Dr. Mohamed Mosaad Hasan

MD, MPH, CPHQ, CPPS, GBSS

Discuss various aspects of patient, employee and environmental safety.

Explain workers’ compensation from a risk manager’s perspective.

Define the purpose of a medical record. Explain five legal essentials of a contract. List and explain three elements of a risk management

review of an organization’s mergers, acquisitions, and divestitures

Create a list of exposures that deal with organizational advertising liability.

Job descriptions with quantifiable physical-based criteria.

Employee pre-placement physical evaluations.

Baseline examinations.

Specific skills required for position.

Employee health program.

Accident prevention program.

Interaction with injured employee.

Provide sure, prompt, and reasonable income and medical benefits to work-accident victims.

Provide remedy and reduce court delays, costs, and workloads arising out of personal injury litigation.

Eliminate payment of fees to lawyers and witnesses.

Encourage maximum employer interest in safety and rehabilitation.

Promote study of causes of accidents.

Risk Control and Loss Prevention

– Proactive program; not just reactive.

– Accident prevention plans.

– No retaliation for reporting.

– Accidents, illnesses, and near misses are

Investigated.

– Feedback on program effectiveness.

– Safety orientation and training.

Other Issues– Pre-placement Program; Drug screens and physical exams.

– Post-employment Programs Employee assistance and wellness programs

– Ergonomics - the science of designing work tasks to fit the employee rather than forcing the employee to adapt to the job requirements.

Management of Workplace Risk– Employment handbook.– Employee orientation process.– Harassment policy.– Protection against violence in the workplace.– Regulations of wages and working hours.– Drug and alcohol testing.– Guidelines for personnel records.– Educational programs that address provider andstaff behavioral issues.

Human capital risks – refers to employee events and behaviors that occur both in and out of the workplace that prevent employees from being on the job or being fully productive, and that negatively affect operational and financial results.

– Leadership issues.

– Work processes.

– Employee attraction and selection.

– Absence/health and wellness.

– Employee retention.

Components of an Effective Absence Management Program

– Return to work programs.– Medical case management.– Absence reporting.– Absence tracking.– Disability prevention. Disease Management Employee Health & Wellness Programs Safety & Accident Prevention Employee Assistance Programs

Safety Program and Environment of Care (EOC)

– Mission and policy statement.

– Membership of the EOC Committee.

– Subcommittees of the EOC Committee.

– Role and responsibilities of the safety officer.

Purpose: To ensure that buildings, grounds, equipment and systems pose no hazards to occupants

Prevent accidents

Maintain safe conditions for patients, families, visitors, and staff

Reduce and combat hazards and risks

Facility Inspections

– periodic

use of checklists

by whom: “safety officer”

unit leaders

‘real estate’ owners/occupants

including laboratory and radiology

Preventive program

Periodic evaluations

How often

Recording of findings

Initiate corrective actions/ work requests/ etc.

Forward findings to the hospital safety committee

Active program

Management of accidents: staff, visitors, and patients

Incident reports; format or form

Employee accidents; form

To safety officer

To safety committee

Role of Safety Committee to analyze data

Forward data /analysis to Quality Improvement Committee

Coordination with Lab and X-ray safety programs

Training program

– management of hazardous material

- training in safety awareness.

Purpose: To protect the security of the staff, visitors, patients

Responsibilities:

Security Officer – responsibilities……….

Department and other leaders responsibilities

Unit leader responsibilities………..

Access to hospital

Control of entrances and exits

Check points in hospital

After-hours checks

Sporadic, random checks

Coordination with Police – communication, phone numbers

Identification Badges and picturesRequirement for staffVisitor badgesContractor badgesVolunteers identification

Telemonitoring of corridors, Parking lots, garages, etc.Screening/detecting – visitors, families, contractors, etc.Periodic drill to challenge effectiveness

Security alert code

Purpose: To ensure all occupants of the organization’s facilities are safe from fire and smoke

To Follow laws and inspections by local authorities

Reduction of risk

Guidance on storage of flammables.

Types of cabinets; locations; central location; warning signage

Guidance on location(s) of storage

Guidance on how to store

Fire safety checklist for monitoring (by hospital fire specialist, unit supervisors, etc)

Report of monitoring to hospital safety group

Managing risk during adjacent or internal construction

Safe exits maintained.

Signage for altered fire exit routes.

Orientation of construction workers (e.g, hospital is no-smoking facility, safety practices).

Early warning detection

Alarms (wall boxes, phones, triggers).

‘Codes’ and meaning.

Fire number to report or alert system to initiate.

Automatic monitors/reporting.

External notification

Automatic, someone’s responsibility.

Suppression

Automatic closure of fire doors.

Automatic ventilation control or shutoff.

Sprinkler systems.

Fire hoses, extinguishers.

Fire door requirements (location in long corridors, stairwells, etc., construction of doors).

Responsibility for shut off of O2 and other gases and utilities.

Inspection of equipment – frequency of testing, maintenance of equipment.

Education of staff in:

Fire response (? Use of an acronym – “RACE”)

Fire equipment use (? Use of an acronym – “PASS”)

Responsibilities and methods of evacuation of patients

Management of patient support equipment (oxygen, IV’s, ventilators, temp control, etc)

Testing and documentation of successful learning and understanding

Plan for twice-a-year testing including

Management of patients, visitors

Use of alerting and suppression equipment

Localized or general responses

Documentation of exercise, participants, critique, lessons learned

Report to safety and leadership

Orientation for new staff to fire and smoke safety

Purpose: Emergency Response Plan – Plan(s) to respond to natural, manmade disasters and epidemics.

External plan: working with community resources -: Police – directing traffic, allowing hospital personnel to

pass Special ID for staff identification. Communication – backup systems between hospital and

municipality, etc. Security – limiting access to property, guards at doors, etc Civil defense. News – determining news ‘room’ or location, hospital

spokesman Ambulance services Testing recall system

Internal plan:

Triage (entry) points in hospital.

Triage methodology and supplies.

Identification of teams, membership of teams and numbers of teams.

Identification of location of teams within hospital.

Communication with staff

Command center.

Special phones for staff.

Notification of inpatients Who is responsible? What is told? HowBed space utilization What is done to create space in hospital for admissions? Cancellation of all surgery? Movement of or discharge of inpatients? Who decides?

New locations?

Registration supplies/pre-prepared charts at entry and surgery areas.

Training of staff – frequency, trainers, location, etc.

Testing of staff: Yearly exercise to include:

Documentation of attendees during exercise

Follow-up critique of exercise (or real life disaster)

Report of exercise and critique to

-hospital safety – to improve plans

-leadership – for budget, planning

Plan addresses: Hazmats Chemotherapy Radioactive materials and waste Hazardous gases and vapors management Medical and infectious wastes

Preventive management plan for each type of hazmat describes:

Proper use of Hazmat Proper handling of Hazmats (various color bags,

containers) Proper storage of Hazmats Proper destruction or removal of Hazmats

o Minimal equipment required to handle various Hazmats.

o Minimal equipment required for spills, exposure to Hazmat

Spill kits

Personal equipment

o MSDS sheets at site of Hazmats.

o Proper labeling of Hazmats/ wastes.

o Method to report incidents.

o Surveillance to ensure compliance -

periodic evaluations

checklist

forward to safety officer and committee

Purpose: To ensure that medical equipment is available for use and functioning properly.

Definition of medical equipment – priorities, life-sustaining vs. non life-sustaining.

Inventory of all equipment – numbering tag system

Who performs?

What process?

Where recorded

Inspection of equipment By manufacturer or supplier By hospital Self, bio-maintenance, or contract By priority (category) including frequency and scope of

inspection Documentation of inspections

Tagging of equipment and required information on tagLogging in central book (? and at location site of equipment)

Testing of equipment By category Per manufacturer’s instructions Before infrequent use, when coming out of storage Documentation of testing

Preventive maintenance requirements

By whom? How recorded?

Equipment brought into hospital for evaluation, trial? (responsibilities of hospital, bio-maintenance, salesmen, staff, etc.)

Training of staff on equipment

Defibrillators for code responses.

Use of ‘laboratory’ equipment in hospital by non-lab personnel (glucometers, etc.).

Monitors, perfusion pumps, etc., in work area.

Other equipment staff uses and maintains

Quality control procedures and documentation

Equipment management team To prioritize purchases vs. hospital mission and strategic

plan To address upgrades and replacements To address problem areas Representative from or liaison with Safety group

Data collected Forwarded to Safety committee, leadership (planning, budgeting), quality oversight committee.

Purpose: To ensure that electrical, water and other utility systems are maintained to minimize the risks of operating failures.

Identification of areas of vulnerability for failure in:

Lighting/illumination

Refrigeration

Life support

Water

Dialysis service

Sterilization of supplies

Ventilation

Plumbing lines, others.

Monitoring for performance or failure: in hospital, In units, In pieces of specific equipment.

Provision of emergency power and water for these systems

Generators (size, load, number, backup, fuel).

Reservoirs (size, location, duration of supply).

Testing of equipment

Generators: frequency, under load, not under load, documentation and reporting.

Water/reservoirs: frequency, type (bacteriologic, chemical analysis).

Dialysis equipment; (bacteriologic, chemical analysis).

Documentation and forwarding of reports (safety committee, leadership).

Preventive maintenance

Analysis of failures

Monitoring

Documentation and reports

Forwarding of reports:

To safety committee

To leadership

To quality and patient safety oversight committee.

Environmental Issues

– Underground storage tanks.

– Aboveground storage tanks.

– Asbestos removal.

– Disposal of hazardous waste.

– On-site medical waste incinerators.

Environmental Issues in Acquisitions

– Inspection of the property.

– Records review.

Four Steps

– Prevention: establish excellent internal reporting

systems

– Preparation: develop an effective, comprehensive

emergency response plan

– Implementation/response: practice the plan so

everyone knows the steps and their roles

– Recovery: manage the financial, physical, and

emotional challenges expeditiously.

Requirements

– The Joint Commission requires at least one drill annually.

– Tabletop drill does not fulfill requirement for a drill.

– Each drill should be evaluated with identified concerns addressed appropriately.

Purpose of the Medical Record

– Primary communication medium for planning,

coordinating, and orchestrating patient care.

– Legal document.

– Defense against malpractice claims.

– Basis for many other important activities.

Documentation

– State statutes,

– Professional practice standards,

– Specific health care facility protocols,

– Third party payers,

– Accrediting organizations,

New variations of old concerns introduced by new information technologies.

Electronic Patient Records

– Confidentiality and security issues

– Accessibility and durability

– Accuracy and evidentiary concerns

– Security.

Risk Manager’s Role

– Monitor to assess quality of documentation

– Communicate regularly with the Medical Records Committee

– Educate the clinical staff

Contract: an agreement between two or more persons that creates an obligation to do or not do a particular thing.

Five Legal Essentials

– The parties to the contract are competent

– The contract represents mutual understanding

between the parties

– There is consideration; a bargained-for exchange of

legal value exists between the parties

– The contract is documented in writing if required for

legal enforcement in the state

– The purpose or object of the contract is legal

Confidentiality Provisions

– Confidentiality and privacy issues

– Negligent disclosure

– Legal counsel for developing sample confidentiality provisions

Contract File Management

– Reviewing or filing

– Insurance certificates.

– Tickler system

– Policy and procedure development

Directors and Officers’ Liability Prevention

Mergers, Acquisitions, and Divestitures

Partnerships, Joint Ventures and Collaborative Relationships

Advertising

Determination of potential areas of board liability exposure: discrimination, hazardous management, medical staff.

Assessment of the degree of liability exposure in such areas: credentialing and privileging.

Implementation of corrective action to minimize liability exposure in high risk areas or activities: revise policies and procedures.

Concept of Successor Liability

– Stock acquisition: normally the acquiring company assumes all legal liabilities

– Asset purchase: normally there is no transfer of liability

– Successor liability: the acquiring company can be held liable for the torts of the target company’s previous owners.

Key Steps in the Due Diligence Process– Determine what information is crucial– Assign responsibility for data gathering and collect information.– Organize the various pieces of information and analyze the exposures to loss.– Assess the loss prevention and risk financing programs

– Evaluate effectiveness of organization’s risk management policies and procedures

– Express in summary form the key issues

Partnership: voluntary contract between two or morecompetent persons to place their money, effects, laborand skill or some or all of them in lawful commerce orbusiness, with the understanding that there will be aproportional sharing of the profits and losses betweenthem.

Joint Venture: a legal entity in the nature of a partnershipengaged in the joint pursuit of a particular transaction formutual profit.

Collaborative relationship: those in which partiescooperate in an endeavor related to the needs of one orthe other or both.

Evaluating Potential Business Partners– Areas of Focus Compliance Directors and officers’ coverage Document review Environmental assessment Errors and omissions General liability Product liability Professional liability Property coverage Workers’ compensation

Regulatory Implications

False advertising might be proven if there is nocompetent and reliable scientific evidence to supportthe claims made.

Managing Advertising Liability Exposures

– Know the standards related to health care advertising.

– Know the organization’s marketing philosophy.

– Partner with the marketing director.

– Review proposed advertising initiatives.

– Avoid statements about success rates or outcomes.