Medical Record Audits Documentation and Risk Management Emerging Risk Exposures The Risk Management Professional’s Role 287 287 291 310 310 311 312 313 320 321 TEN STATUTES, STANDARDS, AND REGULATIONS Learning Objectives Patient Care Medicare Modernization Act 327 327 328 331 3/3/09 3:02:28 PM vi Contents Medical Staff 332 Life Safety Code 350 Federal Health Insurance Laws and Regulations 354 Tort Reform 357 Policy and Procedure Manuals 359 Case Law 360 ELEVEN BASIC CLAIMS ADMINISTRATION Learning Objectives The Claims Environment The Claims Process The Risk Management Professional’s Responsibilities Regulatory Reporting of Claims 367 367 368 369 371 378 TWELVE INTRODUCTION TO RISK FINANCING Learning Objectives Risk Financing in the Context of the Risk Management Process Risk Retention 381 381 384 384 THIRTEEN INSURANCE: BASIC PRINCIPLES AND COVERAGES Learning Objectives Definition of Insurance Specific Types of Insurance for the Health Care Industry 395 395 396 408 FOURTEEN INFORMATION TECHNOLOGIES AND RISK MANAGEMENT 427 Learning Objectives 427 Risk Management Information Needs 430 Risk Management Information Systems 431 Using Information Systems to Generate Reports 432 Integrating Risk Management, Quality Assurance, and Patient Safety 433 Electronic Mail 434 Internet- and Web-Based Technology 435 Personal Health Record 435 ftoc.indd vi 3/3/09 3:02:28 PM Contents Electronic Health Records and Systems 436 Clinical Information Systems and “Smart” Technologies 437 Infrastructure Technology 440 Point-of-Care Technology 442 Telemedicine 442 Appendix 14.1: IT Glossary for Risk Managers 447 FIFTEEN RISK MANAGEMENT METRICS Learning Objectives Benchmarking Defined Claims Measuring Change Developing New Metrics SIXTEEN ACCREDITATION, LICENSURE, CERTIFICATION, AND SURVEYING BODIES Learning Objectives The Consumer Era of Health Care What the Health Care Risk Management Professional Needs to Know Mandatory Surveying Bodies Voluntary Surveying Bodies URAC Appendix 16.1: Accreditation and Licensure Organizations, Surveying Bodies, and Government Agencies SEVENTEEN EMERGENCY MANAGEMENT Learning Objectives The Steps of Emergency Management Prevention Planning and Preparation Implementation and Response Recovery Recommended Web Sites ftoc.indd vii vii 451 451 453 456 459 461 467 467 468 469 471 475 489 501 503 503 505 506 511 525 526 528 3/3/09 3:02:29 PM viii ftoc.indd viii CONTENTS EIGHTEEN OCCUPATIONAL SAFETY, HEALTH, AND ENVIRONMENTAL IMPAIRMENT Learning Objectives Administrative Procedure Act Administrative Enforcement Specific Occupational Safety and Health Issues 529 529 530 532 535 APPENDIX A A RISK MANAGEMENT PROGRAM (EXAMPLE) 543 APPENDIX B REQUEST FOR RECORDS FORM (EXAMPLE) 549 APPENDIX C A GUIDE TO MEDICAL TERMINOLOGY 551 GLOSSARY 565 INDEX 623 3/3/09 3:02:29 PM EXHIBITS, FIGURES, TABLES, AND, PHOTOS EXHIBITS 2.1 2.2 2.3 2.4 2.5 2.6 3.1 6.1 6.2 6.3 6.4 9.1 10.1 10.2 10.3 14.1 15.1 17.1 17.2 17.3 17.4 Patient Safety Officer Job Description Risk Manager Position Description, Level One Risk Manager Position Description, Level Two Risk Manager Position Description, Level Three Chief Risk Officer Position Description Physician Risk Manager Job Description The 2009 National Patient Safety Goals MedWatch Form 3500 USP Medication Errors Reporting Program Form NCC MERP Index for Categorizing Medication Errors NCC MERP Index for Categorizing Medication Errors Algorithm Questions for Medical Record Review MedWatch Form for Reporting Serious Patient Injury or Death Sample Board Resolution Sample Legislative Update Security Checklist for Information Technologies Total Cost of Risk Report Vulnerability Analysis Chart Training Drills and Exercises Schedule Hazard Vulnerability Analysis Emergency Management Planning—Standards and Regulations 34 36 41 46 59 71 100 207 209 210 211 312 341 359 360 440 458 506 508 512 517 ix ftoc.indd ix 3/3/09 3:02:29 PM x Exhibits, Figures, Tables, Photos, and Appendixes FIGURES 1.1 3.1 3.2 3.3 3.4 3.5 7.1 7.2 7.3 12.1 12.2 Steps in Risk Management Decision Making Most Frequent Adverse Events in Hospitalized Patients The Swiss Cheese Model of Accident Causation The Blunt End/Sharp End Model of Accident Causation Human-Machine Interface Components of Human Factors Assessment Entry for Benzathine on the Patient’s Chart Faxes Don’t Always Resolve Order Communication Problems Error Reduction Strategies Risk Management Process Structure Risk Financing Continuum 14 90 93 94 103 104 223 230 253 385 391 TABLES 2.1 2.2 2.3 2.4 6.1 6.2 6.3 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 9.1 9.2 ftoc.indd x Types of Organizations Level of Education Highest Level of Educational Training Job Functions and Titles Common Barriers to Incident Reporting Key Points to Remember About Incident Reports Emergency Department Occurrence Reporting Criteria Essential Patient Information Patient-Controlled Analgesia (PCA) Problems and Safety Recommendations Using Failure Mode and Effect Analysis to Predict Failures with Infusion Pumps Effects of Fatigue High-Alert Medications by Class or Category Specific High-Alert Medications High-Risk Patient Populations Error-Prone Processes What Constitutes a Medical Record? Types of Documents of Interest to Health Care Risk Managers 54 79 80 80 191 193 197 225 239 245 249 254 255 256 256 288 289 3/3/09 3:02:29 PM Exhibits, Figures, Tables, Photos, and Appendixes 9.3 9.4 9.5 9.6 12.1 16.1 16.2 Advantages and Disadvantages of the SOAP Model of Documentation Documentation Dos and Don’ts What Plaintiff’s Attorneys Look for in the Medical Record Essential Charting Components of Interest to the Health Care Risk Management Professional Types of Insurance CMS Regional Offices Major Requirements of ISO 9001 Standards xi 298 308 314 318 389 474 482 PHOTOS 3.1 7.1 7.2 7.3 7.4 7.5 7.6 7.7 ftoc.indd xi Poorly Designed Paper Towel Dispenser and Disposal Unit Door Handle Capsule Quantity Is Often Mistaken for Product Strength Top Six Vials Are Brethine; Bottom Eight Are Methergine Mix of Opthalmic and Respiratory Medications Tubing Lines IV Tubing to Oxygen IV Misconnection 106 224 232 233 234 243 244 245 3/3/09 3:02:30 PM ftoc.indd xii 3/3/09 3:02:30 PM THE CONTRIBUTORS ELLEN L. BARTON, JD, CPCU, DFASHRM, principal, ERM Strategies LLC, is an independent consultant. Previously, she held positions as vice president, risk management, MedStar Health, Inc., an integrated health care delivery system (1999–2000); vice president, claims and health care practice leader, Aon Risk Services, Inc., of Maryland (1998–1999); vice president, legal services for American Radiology Services, Inc. (1997–1998); and vice president and general Counsel of New American Health, Inc. (1996–1997). She served as president, Neumann Insurance Company, and director of risk management, Franciscan Health System (1987–1996). She also served as general counsel for Franciscan Health System (1993–1996) and as senior vice president, legal services (1994–1996). Barton sat on the board of directors and served as chairperson of Preferred Physicians Insurance Company, a Nebraska stock insurance company; Consolidated Catholic Casualty Risk Retention Group, Inc., a Vermontbased captive insurance company; and Alternative Insurance Management Services, Inc., a captive insurance company management firm based in Colorado. Barton also served as a member of the Trinity Health System Insurance Management Advisory Committee. She is a graduate of Rosemont College and received her JD degree from the University of Cincinnati. She is also a chartered property and casualty underwriter. Barton has conducted numerous seminars on risk management issues on a national as well as regional level and has published articles in related areas. She is admitted to the bars in Ohio, Maryland, and Pennsylvania and holds membership in the Maryland Bar Association, the Society of Chartered Property and Casualty Underwriters; the American Health Lawyers Association, in which she currently serves as chairperson of the Risk Management Affinity Group of the Hospitals and Health Systems Practice Group; the Maryland Society for Healthcare Risk Management, of which she was president in 2002–2003, and the American Society for Healthcare Risk Management, of which she was president in 1990. She is also the 1993 recipient of the Distinguished Service Award of the American Society for Healthcare Risk Management (ASHRM). In 2001, the ASHRM Modules Program, the Barton Certificate in Healthcare Risk Management, was named in her honor. ROBERTA L. CARROLL, RN, ARM, CPCU, MBA, CPHRM, CPHQ, LHRM, HEM, DFASHRM, is senior vice president, Aon Healthcare, based in Tampa, Florida. Previously she was director of Risk Management Consulting Services and senior vice president and manager of the health care unit, Aon Risk Services of Northern California. She has held a variety of positions, including vice president of risk and xiii fbetw.indd xiii 3/2/09 1:54:38 PM xiv The Contributors insurance management for UniHealth in Burbank, California; senior vice president and manager of the health care unit for Corroon & Black of Illinois; vice president of risk management, claims, and marketing for Premier Alliance Insurance Company; trust administrator and risk manager for Premier Hospitals Alliance in Chicago; and director of risk management at Mount Sinai Medical Center, Miami Beach, Florida. Carroll served on the American Society for Healthcare Risk Management (ASHRM) board for six years and was president in 1995–1996. She was elected to the board of the Southern California Association for Healthcare Risk Management (SCAHRM) and was one of the founding members, first president, and board member of the Florida Society for Healthcare Risk Management and Patient Safety (FSHRMPS). In addition, she was one of the founders and an officer of the Florida Medical Malpractice Claims Council, Inc. (FMMCCI). She is a licensed healthcare risk manager (LHRM) in the state of Florida and faculty member for the health care risk management course at the University of South Florida (USF). Carroll is also a faculty member for the ASHRMsponsored Barton Certificate program “Essentials” module. Previously, she was a faculty member for Module 1, “The Fundamentals of Health Care Risk Management: Constructing the Comprehensive Program,” for eight years. Carroll received a bachelor of science degree in health services administration and a certificate in emergency medical services systems administration from Florida International University and a master of business degree from Nova Southeastern University. She has earned the right to use the ARM, CPCU, HEM, CPHQ, and CPHRM designations. She is editor of the Risk Management Handbook for Health Care Organizations’ second (1997), third (2000), and fourth (2004) editions and the series editor for the fifth (2006) and student (2009) editions. Carroll has received numerous awards: in 1997, ASHRM’s highest honor, the Distinguished Service Award (DSA); 1998 Distinguished Alumni Achievement Award from the School of Business and Entrepreneurship, Nova Southeastern University; Most Contributing Member to Risk Management in 1996 from the SCAHRM; and Most Valuable Contribution to the Field of Risk Management in 1993 from that same organization. She is a member of ASHRM, FSHRMPS, and the Publication Committee of the Risk Management Affinity Group (RMAG) of the American Health Lawyers Associations (AHLA). She is a well-known author, speaker, and educator in the areas of alternative risk financing, risk mitigation strategies and solutions, claims administration, early intervention programs, enterprise risk management (ERM), strategic planning, and reengineering. Her activities are on a local, state, and national level. Her professional and committee activities are numerous. HEDY COHEN, RN, BSN, MS, vice president for the Institute for Safe Medication Practices (ISMP). She received an associate of arts degree in nursing from Bucks County Community College in Newtown, Pennsylvania; a bachelor of science in nursing from LaSalle University in Philadelphia; a master’s degree in health systems administration from Rochester Institute for Technology, in Rochester, New York; and is presently a doctoral candidate in health policy at the University of the Sciences in Philadelphia. Her clinical nursing background of more than eighteen years was focused fbetw.indd xiv 3/2/09 1:54:38 PM The Contributors xv in critical care and nursing management. She is a frequent speaker for health care organizations on current issues in medication safety and has written numerous articles on improving the medication use process. She also edits ISMP’s monthly newsletter, Nurse Advise-ERR; cowrote a handbook on high-alert drugs; and is on the national advisory board for the Nursing Advance Journal and Davis’s Drug Guide for Nurses. Cohen has been appointed adjunct associate professor at Temple School of Pharmacy and faculty fellow in the Executive Patient Safety Fellowship, which is offered through Virginia Commonwealth University in Richmond. She also serves as a medication error clinical analyst for the Pennsylvania Safety Authority’s reporting program. MARK COHEN, ARM, RPLU, CPHQ, CPHRM, DFASHRM, risk management consultant, Sutter Health Risk Services. Cohen began his career in risk management in 1982 at the UCLA Medical Center and Center for the Health Sciences and was subsequently appointed director of risk management. In 1987, he moved to Sacramento to become director of risk management for the University of California, Davis Health System. Cohen joined Sutter Health as a corporate risk management consultant in 1995. He provides a broad range of risk management consultation services to Sutter Health’s not-for-profit network of acute-care hospitals; physician organizations; medical research facilities; regionwide home health, hospice, and occupational health networks; and long-term care centers that serve more than one hundred Northern California communities. Cohen writes and lectures on Emergency Medical Treatment and Labor Act (EMTALA) compliance and is a member of the faculty of the California Healthcare Association’s annual EMTALA seminars. He is a past president of both the Southern California Association for Healthcare Risk Management (SCAHRM) and the California Society for Healthcare Risk Management (CSHRM), and served as a member of ASHRM’s board in 2002 and 2003. He currently serves on the board of the Sacramento Risk Management Forum and the South Natomas Transit Management Association. Cohen has served on the faculty of ASHRM’s “Modules” and “Essentials” and CPHRM study session programs and on several ASHRM committees, most notably as longtime chair of the Online Education Committee. DOMINIC A. COLAIZZO, MBA, is managing director of Aon’s National Healthcare Alternative Risk Practice, based in Philadelphia. He is responsible for directing Aon resources for the development, implementation, and servicing of alternative risk transfer programs for the health care industry. His sixteen years of experience in health care administration and nineteen years of broking and consulting experience with Aon have provided him with a broad understanding of the issues faced by all health care providers. He had served as chief operating officer and senior vice president of a community hospital and has held various administrative positions in a major teaching hospital. He has extensive experience in developing and servicing alternative risk financing and innovative insurance programs for profit and not-for-profit health systems, health insurers, managed care organizations, extended care organizations, and physicians’ groups. Colaizzo also serves as a key adviser for Aon’s National Healthcare Practice. fbetw.indd xv 3/2/09 1:54:39 PM xvi The Contributors He has earned a master of business administration for the Leonard Davis Institute for Health Economics at the Wharton School of the University of Pennsylvania. He has also earned a bachelor of arts degree in economics and mathematics from Washington and Jefferson College. Colaizzo is a diplomate of the American College of Health Care Executives and holds memberships in the American Society for Healthcare Risk Management (ASHRM), the American Hospital Association, and the Health Care Financial Association. He serves on the faculty for professional development seminars and has cowritten an article for the ASHRM Journal titled, “Integrating Quality with Risk Financing Through a Risk Retention Group.” HARLAN Y. HAMMOND JR., MBA, ARM, CPHRM, DFASHRM, assistant vice president for risk management services, Intermountain Healthcare, Salt Lake City, Utah. His responsibilities include oversight for Intermountain’s risk financing, loss prevention, loss control, and claims administration efforts and safety, security, and systemwide emergency response. Hammond received his bachelor’s degree in business administration from the University of Utah, followed by a master’s of business administration degree from the University of Washington. Hammond has served in various capacities with ASHRM, including twice as a member of the ASHRM board of directors and as a faculty member for the Barton Certificate in Healthcare Risk Management program. He received ASHRM’s Distinguished Service Award in 2000. MONICA HANSLOVAN, JD, formerly was an associate of Horty, Springer & Mattern, PC, in Pittsburgh, Pennsylvania. She focuses her practice exclusively on hospital and health care law, with particular emphasis on medical staff matters. She advises clients on a wide range of medical staff issues, including development of, analysis of, and proposed revisions to medical staff bylaws and related documents; development of hospital and medical staff policies; and management of issues related to protection of peer review documents and sharing of confidential peer review and credentialing information. Hanslovan received her doctor of law degree magna cum laude from Widener University School of Law and her bachelor of arts with high distinction from Pennsylvania State University. She is a member of the Allegheny County, Pennsylvania, and American Bar Associations and the American Health Lawyers Association. JUDY HART is executive vice president of Endurance Specialty Insurance, Ltd., and heads the company’s health care practice. Hart has more than thirty years of experience in the insurance industry and has been dedicated to health care risk financing for the past twenty-six years. She spent most of her career at Alexander & Alexander Services, where she was a managing director and deputy national director of health care practice. During that time, she participated in the development of alternative risk financing programs for health care organizations across the United States. Before joining Endurance, she spent four years as vice president of Employers Reinsurance Corporation, where she was responsible for marketing, new product development, and the development of health care strategies and was a member of the health care senior fbetw.indd xvi 3/2/09 1:54:39 PM The Contributors xvii leadership team. She is the current president of the Bermuda Society for Healthcare Risk Management. She is a frequent speaker and author on risk management issues associated with risk financing, managed care, and the evolving risks facing health care providers. She attended Southeast Missouri State University and Washington University in Saint Louis, Missouri. PETER J. HOFFMAN, JD, is a partner of the Philadelphia law firm of McKissock & Hoffman, PC. He received his bachelor of arts degree from Washington and Jefferson College, his master of arts from the State University of New York Graduate School of Public Affairs, and his doctor of law degree cum laude from Temple University School of Law, where he was the executive editor of the Law Review. Hoffman was a member of the Pennsylvania Select Committee on Medical Malpractice from 1984 to 1986. He was a member of Governor Edward Rendell’s Medical Malpractice Task Force and is currently counsel to the Commonwealth of Pennsylvania Patient Safety Authority. He is a past president of the Pennsylvania Defense Institute. He was the recipient of the Defense Research Institute’s Exceptional Performance Citation in 1989 and the Fred H. Sievert Award in 1989. Hoffman was a coauthor of the book Laws and Regulations Affecting Medical Practice. He was chairman of Hearing Committee 1.15, Supreme Court of Pennsylvania Disciplinary Board, from 1993 to 1998 and serves on the faculty for the Temple University School of Law, Masters of Laws in Trial Advocacy, and Academy of Advocacy. He has been listed as a top attorney in Philadelphia Magazine each time the article appears and has been listed in Best Lawyers in America since 1995. He was cited as one of the top hundred lawyers in Pennsylvania in Pennsylvania Super Lawyers, 2004 and 2005. Hoffman was a member of the Temple Inns of Court. He is a member of ASHRM, a Fellow of the International Academy of Trial Lawyers, of the American College of Trial Lawyers, and of the American Board of Trial Advocates. JOHN HORTY, JD, is the managing partner of Horty, Springer & Mattern, PC, and the editor of all HortySpringer publications. He presently serves as chair of the board and a faculty member of the Estes Park Institute in Englewood, Colorado, and president and chair of the Indigo Institute in Washington, D.C. He is an honorary fellow of the American College of Hospital Executives, a recipient of the Award of Honor of the American Hospital Association, and an Honorary Life Member of the American Hospital Association. He is a founding member of the American Academy of Hospital Attorneys; a past board member of the Hospital Association of Pennsylvania, the Health Alliance of Pennsylvania, and the Hospital Council of Western Pennsylvania; and was chair of Saint Francis Central Hospital in Pittsburgh, Pennsylvania, from 1971 to 1999. SANDRA K. JOHNSON, RN, ARM, LHRM, FSHRM, is director of risk services for Broward Health in Fort Lauderdale, Florida. She began her career in risk management twenty-eight years ago, working for PHICO Insurance Group, Inc., in Mechanicsburg, fbetw.indd xvii 3/2/09 1:54:40 PM xviii The Contributors Pennsylvania. Past positions include director, risk and insurance, for Keystone Health System in Drexel Hill, Pennsylvania; director, risk and insurance, at Holy Cross Hospital in Fort Lauderdale, Florida; and system director of risk management at Intracoastal Health System, West Palm Beach, Florida. She has served on many ASHRM committees and as a faculty member of the 1988 annual conference and nominations committee. She has served two terms on the ASHRM board of directors. While in Philadelphia, she held various officer and committee positions with the Philadelphia Area Society for Healthcare Risk Management and the Pennsylvania Association of Health Care Risk Management. She has also been recognized on three occasions for outstanding contributions to the field of risk management by the Philadelphia Area Society for Healthcare Risk Management and the Pennsylvania Association of Health Care Risk Management. She is a past president and a board member of the Florida Society for Healthcare Risk Management and Patient Safety and was reelected as president for 2008–2009 term. Johnson is a member of the advisory board for the journal, Healthcare Risk Management, published by American Health Consultants, and has held positions on the Broward County Risk and Insurance Management Society board of directors. She was awarded the ARM designation in 1990 and the FASHRM designation in 1991. She is a licensed health care risk manager (LHRM) in the state of Florida. TRISTA JOHNSON, PhD, MPH, is the director of performance measurement and analysis for Allina Hospitals and Clinics. Johnson provides coordinated, accurate analysis and results to drive organizational improvement. Previously, she served as the director of patient safety and coordinated initiatives and measurements across the eleven hospitals and forty-four clinics in the Allina system. She was involved in the creation of a standard data collection tool and taxonomy for patient safety events and continues to work with this system through analysis of the data and use of the results in safety collaboratives. A few examples of collaboratives conducted while leading patient safety include falls prevention, teamwork and patient safety, insulin safety, and the IHI trigger tool analysis. Johnson serves as a member of the Minnesota Alliance for Patient Safety (MAPS), which is involved in implementing the mandatory statewide reporting of the twenty-seven National Quality Forum events. She completed her doctoral work on the application of epidemiology to the study of medical errors. LEILANI KICKLIGHTER, RN, ARM, MBA, CPHRM, DFASHRM, principal, the Kicklighter Group, is an independent consultant offering health care risk management, patient safety consulting, and stress management education. She serves as a risk management consultant to ambulatory surgery centers and is the course coordinator and instructor for the health care risk management online certificate course offered by the University of South Florida. This is a preparatory course laying the foundation for licensure in Florida as a health care risk manager. Most recently, she served as the corporate director of risk management services and patient safety officer for a large longterm care and skilled nursing facility. Previously, she was a health care risk management fbetw.indd xviii 3/2/09 1:54:40 PM The Contributors xix consultant with a large global insurance broker and consulted throughout the United States and internationally. Kicklighter began her career as a registered nurse. Her experience in health care risk management spans more than thirty years and has afforded her experience in a variety of health care organizational settings, including a large teaching hospital, a university medical school, a large multispecialty clinic, a forprofit community hospital, a not-for-profit integrated health care multifacility system, and a large HMO. She has been a member of the American Society for Healthcare Risk Management (ASHRM), since its inception, serving on numerous committees, the board of directors, and as president in 1997–1998. Kicklighter has been awarded the DFASHRM designation from ASHRM. She is the past president and board member of the Florida Society for Healthcare Risk Management and Patient Safety. She has a master’s in business administration from Nova Southeastern University and has earned designations as an associate in risk management (ARM) and a certified professional in health care risk management (CPHRM). Kicklighter is a licensed health care risk manager (LHRM) in the state of Florida. She is a well-known author and lecturer in the fields of infection control and risk management on the local, state, national, and international levels. JANE J. MCCAFFREY, MHSA, DFASHRM, is the director of Quality Management Services at Self Regional Healthcare in Greenwood, South Carolina. She has developed risk management programs at several South Carolina hospitals over the past twenty years. McCaffrey has served twice as president of the American Society for Healthcare Risk Management (1985 and 2003). She participates on several state-level patient safety and risk committees and was a faculty member for fundamentals of risk management for over a decade. McCaffrey received ASHRM’s Distinguished Service Award in 1994. She also serves on the editorial advisory boards for ECRI’s newsletter Risk Management Reporter and American Healthcare Consultants’ Healthcare Risk Management. In 2005, she became a member of Health Research and Educational Trust’s 2005–2006 Patient Safety Leadership Fellowship Class. DENISE MURPHY, RN, BSN, MPH, CIC, Vice President and chief safety and quality officer at Barnes-Jewish Hospital JC Healthcare in Saint Louis. Before taking that position, she spent seven years as director of health care epidemiology and patient safety for BJC HealthCare. Murphy went to nursing school in Philadelphia, received her bachelor of science in nursing in Portland, Maine, and holds a master of public health degree from the Saint Louis University School of Public Health. Murphy’s early nursing experience was in pediatric ICUs, surgical nursing, and nursing management. She entered the field of infection control in 1981, sitting for the first certification in infection control (CIC) exam in 1983. She has been an ICP in hospitals ranging from 100–1200 beds in rural and urban settings. Her presentations and publications are numerous on prevention of surgical site infections, bloodstream infections, and ventilator-associated pneumonia and on redesigning infection control services, the business of infection control, and establishment of patient safety programs. Murphy is an active fbetw.indd xix 3/2/09 1:54:40 PM xx The Contributors member of the Association for Professionals in Infection Control and Epidemiology (APIC), the Society for Healthcare Epidemiology of America (SHEA), and the American Society for Healthcare Risk Management (ASHRM). She is a past president of the APIC Greater Saint Louis chapter and currently serves as a director on the APIC national board and chair of strategic planning. Murphy was a four-year member of the APIC annual conference task force and is currently the ICP representative on the SHEA educational conference planning committee. She graduated from the first AHA/National Patient Safety Foundation-sponsored leadership fellowship training program in 2003. JUDITH NAPIER is corporate director, risk management and patient safety, for Allina Hospitals and Clinics in Minnesota. Before joining Allina, Napier was senior director, patient safety and risk management services, for Children’s Hospitals and Clinics in Minnesota. Napier has held the position of senior vice president for MMI Companies, an international health care risk management firm, where she was responsible for an international consulting division and product innovation and customization, specifically introducing new risk management strategies and products to the health care industry. Before her work with MMI Companies, she practiced nursing in high-risk perinatal units and taught maternal child nursing in several academic accredited nursing programs at both the baccalaureate and associate degree level. Her career includes clinical practice, consultation, teaching, and more than twenty years as an executive in the health care industry. Napier holds a bachelor’s degree in nursing from Niagara University and a master’s degree in maternal child clinical specialty nursing from California State University at Los Angeles. She has received a certificate of completion from HRET and the Health Forum Patient Safety Leadership Fellowship. Napier has been a frequent national and international speaker in the area of patient safety, quality, and risk management. PAMELA J. PARA, RN, MPH, CPHRM, ARM, FASHRM, is a nurse consultant for the Midwestern Consortium of the Centers for Medicare and Medicaid Services (CMS) in Chicago, Illinois. In this role, Para is responsible for the coordination of non-long-term care federal oversight functions in the Division of Survey and Certification for transplant centers, organ procurement organizations, end-stage renal dialysis centers, critical access hospitals, home care, and hospice providers. Para has served as the director of professional and technical services for the American Society for Healthcare Risk Management of the American Hospital Association in Chicago. Other experience includes evaluating a variety of health care organizations, nationwide and in Puerto Rico, for potential medical professional, general, and workers’ compensation liability exposures for a major commercial insurance carrier. She has also performed medicolegal reviews of potential and litigated claims, negotiated settlements, managed workers’ compensation claims, and served as adviser to risk managers and other corporate claims coordinators of various selfinsured health care facilities in the metropolitan Chicago area and nationwide for a fbetw.indd xx 3/2/09 1:54:41 PM The Contributors xxi third-party claims administrator. Para has nearly twenty-five years of professional health care experience, beginning as a registered professional nurse in both civilian and military maternal-child clinical settings. She received a bachelor of science degree in nursing with a minor in Spanish from DePauw University in Greencastle, Indiana, and a master of public health degree from the University of Illinois at Chicago. She holds the designations of certified professional in health care risk management (CPHRM), associate in risk management (ARM), and Fellow of the American Society for Healthcare Risk Management (FASHRM). Para is a published author, educator, and frequent presenter on risk management and workers’ compensation topics. GINA PUGLIESE, RN, MS, vice president of the Safety Institute, Premier Inc., Chicago. She holds associate faculty appointments at the University of Illinois School of Public Health, Division of Epidemiology and Biostatistics, and Rush University College of Nursing, Chicago. Pugliese is on the editorial advisory board of the Joint Commission Journal on Quality and Safety and is the senior associate editor of Infection Control and Hospital Epidemiology. She is the codirector of the international Healthcare Epidemiology Training Program sponsored by the Society for Healthcare Epidemiology of America (SHEA) and the Centers for Disease Control and Prevention (CDC). For eight years, Pugliese was the director of safety of the American Hospital Association, Chicago. She was a founding board member and past president of the national Certification Board of Infection Control (CBIC) and has served as a board member of the national Association for Professionals in Infection Control and Epidemiology (APIC). She is the author of more than 130 publications and has served on the faculty in more than 300 educational conferences in thirteen countries and has appeared in more than thirty videotape, television, and teleconference programs. Pugliese currently serves on several national committees, including the expert panel for the CMS National Surgical Infection Prevention (SIP) and Surgical Care Improvement Projects (SCIP), AHRQ’s Patient Safety Research Coordinating Center Steering Committee, and FDA’s Medical Product Surveillance Network (MEDSUN) Advisory Group. Pugliese is the 2001 recipient of the APIC Carole DeMille outstanding achievement award in safety and epidemiology. In 2004, the Gina Pugliese Scholarship was established for five clinicians to attend each of the SHEA-CDC international health care epidemiology training courses, held every other year, in recognition of her contributions to health care epidemiology. MADELYN S. QUATTRONE, JD, is a senior risk management analyst for ECRI, Plymouth Meeting, Pennsylvania. She is editor of ECRI’s publication Continuing Care Risk Management and is a regular contributor to ECRI’s Healthcare Risk Control System. She has been a panelist in ECRI audioconferences discussing risk management and legal issues involving the health information privacy regulations and the security regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Before joining ECRI, Quattrone was a shareholder in the law firm fbetw.indd xxi 3/2/09 1:54:41 PM xxii The Contributors of George, Koran, Quattrone, Blumberg & Chant, PA, in Woodbury, New Jersey, concentrating on the defense of medical malpractice cases, from 1982 to 1999. A member of the bar of the Commonwealth of Pennsylvania, New Jersey, the U.S. District Court of New Jersey, the Third Circuit Court of Appeals, and the U.S. Supreme Court, Quattrone achieved certification by the New Jersey Supreme Court as a civil trial attorney in 1990 and was selected for membership in the American Board of Trial Advocates in 1993. Quattrone has also provided risk management consultation to physicians, hospitals, and professional liability insurers and contributed to the development of a clinical-legal correspondence course for the Medical Inter-Insurance Exchange of New Jersey. She has written regularly for numerous publications, including the Emergency Physician Legal Bulletin, the Emergency Nurse Legal Bulletin, and the Emergency Medical Technician Legal Bulletin. For many years, Quattrone cowrote a column on legal and risk management issues affecting emergency nurses in the Journal of Emergency Nursing. She has developed case scenarios and participated in mock medical malpractice trials for audiences of physicians, medical students, residents, and clinical engineers and has been a frequent speaker in numerous risk management areas, including informed consent, ethical and legal issues involving human reproduction, obstetrics, the provision of emergency care, and medical record documentation. Quattrone earned a doctor of law degree from Rutgers University School of Law, Camden, New Jersey, and a bachelor of arts degree in anthropology from Temple University, Philadelphia, Pennsylvania. MICHAEL L. RAWSON is the former corporate director of safety, security, and environmental health for Intermountain Health Care (IHC) in Salt Lake City, Utah, where he has been employed for twenty-six years. His responsibilities include management of safety, security, and environmental health issues and compliance with regulatory activities specific to these areas. Rawson holds a bachelor of science degree in sociology with a certificate in law enforcement from the University of Utah and a master’s degree in administration of justice from Wichita State University. He is a certified health care safety professional (CHSP), a certified health care environmental manager (HEM), and a senior of the American Society for Healthcare Engineering (SASHE). Rawson has served on various committees with the American Society for Healthcare Engineering, the National Fire Protection Association (NFPA), the U.S. Department of Homeland Security (DHS), and the U.S. Department of Veterans Affairs–Facilities (VA) and as president of the Mountain States Society for Healthcare Engineering (MSSHE). Rawson is a faculty member for ASHE-sponsored Environment of Care Joint Committee Survey Process Preparation programs and has presented programs on hospital security, safety, and emergency preparation and management throughout the United States. ELAINE RICHARD, RN, MS, earned a master’s degree in public health at the University of Minnesota, where she served on the faculty from 1972 to 1984. During her tenure there, she pioneered one of the first post-RN and ANA-accredited geriatric nurse practitioner programs before nurse practitioner programs were recognized by fbetw.indd xxii 3/2/09 1:54:42 PM The Contributors xxiii the National League for Nursing. In 1977, she developed a National Institute of Occupational Safety and Health (NIOSH) graduate-level program in occupational health nursing and was subsequently promoted to associate professor. Richard later served as a NIOSH consultant reviewing university applications for occupational health training programs in the fields of medicine, nursing, safety, and industrial hygiene. She has lived in Tampa since 1984. Richard served as executive director of Saint Joseph’s HealthLine and Community Care over a period of ten years. In this capacity, she planned and developed the occupational health program and clinic and corporate wellness programs. As part of the Hillsborough County initiative to serve the indigent population, she developed and implemented Saint Joseph’s first off-site primary clinics to serve this population. In 1995, she became the executive director and regional vice president of EverCare, a subsidiary of United Healthcare, and implemented the EverCare Program in Florida for residents in long-term care institutions. This successful Medicare demonstration project uses geriatric nurse practitioners to bring added value to patients residing in nursing homes. Since retirement, she has worked with the University of South Florida’s School of Aging Studies in the development and maintenance of the risk management course. SHEILA HAGG-RICKERT, JD, MHA, MBA, CPCU, PHRM, DFASHRM, associate system director of risk management, CHRISTUS Health. She is responsible for oversight of CHRISTUS’s loss prevention, claims management, and risk financing programs. Previously, she served as corporate risk manager for both for-profit and notfor-profit acute care and long-term care health systems, as an insurance broker, and as a health care risk management consultant. She has served on the board of directors for the American Society for Healthcare Risk Management (ASHRM) and has presented and written extensively on health care risk management and health law topics. She served as faculty for ASHRM’s Advanced Forum, the third learning module in the Barton Certificate program, for more than a decade. Hagg-Rickert holds a doctor of law degree from the University of Iowa and masters degrees in both business administration and health care administration from Georgia State University. She has earned chartered property and casualty underwriter (CPCU) and certified professional in health care risk management (CPHRM) designations and is a Distinguished Fellow of the American Society of Healthcare Risk Management (DFASHRM). FREDERICK “RICK” ROBINSON, JD, is partner in charge of the health law practice in Fulbright & Jaworski’s Washington, D.C., office. His cases cover all phases of trial and appellate practice in both criminal and civil matters, including qui tam or “whistleblower” lawsuits under the federal False Claims Act. He helps health care providers create and implement corporate compliance programs and with voluntary disclosure matters. Robinson graduated with honors from Duke University School of Law in 1982 and is admitted to the bar in Maryland and the District of Columbia. He has written numerous articles and is a regular speaker at seminars and conferences regarding health care litigation and compliance matters. fbetw.indd xxiii 3/2/09 1:54:42 PM xxiv The Contributors JEANNIE SEDWICK, ARM, is a former health care broker for Aon Risk Services, Inc., based in Winston-Salem, North Carolina. Previously, she was director of risk management for Wake County Hospital System, Inc., in Raleigh, North Carolina, for more than twenty years. She held the position of vice president of marketing for the Medical Protective Company/Employers Reinsurance Company and was responsible for production of health care accounts for the southern United States. She served as managing director for property casualty for Insurance Resource, Inc., a division of the American Hospital Association, in Chicago, Illinois. She served on the ASHRM board for six years and was president in 1996–1997. She is a founding member of the North Carolina Chapter of ASHRM and has served as its president and board member and on many committees. She was recognized for her contributions to the North Carolina ASHRM chapter and was awarded the Distinguished Service Award in 1996. Sedwick was named to the Business Insurance Risk Manager of the Year Honor Roll in 1997 for her contributions to the field of risk management and for her achievements as risk manager at Wake County Hospital System. KATRINA A. SHANNON, BA, JD, risk management coordinator for Barnes-Jewish Hospital in Saint Louis, and adjunct professor at Maryville University in Saint Louis. Shannon received her bachelor of arts degree in business management and her certificate in health information management from Saint Louis University. She received her doctor of law degree from Saint Louis University School of Law and a health law certificate from the Saint Louis University School of Law Center for Health Law Studies. She is licensed to practice in Missouri. Shannon is a former law clerk for the BJC Health System, Armstrong Teasdale LLP, and a former associate attorney for Lashly & Baer, PC. In these roles, Shannon practiced corporate, government, education, and health care law. Shannon is a member of the Missouri Bar Association, the Mound City Bar Association, the Saint Louis Area Health Law Association, the Saint Louis Association for Health Care Risk Managers, and the American Society for Healthcare Risk Management. RONNI P. SOLOMON, JD, is executive vice president and general counsel at ECRI, a nonprofit health services research agency in suburban Philadelphia that focuses on the safety, quality, and cost-effectiveness of patient care. Solomon has approximately twenty years’ experience in health care risk management, patient safety, law, and regulation. She works with leaders at hospitals, health systems, government agencies, continuing care organizations, and insurance providers to implement patient safety and quality assessment systems. She has published numerous articles and book chapters and has lectured frequently in the United States and abroad. Solomon serves as the center director for ECRI’s Collaborating Center for the World Health Organization in patient safety, health care technology and risk management. She is a past member of ASHRM’s board of directors and has served in many other leadership roles for ASHRM. She received ASHRM’s first Award for Writing Excellence. fbetw.indd xxiv 3/2/09 1:54:42 PM The Contributors xxv NANCY TUOHY, RN, MSN, is a medication safety specialist at ISMP. She is also the assistant editor for ISMP’s Nurse Advise-ERR and a contributor to the other ISMP medication safety alert publications. Tuohy’s interests include patient safety and health care systems analysis, including the evolution of health care informatics. Her prior work experiences cover a broad range of health care settings, including pediatrics, critical care, outpatient clinic, elementary school, pharmaceutical research, and prehospital care as an emergency medical technician. Tuohy obtained her bachelor of science in nursing degree at the University of North Carolina at Chapel Hill and her master of science in nursing degree at the University of Pennsylvania. She also holds a bachelor’s degree in psychology from Wake Forest University. JOHN C. WEST, JD, MHA, DFASHRM, is a senior health care consultant with AIG Consultants Inc., Healthcare Management Division. He holds a bachelor’s degree from the University of Cincinnati, a law degree from Salmon P. Chase College of Law, and a master’s degree in health services administration from Xavier University. He received the Distinguished Service Award from ASHRM in 2001, the highest honor bestowed by that society. He also received the designation of Distinguished Fellow of the American Society for Healthcare Risk Management (DFASHRM) in 1999. West has been a frequent speaker at national and regional educational programs and has published numerous articles on various aspects of health care risk management. He currently writes the “Case Law Update” column on a quarterly basis for the Journal of Healthcare Risk Management. KIMBERLY M. WILLIS, CPCU, ARM, is senior vice president of Endurance U.S. Healthcare Insurance Services. In this capacity, she is responsible for developing and executing strategy for the U.S. Healthcare practice. Prior to joining Endurance, Willis served as vice president, field underwriting, for Berkley Medical Excess Underwriters. She was responsible for management of underwriting strategy, achievement of profitability and premium volume goals, and oversight of distributor relationships. Willis also served as managing director, health care syndication, for Aon Risk Services. She managed a team responsible for the design, negotiation, and broking of over $500 million in health care professional liability premiums. Willis earned her bachelor of science degree in business administration at the University of Missouri and a master of business administration degree from Maryville University. She holds the chartered property and casualty underwriter (CPCU) and associate in risk management (ARM) designations. SHEILA COHEN ZIMMET, BSN, JD, is associate vice president for Regulatory Affairs at Georgetown University Medical Center. Previously she was associate dean, research compliance, at Weill Medical College of Cornell University, where she serves as the course director for the Tri-Institutional Responsible Conduct of Research course for Weill Cornell Medical College, Rockefeller University, and Memorial fbetw.indd xxv 3/2/09 1:54:43 PM xxvi The Contributors Sloan-Kettering Institute. She previously served as Director of Research Assurance and Compliance and as senior counsel for Georgetown University Medical Center. She started her professional career as a neonatal intensive care nurse after earning her undergraduate nursing degree from Georgetown University in 1971. After she received her JD from Georgetown in 1975, Zimmet pursued a legal career with the federal government in occupational and mine safety and health. She returned to Georgetown University in 1984, where her health law practice focused on clinical, bioethical, and biomedical research issues, professional liability and risk management, and other hospital and higher education legal issues involving patients, students, faculty, and staff that are common to academic medical centers. Zimmet also serves as a member of the National Advisory Research Resources Council to the National Institutes of Health. fbetw.indd xxvi 3/2/09 1:54:43 PM PREFACE The student of risk management is entering a field in health care filled with challenges, excitement, obstacles, passion, frustration, and confusion, all combined with a strong sense of purpose and commitment. You’ll either love it or be frightened by it. Risk management is not a stop on the road; it is a journey. For individuals who like a challenge, consider themselves change agents, understand organizational systems and processes, and have the ability to see the big picture and connect the dots, this is the profession for you. The position of risk manager is an engaging one with never-ending tasks and a boredom factor of zero. You’ve heard the phrase “The job is what you make it.” Nothing could be truer in health care risk management. The experience and expertise necessary (or as required in the job description) to carry out the assigned responsibilities and tasks are often discussed, but seldom identified are the other skills or personal attributes that are equally important if one is to succeed as a risk management professional. They include good judgment, common sense, tenacity, intuition, critical thinking skills, the ability to team well and lead well, and excellent communication skills, both verbal and written. These essential personal attributes are generally not specified in job descriptions, are hard to test, and are often difficult to assess during the interview process. This Student Edition offers a blend of necessary technical information and guidance on how to apply that information using the personal attributes just mentioned. “What does all this mean to the risk management professional?” is a question that is answered throughout the book. The Student Edition is thus intended to be both practical and technical. It offers a wide range of expertise from twenty-nine nationally recognized experts on a variety of health care-related risk subjects. Although the focus of responsibilities for the risk management professional has changed over time, the underlying principle of asset preservation through safe patient care has not. Nothing in risk management ever seems to go away; we keep adding to the wealth of information through new practices, procedures, protocols, systems, legislation, technological advances, value-based purchasing strategies, and so on. What has changed is how we evaluate organizational risks, the impact that one risk has on another, and our approach to eliminate or manage those risks through alternative risk financing strategies and risk control initiatives. The field of health care risk management continues to evolve, mature, and expand as the concept of enterprise risk management takes hold in health care organizations. This necessitates that the professionals responsible for managing risk also grow and change. xxvii fpref.indd xxvii 3/3/09 3:03:26 PM xxviii Preface In today’s health care environment, the risk management professional is a facilitator, mediator, negotiator, coordinator, orchestrator, and agent of change. The function has also changed, from employing tactical skills to developing and implementing strategy. Consequently, the role is becoming more proactive and less reactive. What comes to mind is a famous line from the movie All About Eve: “Fasten your seatbelts; it’s going to be a bumpy night.” The challenge for the risk management professional is how to get it all accomplished and in a timely manner given limited resources (financial, human, and time) while preserving our own quality of life. Preparing this book for publication has required the resolve of a dedicated team. I want to express my gratitude and thanks to all the members of the Student Edition and Faculty Guide work group for their determination and commitment to this project: Kathryn Hyer, University of South Florida; Peggy Martin, Lifespan Risk Services; Glenn Troyer, Kreig DeVault, LLP; Sylvia Brown, Premier, Inc.; Ben Gonzales, Montana Health Network, Inc.; Peggy Nakamura, Adventist Health; Kathleen Shostek and Karen Holloway, ECRI; and Joe Pixler, American Society for Healthcare Risk Management. I also extend a personal thank-you to my family for allowing me to miss many meals and stimulating conversations so that I could concentrate on getting this Student Edition ready for publication. A special thank-you goes to Terrance “Red” Carroll, my brother, who continues to support all my efforts. We hope you find this Student Edition easy to use and a valuable resource for your reference library. Welcome to the world of risk management! Roberta L. Carroll, Editor ??? fpref.indd xxviii 3/3/09 3:03:27 PM ABOUT THIS BOOK The goal in developing the Student Edition of the Risk Management Handbook for Health Care Organizations was to offer students of risk management from a variety of backgrounds and settings a handbook that could be used both as a tool for study and as an authoritative reference text for later consultation. The Student Edition of the Handbook is not meant to be the final authority on any risk subject covered but rather an incitement to whet the appetite for additional reading and further learning. That being said, however, a beginning risk management professional desirous of implementing a risk management program could pick up this book and have a comprehensive road map of what to do, how to do it, and why it must be done. The Student Edition begins by addressing basic concepts and considerations such as developing a risk management program, the risk management professional and stages in professional development, relationship with patient safety, legal concepts made easy, and the importance of effective governance. The student then progresses to recognize and understand the complexity and risks associated with medication safety, documentation, noncompliance with statutes, standards and regulations, and accreditation and licensure requirements. Basic claims administration, an introduction to risk financing and its basic principles and coverage, and the different internal and external methods used to identify organizational risks are all covered in a basic, uncomplicated manner. Ethics in patient care, risk management metrics and benchmarking, emergency management, and occupational health and safety, are discussed in terms of organizational culture and environment, organizational preparedness, and measurement. These chapters have been carefully selected for the Student Edition from among the fifty-nine chapters in the three-volume Risk Management Handbook for Health Care Organizations, Fifth Edition. Consideration was given to what could reasonably be covered in a one-semester university course at either the graduate or undergraduate level. Other chapters could have been included, covering a whole host of other subjects (all equally relevant to health care risk management); however, the desire was to keep the Student Edition an introduction to the subject of risk management that can be used as a basic guide. The design of the Student Edition also lends itself to the study of a specific topic by the nonacademic student. For anyone desiring to learn more about health care risk management or to understand a particular topic more fully, this text fits that need as well. To facilitate the learning process, each chapter has been expanded to include learning objectives, key concepts, key terms, and acronyms. The learning objectives at the beginning of each chapter will highlight, in a concise manner, relevant questions xxix flast.indd xxix 3/2/09 1:57:52 PM xxx About this Book the student should be able to answer after reading the material. The key concepts are fundamental principles of the chapter; combined with the learning objectives, they set expectations for the student reader. They identify the focus of the chapter and concepts to keep in mind as they study the material. At the back of each chapter are lists of important key terms and acronyms used in the chapter. These can serve as a quick test to see how easily students can identify their meanings. Health care professionals speak a language of their own. To complement the Glossary at the back of the book and to assist students who do not have a clinical or medical background or may not work in a health care setting, a “Guide to Medical Terminology” has been included in the Student Edition. This book has been developed for the academic environment; therefore, an accompanying Faculty Guide is available online. The Faculty Guide will track each chapter and offer the faculty member, teacher, or learning facilitator additional tools not offered in the Student Edition, such as chapter outlines, case scenarios, vignettes, puzzles, word games, test questions and answers, and other materials supporting specific topics. The Faculty Guide can be quickly updated and new material easily added. In this manner, the teacher can keep the course fresh and up-to-date without changing the core information in the Student Edition. It is anticipated that its shelf life will be long, making it a desirable book to own. Roberta L. Carroll, Editor ??? flast.indd xxx 3/2/09 1:57:52 PM CHAPTER 1 DEVELOPMENT OF A RISK MANAGEMENT PROGRAM JANE J. McCAFFREY, SHEILA HAGG-RICKERT LEARNING OBJECTIVES ? ? ? ? To be able to describe the key elements necessary to have a successful risk management program To be able to discuss three barriers for successful risk management program development and provide at least one strategy for overcoming each To be able to discuss one nonclinical area of related risk for a health care organization To be able to identify the various organizational structures that can be successful in implementing a risk management program 1 c01.indd 1 3/3/09 3:06:41 PM 2 Development of a Risk Management Program Organizations and individuals have always sought ways to identify and reduce the risks that threatened their existence. In primitive agrarian societies, where families and villages produced barely enough to meet their most basic needs, the loss of a year’s harvest, whether to forces of nature or to the plunder of warring tribes, surely spelled disaster. The attempts of such cultures to protect their food supplies and other necessities of life from destruction by fire, flood, and theft represent history’s earliest risk management efforts. As societies developed into industrialized economies, individuals and organizations continued to seek ways to understand and anticipate the risks associated with such perils in an attempt to protect valuable property from such threats, ultimately establishing mechanisms for transferring the financial consequences of such losses through policies of insurance. Despite the age-old concern with protecting assets from the risks associated with accidental losses, risk management has existed for only about fifty years.1 Health care risk management in its present form did not really begin to emerge until the malpractice crisis of the mid-1970s, when hospitals and other health care entities experienced rapid rises in claims costs, and subsequently insurance premiums, and witnessed the exit of several major medical professional liability insurers from the market.2 This crisis formed the basis for health care entities to develop the first risk management programs. The American Society for Healthcare Risk Management (ASHRM; formerly known as the American Society for Hospital Risk Management) was established in 1980 in response to this developing interest in risk management among health care organizations. Over the years, health care risk management has moved from a discipline focused almost exclusively on medical professional liability issues to a profession concerned with all of the risks associated with accidental losses facing a health care organization.3 In addition to hospitals, managed care organizations, long-term care, and ambulatory care, other providers of health care have come to realize the value of effective risk management and have developed formalized programs.4 Increasingly, risk management is moving toward the concept of enterprise risk management and considering the myriad of complex legal, regulatory, political, business, and financial risks facing health care organizations. As risk management moves toward this more strategic orientation and risk management professionals prepare themselves for new roles as chief risk officers, such factors as diverse work experience, higher education, and broad-based business, financial, and technical skills will be valued in health care risk management professionals more than ever before.5 Another recent development in risk management has been the return focus on patient safety. The patient safety movement was prompted in large part by the 1999 publication of To Err Is Human: Building a Safer Health System,6 which articulated the findings of an Institute of Medicine study of the devastating consequences of widespread medical error in the nation’s hospitals. Risk management professionals who had long had primary responsibility for investigating, analyzing, and maintaining data regarding adverse patient incidents joined with colleagues from performance improvement, health care administration, and a variety of clinical disciplines in an attempt to systematically identify the c01.indd 2 3/3/09 3:06:42 PM Risk Management Program Development 3 underlying causes of medical errors in their organizations and to design and implement effective interdisciplinary organizationwide patient safety programs. KEY CONCEPTS ? Risk management as a discipline is focused on all risks of an organization. ? An effective risk management program incorporates several building blocks, including key structural elements, sufficient scope to cover all organizational risks, appropriate risk strategies, and written policies and procedures. ? Risk management as a process uses a five-step management decision-making model. ? Risk management programs protect organizational assets through the delivery of safe patient care. ? Risk management program responsibilities vary in terms of organizational structure, size, scope of services, available resources, management commitment, and location. RISK MANAGEMENT PROGRAM DEVELOPMENT Whatever the health care setting or the sophistication of the risk management professional, an effective risk management program requires certain elementary building blocks: key structural elements, sufficient scope to cover all applicable categories of risk, appropriate risk strategies, and written policies and procedures. This chapter focuses on these building blocks, giving the novice risk management professional guidance in developing a comprehensive risk management program and providing the experienced risk management professional with a program overview that may be used as a self-assessment guide. ??? Developing a comprehensive risk management program depends on addressing several specific considerations. An effective risk management effort is built on key structural elements that enable the risk management professional to develop and enforce a risk management plan and enact the necessary changes in organizational policy. The program must include a defined scope of risks to be managed, including an examination of the risks associated with patients, medical staff, employees, governing bodies, property, automobiles, and other risks that subject the health care organization to potential liability or the threat of loss. Risk management strategies represent the mix of techniques employed to prevent or reduce potential losses and preserve the organization’s assets. c01.indd 3 3/3/09 3:06:42 PM 4 Development of a Risk Management Program The final building block is a set of written policies and procedures that ensures program uniformity and consistency and assists in communication of the program to affected parties. This chapter describes how each of these four important considerations contributes to an effective risk management program. KEY STRUCTURAL ELEMENTS OF THE RISK MANAGEMENT PROGRAM The exact structure of a health care organization’s risk management program depends on the size and complexity of its functions and the scope of other services that it offers. Several key structural components are necessary for any health care risk management program to succeed. Whether an entity is just beginning to organize its risk management program or is seeking to revamp or expand an existing program, attention to these structural factors will help ensure that the program has a solid foundation. Authority The risk management professional in a health care organization must maintain sufficient authority and respect to enact the changes in clinical practice, policies and procedures, and employee and medical staff behavior that are necessary to fulfill the purpose of the risk management program. The risk manager must deal on a daily basis with highly sensitive and confidential information that directly affects the organization’s public image and financial status. The risk management professional is responsible for coordinating risk management activities with members of the medical staff and outside parties and with managers and employees at all levels of the organization. For these reasons, the risk management professional’s position should be relatively high in the organizational hierarchy. Ideally, the risk management professional should report directly to the CEO, or at least to another member of the senior administrative management team. Risk management professionals whose positions rank below the department manager level on the organizational chart will almost certainly face difficulty in dealing authoritatively with medical staff, nursing administration, and department managers. They may also have difficulty gaining access to senior management and representing the organization in its relations with insurers, attorneys, and other outside parties involved in the risk management process. In many nonhospital health care organizations and in smaller hospital facilities, the designated risk management professional may serve primarily as a senior manager or clinician and devote only a relatively small percentage of work time to risk management activities. Under such a model, risk finance and insurance program administration are typically handled by the organization’s finance department, workers’ compensation programs are managed by human resource personnel, and safety programs are developed and overseen by a facility or maintenance manager. Although this division of labor might be efficient for apportioning the workload required for a successful risk management effort, it creates special challenges when establishing ownership of the risk management function and creating an identity for those activities that comprise risk management. Such part-time risk management professionals, especially those who view their risk management c01.indd 4 3/3/09 3:06:43 PM Key Structural Elements of the Risk Management Program 5 responsibilities as subordinate to their other job duties, might find it difficult to acquire the wide range of expertise necessary to adequately fulfill their risk management obligations and to stay abreast of rapidly changing and often complex legal and regulatory developments affecting the field. Visibility The risk management professional should be highly visible in the health care organization. No one individual can perform every function of a comprehensive risk management program single-handed, even in the smallest health care facility. Therefore, it is necessary for the organization’s risk management professional, through consciousnessraising, education, and communication, to foster an awareness of risk management practices and techniques among senior management and the governing body, medical staff members, and employees at all organizational levels. The risk management professional’s position should be structured to enhance opportunities for interaction with others through service on appropriate committees, participation in educational activities such as employee orientation and staff in-service offerings, and access to organizationwide communication mechanisms. Communication As health care facilities have merged into alliances and networks and acquired physician practices, clinics, and managed care organizations to form integrated delivery systems (IDSs), additional issues relating to potential liability, insurance coverage, claims management, and loss control have emerged. To anticipate risk management pitfalls and opportunities in this environment, the risk management professional must be an insider who is provided with information on proposed mergers, acquisitions, and joint ventures early in the due diligence process. Equipped with such information, the risk management professional is in a position to advise senior management on the risk management implications of various new business arrangements, many of which can be substantial but are frequently overlooked by executives not attuned to risk management issues and specific insurance requirements. Coordination Because of the wide range of risk management functions and the diversity of activities necessary for a successful risk management program, the health care organization should establish both formal and informal mechanisms for the coordination of the risk management program with other departments and functions. To adequately integrate and coordinate risk management with other functions, the risk management professional needs to establish reporting and communication relationships with key individuals within the organization: The chief executive officer (CEO) provides a vital link to the entity’s governing board and medical staff and establishes the necessary support for the risk management program. The CEO serves as the key decision maker for many activities crucial ? c01.indd 5 3/3/09 3:06:43 PM 6 Development of a Risk Management Program to the risk management program, such as authorizing the settlement of larger claims and establishing insurance limits. Furthermore, the CEO often heads the team of senior managers responsible for the development of new business opportunities, mergers, and acquisitions. ? The chief financial officer (CFO) may have multiple risk financing responsibilities and provides valuable information for the risk management program. These functions include establishing limits on self-insured retentions or trusts, monitoring the financial operations of captives, and overseeing the performance of actuarial analyses. In some organizations, the CFO is the primary purchaser of insurance coverages and must therefore rely on information provided by the risk management professional to make appropriate decisions regarding risk financing activities on behalf of the organization. ? The performance improvement or quality management director serves as an important source of information regarding adverse clinical events occurring within the facility that have potentially serious risk management implications. The risk management standards promulgated by The Joint Commission (until 2007 known as the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO) emphasize the interdependence of risk management and performance improvement activities.7 Both the development of proactive patient safety initiatives and an effective root cause analysis process for post-occurrence sentinel events depend on the active leadership and close coordination of the risk management professional and performance improvement director. The performance improvement director may also be able to assist a risk management professional who lacks clinical training in interpreting and analyzing information contained in medical records, and in providing clinical loss prevention services. ? The patient safety director or officer is responsible for systematically analyzing the sources of human error and systems issues that affect patient care. Patient safety directors or officers may report to the risk management professional or performance improvement director or to senior management in a health care organization. Patient safety directors or officers are very involved in the development of clinical risk management loss prevention initiatives. ? The compliance officer guides the development of policy and staff education efforts related to legislative and regulatory initiatives such as HIPAA, Sarbanes-Oxley, and Medicare fraud and abuse prevention.8 ? The infection control practitioner (ICP) provides information on patient infections that might give rise to liability claims and can assist the risk management professional in understanding infection control protocols aimed at reducing the frequency and severity of hospital-acquired infections and establishing guidelines for coping with AIDS, tuberculosis, and other communicable diseases. ? The safety officer may have primary responsibility for, or assist the risk management professional in, performing fire safety, hazardous materials management, emergency preparedness, and employee safety activities in compliance with Joint Commission standards. The safety officer usually chairs the organization’s safety committee, which serves as a vital source of risk management information and organizational problem solving. c01.indd 6 3/3/09 3:06:44 PM Key Structural Elements of the Risk Management Program 7 The patient representative (or ombudsman) relays information regarding patient complaints and works with patients and families who have experienced difficulties with the organization or specific staff members to reach satisfactory resolutions of their concerns. Patient representatives, whether employees or volunteers, must be trained to recognize and appropriately manage risk management concerns that arise in the course of their activities and to relay information to the risk management professional. ? The employee health nurse (or workers’ compensation coordinator or personnel director) may, in some organizations, manage the daily operational aspects of the facility’s workers’ compensation program and provide claims and injury information to the risk management professional. Often this individual is instrumental in developing transitional return-to-work and other injury management programs. The risk management professional in some health care organizations is personally responsible for the operation of workers’ compensation programs but must nonetheless coordinate activities with the human resource director and various line managers. ? The health information manager (or medical records director) notifies the risk management professional of requests from attorneys for medical records that might signal initiation of legal proceedings or claims. The health information manager also develops policies and procedures relating to the documentation of patient care activities, patient confidentiality, and appropriate release of information and ensures the organization’s compliance with HIPAA privacy requirements. ? The medical director (or chief medical officer) serves as a liaison between the risk management program and the medical staff and assists the risk management professional in “selling” risk management to physicians. The risk management professional must also work with the medical staff services professional to ensure that the organization’s medical staff appointment, credentialing, privileging, and disciplinary procedures are conducted in accordance with sound risk management practices. ? The patient accounts representative works with the risk management professional to identify patient complaints and concerns that surface during the billing and collections process. Such concerns may be based on perceived patient care problems. They hold the potential for becoming liability claims if collection efforts are vigorously pursued. ? Nursing and departmental managers offer the risk management professional the technical and clinical expertise necessary to identify and analyze potential patient care risks and assist with the investigation of liability claims and incidents. Middle management personnel also play a crucial role in building and maintaining support for the risk management program and in educating and raising the risk management consciousness of employees within their areas of responsibility. ? The education director (or in-service program coordinator) assists the risk management professional in identifying staff education needs pertaining to risk management and in planning, organizing, and presenting orientation and in-service education programs. ? The human resource director maintains responsibility for developing effective job descriptions and performance appraisal processes, employee background checks and competency testing, verification of licenses and certifications, and maintenance of a ? c01.indd 7 3/3/09 3:06:44 PM 8 Development of a Risk Management Program drug-free workplace, all of which are crucial to the prevention and defense of medical professional liability actions. In addition, the human resource staff generally take the lead in preventing and managing claims and complaints related to issues such as alleged sexual harassment, discrimination, and wrongful termination. Accountability Just as risk management professionals need sufficient authority to perform assigned functions, they should be held accountable for that performance. Every health care organization’s risk management professional, including those in small institutions that have job duties in addition to risk management, should have a written job description that outlines key risk management responsibilities. Annual performance appraisals assessing the risk management professional’s achievement of specific, measurable risk management goals and objectives should be conducted to gauge and document the individual’s effectiveness. The risk management professional should submit an annual report to senior management and the governing body that summarizes claims, insurance, and risk management program activities and documents the progress made toward the attainment of established goals. SCOPE OF THE RISK MANAGEMENT PROGRAM The purpose of a health care risk management program is to protect the organization against risks associated with accidental losses, regardless of the cause. One of the building blocks of an effective program is sufficient scope to cover all potential sources of risk. Although many risk management professionals focus on the medical professional liability aspects of health care risk management, the discipline extends into many other areas that are equally important to the survival of the modern health care organization. Defined broadly, health care risk management is concerned with a tremendous variety of issues and situations that hold the potential for liability or casualty losses for the organization. To be truly comprehensive, a risk management program must address the full scope of the following categories of risk: ? Patient care–related ? Medical staff–related ? Employee-related ? Property-related ? Financial ? Other Patient Care–Related Risks Over the course of the last several years, U.S. health care institutions and practitioners have once again experienced a “malpractice crisis” evidenced by rising jury verdicts, c01.indd 8 3/3/09 3:06:45 PM Scope of the Risk Management Program 9 settlement amounts,9 insurance premiums,10 dwindling insurance availability due to carrier withdrawals from the medical malpractice market,11 and the imposition of more stringent underwriting criteria.12 The reduction in insurers’ investment income resulting from the general economic downturn in the early part of the twenty-first century and the huge unanticipated insurance losses associated from the terrorist attacks of September 11, 2001, only served to exacerbate the worsening trends for health care medical professional liability insurers and their insureds. Given the substantial proportion of total health care risk management costs associated with medical professional liability claims and insurance premiums and the current national focus on patient safety issues, it is not surprising that most health care risk management efforts begin with patient care–related issues. Patient care or clinical risk management, including information gathering, loss control efforts, medical professional liability risk financing, and claims management activities, forms the core of most health care risk management programs. Although most patient-related risk management activity focuses on direct clinical patient care activities and the consequences of inappropriate or incorrectly performed medical treatments, other important patient-related issues also confront the risk management professional, including the following: ? ? ? ? ? ? ? ? ? Confidentiality and appropriate release of patient medical information, especially in light of HIPAA and other privacy requirements Protection of patients from abuse and neglect and from assault by other patients, visitors, or staff Securing appropriate informed patient consent to medical treatment Nondiscriminatory treatment of patients, regardless of race, religion, national origin, or payment status Protection of patient valuables from loss or damage Appropriate triage, stabilization, and transfer of patients presenting to dedicated emergency departments (DEDs) Patient participation in research studies and the use of experimental drugs and medical procedures Utilization review decisions related to the timing of patient discharges and the provision of medically necessary services under various third-party managed care arrangements Access to care concerns Medical Staff–Related Risks Closely aligned with patient care–related risk management issues are those experienced by medical staff and other clinically privileged practitioners. Many, if not most, of the c01.indd 9 3/3/09 3:06:45 PM 10 Development of a Risk Management Program potentially serious occurrences related to the delivery of clinical patient care involve a facility’s medical staff. It is imperative that the health care risk management professional include physicians in clinical loss prevention and claims management programs and elicit their support for overall risk management activities. Risk management concerns that stem from the unique relationship between a health care organization and its medical staff merit the risk management professional’s particular attention. Of special importance are the following: ? ? ? ? ? ? Medical staff peer review and performance improvement activities and maintaining the confidentiality and protection of the data generated through such peer review processes Medical staff credentialing, appointment, and privileging processes Medical staff disciplinary proceedings, due process considerations, and potential allegations of antitrust and restraint of trade Identification and treatment of impaired physicians and other credentialed providers who pose a threat to patient or employee safety Business arrangements and financial incentives to physicians that might have fraud and abuse or other implications under federal Medicare regulations13 Physician gatekeeper obligations and incentives under various managed care plans In this era of expanding legal theories of corporate liability and vicarious liability, the activities of the medical staff are often deemed the activities of the health care organization. It has become increasingly difficult for defense attorneys to persuade judges and juries to distinguish between the institution and its independent contractor physicians. As physicians become business partners with health care entities and assume ownership interests in new ventures, and as hospitals and other organizations purchase or assume management of physician practices, the distinctions become even more blurred. Employee-Related Risks Several issues relating to the employment of personnel deserve the health care risk management professional’s attention. Of obvious importance is maintaining a safe work environment for employees, reducing the risk of occupational illness and injury, and providing for the treatment and compensation of workers who suffer on-the-job injuries and work-related illnesses. In this regard, it is important that risk management professionals maintain a working knowledge of relevant state workers’ compensation laws and regulations promulgated by the federal Occupational Safety and Health Administration (OSHA). Such understanding allows them to work effectively with human resource departments, employee health nurses, and designated safety officers to establish successful employee injury and management programs. c01.indd 10 3/3/09 3:06:46 PM Scope of the Risk Management Program 11 Posing particularly serious problems for today’s health care organization are allegations of discrimination in recruitment, hiring, and promotion based on age, race, sex, national origin, or disability; wrongful termination; and other claims filed with the Equal Employment Opportunity Commission (EEOC). Claims involving alleged sexual harassment are also increasingly common.14 The risk management professional must work closely with the facility’s human resource director to help minimize such claims exposures, manage the claims that do occur, and finance the costs associated with such losses. Property-Related Risks Many complex health care entities have significant property assets, including large hospital and clinic structures, medical office buildings, and valuable medical and data processing equipment. It is incumbent on the risk management professional to protect these assets from risk of loss due to fires, acts of God, floods, natural disasters, and other perils that might damage or destroy such property. In addition, health care institutions typically maintain a large volume of paper and electronic records that are essential to the ongoing operations of the entity, and they must be protected from damage or destruction. Obviously, the costs associated with repairing and replacing damaged assets can be significant, and the revenues lost during the period of business interruption can have disastrous effects on the organization. Many health care employees routinely handle cash, checks, and credit cards in the course of their job duties. Hospitals and nursing homes are often requested to safeguard cash and other valuables belonging to patients and residents. Home health workers, who function independently and without direct supervision in a client’s home, are particularly vulnerable to allegations of theft. Thus it is important for the risk management professional to evaluate hiring and screening protocols for such workers, to review policies and procedures for handling cash and safeguarding valuables, and to consider various bonding and insurance alternatives to adequately protect the facility from such losses. Financial Risks Although the ordinary business risks associated with new ventures or services and the continued financial viability of the organization’s existing operations are traditionally considered to be outside the sphere of risk management concerns, there are at least two areas of financial risk with which the risk management professional must be concerned. First, the directors and officers of health care organizations, like those of other corporate entities, may face liability imposed by suits from shareholders or others alleging inappropriate conduct in the fulfillment of the directors’ and officers’ duties. Corporate charters and bylaws frequently require the entity to defend and indemnify its directors and officers against such claims. Likewise, the entity itself may be c01.indd 11 3/3/09 3:06:46 PM 12 Development of a Risk Management Program named in such actions. It is therefore important for the risk management professional to understand the corporate structure of the organization; any requirements imposed by the charter, bylaws, or other documents; and the opportunities to transfer such risks through policies of insurance, to adequately protect the organization’s assets. Second, risk management professionals who represent the interests of health care providers who contract with managed care organizations (MCOs) on an “at-risk” basis (typically through capitated payment arrangements) need to consider available options for limiting the financial risks inherent in such agreements. These risks may be characterized as either specific, in which case the costs associated with providing care to an individual plan subscriber greatly exceed expectations, or aggregate, in which case the total costs of providing required health care services under the plan agreement are higher than anticipated. Various options exist for contractual transfer of risks above a certain level back to the MCO or for the purchase of “stop-loss” insurance coverage. Other Risks There are, of course, other areas of potential concern for the health care risk management professional. Among these are property and liability losses related to the operation of automobiles, trucks, vans, and ambulances owned or leased by the organization. Many facilities also own or operate helicopters or fixed-wing air transport services or maintain heliports or helipads that pose additional liability and property risks. Since September 11, 2001, U.S. health care institutions have become increasingly aware of their vulnerability to terrorist and bioterrorist attack. Organizations have sought to augment existing disaster and emergency preparedness plans to address scenarios in which the facility itself is the target of such an attack and those in which the institution plays a key role in triage and treatment response to an attack occurring elsewhere. Planning for such contingencies requires an analysis of patient care, employee-related and property-related risks of potentially staggering proportions, and the coordination of resources on a local, statewide, and national level.15 (For more information on emergency management, see Chapter Sixteen.) Although typically representing a lesser proportion of the total cost of risk, hospitals and most other health care entities are accessible by the public and vulnerable to a wide variety of general liability claims stemming from visitor injuries caused by slips, falls, and other mishaps. The risk management professional must therefore be concerned with the overall maintenance of buildings, parking lots, and sidewalks and with visitor access and supervision. Hazardous materials management is yet another area of concern for health care risk management. Ensuring that appropriate protocols are in place for the safe storage, use, and disposal of the myriad toxic chemicals and radioactive materials routinely used by health care organizations is a highly regulated and important risk management activity.16 The implications for patients, employees, and the community at large should c01.indd 12 3/3/09 3:06:47 PM The Risk Management Process 13 such materials find their way into the environment are chief considerations in managing hazardous materials programs. Proper disposal of infectious biological waste generated by hospitals and other health c.