Risk Management Assesment

Risk Management Assessment

Baptist Hospital of Miami is currently analyzing the possibility of developing risk management strategies that will ensure to meet all needs or the organization related to quality management. Every plan needs to be approved by every member of the board of directors. The purpose of the Clinical Risk Management Plan is to support the vision and mission of Baptist Hospital of Miami as it pertains to risks associated with the safety of employees, patients, visitors, volunteer, staff, third parties; also operational risks and property risks. The risk management plan will basically guide the process of development and implementation of a risk management program. The risk management promotes the philosophy of Baptist Hospital of Miami that the risk management and patient safety is responsibility of members of the organization and team cooperation is essential for an effective and efficient functioning. Baptist Hospital of Miami believes that organizational errors should be addressed through the implementation of evidence-based practices, constructive feedback, and learning from error analysis. Clinical errors should be addressed by using the following: • Proper report and analysis of errors related to medical or patient care. • Proactive identification of hazards and unsafe conditions. • Open discussions of mistakes. • Open acceptance of system improvements. The Risk Management Plan at Baptist Hospital of Miami promotes the development, revision, and review of practices and protocols within the organization by taking in consideration risks, loss prevention, and reduction strategies. Disciplinary actions can be taken if evaluated and investigated errors show evidence of willful violations of organizational policies. Specific policies and procedures are developed for the assessment of daily risk management activities; including the following: • Education of provider and staff including: competency validation and credentials. • Investigation, analysis, and follow up of events. • Information confidentiality and release. • Claims Management. • Management report of adverse events. • Trend analysis of claims and events.

Successful development of Baptist Hospital risk management program requires constant support and commitment from every member of the organization. Authorization of the program and adoption of the plan is done by leaders of the board. Leaders are required to promote safety standards for every patient, employee, visitors, volunteers, and third parties involved in the health care organization. The risk management program is developed with the goal of reducing errors in the system and unsafe condition through the implementation of continual strategies of improvement to promote safety and support of organizational culture. Management and leadership teams are responsible for implementing risk management and performance improvement strategies. The Risk Management Program’s main objective is to constantly upgrade patient safety and to prevent or decrease the occurrence of system breakdowns, unfortunate events, and mistakes that can result in the harming of patients, volunteers, visitors, and staff through patient safety activities and proactive risk management. The program also diminishes the possibility of loss to the organization by investigating, identifying, terminating, and having control over possible clinical, business, and operational risks in order to help and accelerate the compliance with the regulatory, lawful, and qualified agency provision. Other operational departments and services are also linked to the risk management program. Operational department and services may include: • Human Resources department • Information Technology department • Marketing • Quality Performance • Therapeutics and Pharmaceuticals • Staff Education • Incident report and investigation • Billing department • Disaster preparation and management Occupational responsibilities of risk management include: A. Expanding the systems and overlooking the accounting of conflicting events, close calls, and possible unsafe conditions. B. Assigning the responsibilities of administrative, regulatory, and voluntary organizations. This can incorporate the advancement and utilization of event reporting methods and approaches. C. Guaranteeing the analysis as well as the acquisition of information to control the consequences of procedures that can bring in risks or that may involve the occurrence of unwanted events. The risk assessment consists of system analysis, effect analysis, failure mode, and many others. D. Overlooking the organizational RMIS for processing and collecting, data analysis, and the production of statistical trend report. The system consists and uses following: • Event Reports • Patient Complaints • The input of medical professionals • Incident reports, • Etc. E. Ensuring agreement with the acquired information and accounting for the requirements of managing, administrative, authorized agencies. F. Making the process simple and guaranteeing the application of patient security actions such as medication safety systems, diagnostic tests, and falls prevention program; also improved tracking systems for preventive screenings. G. Providing assurance of staff participation in academic and informational programs on risk management and patient safety. H. Reducing the changes of acquiring a lawsuit by coming up with an acceptable and applicable patient communication and informative agreement. This consists of contacting immediate family members of the patient and discussing every event and any errors that may have occurred in the time that the patient was under the care of the facility with an effective plan to deal with complications. I. Filling the organization in on different strategies that can be used to prevent threatening situations from happening and also improve safety of the patient’s surroundings, which would also protect volunteers, visitor, and staff members. J. Adding high quality evaluations and advancement programs al around the organization. K. Applying programs that comply with legal, supervisory, and accreditation requirements. L. Decreasing the chances of unfortunate events that may bring terrible losses to the equipment and physical plant. M. Establishing a committee focusing on patient’s risks as well as their safety that also includes representatives from administrative and clinical departments. N. Minimizing the possibility of death to the organization and not forgetting to protect the human, financial, and any other resources in the organization. O. Analyzing the effectiveness and capabilities of patient safety and risk management actions. Performance examination data includes: • Research data. • Continuous risk assessment information. • Claims and claim trends. • Patient’s concerns on whether or not the organization meets their needs. • Quality performance data. Following the above mentioned guidelines will ensure that organizational goals are met for quality management purposes. Because risk management and patient safety is the responsibility of every member of the organization, it is crucial that a leadership team steps up as an example to follow. The risk management assessment will help the Baptist Hospital of Miami to protect and maintain the safety of patients, employees, volunteers, third parties and property risks.
References
ECRI Institute. (2010). Sample Risk Management Plan for a Community Health Center: Patient Safety and Risk Management Program. Retrieved from: http://bphc.hrsa.gov/ftca/riskmanagement Baptist Health South Florida.(2011). Baptist Hospital of Miami: Quality and Patient Safety. Retrieved from: www.baptisthealth.net/en./quality-safety/pages/default.aspx
Upstate Medical University.(2007). Professional and Health Care Providers: Risk Management Program. Retrieved from: www.upstate.edu/uha/risk/program.php The Art of Patient Care. (2009). Health Care Risk Management Plan
Retrieved from: www.art-of-patient-care.com/health-care-risk-management.html

INTRODUCTION
Mabini General Hospital is committed to providing consistent, exceptional health care that is responsive to the patient’s individual needs. As part of this on-going commitment, the hospital delivers health care that is safe, effective, patient-centered, timely, efficient, and equitable. We believe these six aims form the foundation for living our mission to improve the health and well-being of our patients.
To be Safe means providing care in a responsible manner in a secure environment
To be Effective means providing the very best care that integrates scientific knowledge with clinical expertise and patient values
To be Efficient means to avoid waste in the delivery of health care
To be Timely means reducing delays for those who give and receive health care
To be Equitable means to provide equal care to everyone regardless of gender, ethnicity, or economic status To be Patient-Centered means providing care that holds the patient above all else and is respectful of, and responsive to, individual patient preferences, needs, and values

QUALITY ASSURANCE PROGRAM Quality assurance program is the process of ensuring that clients receive the agreed-upon level of care through the setting up of standards, monitoring practices, evaluating practice problems, and resolving practice problems. Dimensions/Characteristics: 1. Appropriate health services are available and accessible 2. Health care is effective, that is, desired outcomes for clients are obtained 3. Health service is equitable, that is, priority is given to the most needy 4. Health interventions are safe and are based on professional and agency standards 5. Good interpersonal relations are based on nutual respect 6. Presence of proper coordination among different health workers and a working referral system 7. Efficiency and economy in provision of services

THE QUALITY MANAGER The Quality Manager reports directly to Hospital Administrator and is delegated authority and organizational freedom to identify and evaluate quality problems and to initiate, recommend or provide solutions. Responsibilities The Quality Manager is responsible for: a. Update and distribution control of the Quality Manual as required. b. Planning to meet customer's quality requirements. c. Determining inspection points within the system. d. Approval of quality work instructions. e. Directing inspection activities. f. Surveillance of procurement documents. g. Approval of Suppliers. h. Maintaining a listing of approved suppliers. i. Monitoring procedures to assure compliance j. Reviewing and maintaining Quality Records. k. Calibration of Measuring and Test Equipment. 1. Approval of disposition of Nonconforming Articles m. Corrective action coordination

QUALITY ASSURANCE WORK PLAN

The Quality Assurance Program will perform semi-annual and annual medical reviews to assure Internal Quality Assurance Program activities meet standards and are in compliance with State regulations and contractual agreements.

THE MONITORING PROCESS

Monitoring is an essential process for utilization management while determining unique performance awareness, utilization, patterns, and oversight.
The Quality Assurance monitoring and review process is an ongoing assessment that will strive to promote continual quality initiatives and improvements. Initial review areas may be revised and/or updated as necessary to reflect quality concerns in our changing health care environment.

THE REVIEW PROCESS

The MGH must maintain an effective utilization management program which identifies instances of inappropriate utilization (over and under), identifies aberrant provider practice patterns, ensures active participation of a formal review committee, evaluates efficiency and appropriateness of services delivery, facilitates program management and long-term quality, evaluates quality of care, and promotes continuous quality initiatives and improvements. In order to insure that Mabini General Hospital furnishes quality and accessible health care to enrolled recipients, the Quality Assurance Program (QAP) conducts semi-annual audits to determine that there is an effective internal quality assurance system in place. These audits are usually conducted in June and December and may be performed onsite or documentation may be sent to the QAP.
FINANCIAL ALLOCATIONS Just as the allocation of personnel needs to be planned and modified to ensure enhancement in the quality of care given to patients, so do financial allocations. The director of dietetic services makes budget requests on an annual basis and needs to have justification for changes in cost-center allotments r budgetary increases. Quality Assurance provides the justification based on reviews that were conducted. The results help to show the departmental functions and cost-centers that are in need of reallocation of funds or increase financing, and how the quality of care can be improved upon the approval of proposed budgets. By doing this, the purchases of food, equipment, and supplies in terms of how allocation will enhance patient care. It will be up to the department staff to ensure that there is indeed a positive outcome after the investment is made

MANAGEMENT OBJECTIVES

Many health care facilities employ techniques of Management-by-Objectives. The Administration calls for specific departmental objectives each year with time-tables for attaining these objectives.
The objectives set by each department head should conform to the facility-wide objectives. Methods for achieving these goals are normally outlined with descriptions of resources to be utilized and measurable outcomes to be expected.
Since the primary goal of dietetic service is to provide high quality nutrition care and most management objectives fall into this realm, The QAP is convenient mechanism for identifying objectives that should be included and for determining the present status of the department with regard to each specific management objective selected. High priority issues revealed in the QAP should be addressed. The method used to collect and analyze data in the QAP can be used to objectively measure the outcome and progress of departmental efforts as the time-table is implemented. It is difficult to identify whether or not the objectives have really been met without acceptable methods for quantifying results.