This video will focus on the Risk Management Systems: Supplemental Information and ECRI
Institute Resources.
On this slide you’ll see a screen shot of the Clinical Risk Management members’ website
that contains guidance articles, sample policies and tools, toolkits, courses for continuing
medical education credit, self-assessment questionnaires, and other resources you can
download and use in your health centers and free clinics.
Clinical risk management resources are made available by ECRI to you for free on behalf
of HRSA.
Throughout this instructional video, we’re going to be discussing some best practices
that will assist you with preparing the required materials for the risk management systems
portion of the FTCA deeming application, but we’re also going to be referring you to
resources that are available on the Clinical Risk Management website that can help you.
These sample policies and resources are not required, but rather information that you
can review and utilize if you feel it is a good practice that should be implemented in
your health center.
If you are using the policies and resources mentioned in video, you need to make sure
that your health center is actually implementing them and that the resources used are tailored
and appropriate for your health center.
Before you begin filling out the application, you may want to have these documents or items
with you.
The policies you will need to attach to the application and submit to HRSA.
The program assistance letter for calendar year 2013 requirements is for your reference
so you can make sure that you’re meeting all HRSA requirements.
If you are using the policies and resources mentioned in video, you need to make sure
that your health center is actually implementing them and that the resources used are tailored
and appropriate for your health center.
For more information and technical assistance on completing the application, please see
the instructional video, Risk Management Systems: Application Process.
On this slide and the next slide, you’ll see the questions that are included in the
section of the application on Risk Management Systems.
The questions on the application will ask you whether you have these policies and practices
in place and most questions are in a yes or no format.
For the deeming application, you should be able to answer yes to these questions.
If you can’t, there is a comments section provided where you can explain any no answers,
but you should go back to you policies and make sure you revise them to cover these areas.
For three specific areas, referral tracking, hospitalization tracking, and diagnostic tracking,
in addition to documenting on the application form that you have these policies in place,
you are also required to attach your policies to the application form.
If you do not yet have policies and procedures addressing these three areas, there are resources
available on the ECRI Institute Clinical Risk Management Program website that we just mentioned
that can help you.
We’ll show you those resources in a few minutes.
This slide lists some ways that your health center can periodically assess malpractice
risk.
Before using any assessment tool, the health center’s leadership should communicate the
purpose of the assessment to all providers and staff.
An overview of the survey tool should be provided, and the anticipated timeline for performing
the survey should be discussed.
The intent to implement improvement strategies in response to low-scoring areas should also
be conveyed to participating providers and staff.
Once a baseline safety culture survey is completed, it should be repeated at designated intervals,
for example, annually, to measure changes following interventions to establish a more
safety-oriented environment.
Results of safety culture assessments should be communicated to providers, staff, and managers;
a plan to improve the culture through focused interventions should follow.
There are multiple assessment tools and other information on assessment tools available
on the Clinical Risk Management Program website.
You can download any of these questionnaires and tools and use them in your health center.
For this question on the application, rather than checking yes or no, you need to describe
the policies that you have that relate to supervision of clinical and non-clinical staff.
You are not listing the policies you have but rather describing these policies and the
related procedures that you follow in your health center.
It is up to the health center to determine which staff members require direction and
supervision.
Some examples of these staff include, but are not limited to, those listed on the slide.
You’ll want to make sure that your policies specify which staff members require supervision
and who will be responsible for supervising these staff, for example, an independent licensed
provider such as a physician, nurse practitioner, or dentist may be the one who supervises.
In addition, the scope of work for licensed and unlicensed staff and the extent of supervision
necessary must be clearly defined.
The Health Insurance Portability and Accountability Act, or HIPAA, requires privacy policies to
include reasonable safeguards against prohibited use and disclosure of a patient’s protected
health information, steps to mitigate known violations, sanctions for violators, a complaint
process, and documentation procedures.
Detailed information about HIPAA privacy and security regulations is available on the U.S.
Department of Health and Human Services Office for Civil Rights website at www.hhs.gov/ocr.
State statutes, administrative codes, or state medical boards may specify how long physicians
must retain medical records; these requirements should be used to establish the practice’s
policy on medical record retention.
In most states the medical records of adult patients should be retained until 10 years
after the most recent encounter.
Also in most states, medical records of minor patients should be retained until the patient
reaches the age of majority plus time required by the state statute of limitations.
The guidance articles listed at the bottom of the slide are available for more information.
Make sure your medical record policies include what information should be included in the
patients’ medical records.
A list of information that should be included appears on this slide.
This is pretty straightforward.
Grantees filling out the deeming application will need to check yes next to questions asking
whether they have policies addressing triage, walk-in patients, telephone triage, and no-show
appointments.
Some sample policies and forms are available in the Office Administration section of the
Sample Policies and Tools library.
It is important that you click yes next to these questions and the other questions on
the application if you have these policies and you are implementing them.
If you do not have these policies, you need to click on no and provide an explanation
for why you do not have them.
This is also a yes/no answer on the application.
You do not need to specify which conditions are addressed in clinical protocols, but you
just need to check yes to verify that you have them.
On the slide, you can see some examples of conditions for which you might have clinical
protocols.
These are just some examples listed on the slide and this is not an exhaustive list.
Some resources and tools that can help you develop such protocols is available from the
American Academy of Family Physicians at the link on the slide under the section for Clinical
Decision Tools.
As mentioned earlier, policies and procedures for tracking diagnostic tests, patient hospitalizations,
and referrals must be attached to your FTCA deeming application.
Therefore, complete and accurate policies and procedures in these areas is essential.
On this slide, you’ll see important components of policies on tracking diagnostic tests.
Providers are personally responsible for reviewing results of the tests they order.
Policies should designate a staff member such as a medical assistant who can serve as a
backup for these providers by monitoring test tracking logs to ensure results are returned
and acted upon in a timely manner and ensuring providers review results that are returned
to the health center.
Policies should also outline procedures for notifying patients of test results, for example,
by appointment, telephone, or letter, and documenting that the patient was notified.
Special considerations should be made for critical test results.
For example, immediately notifying the patient or enlisting the help of local law enforcement
if the patient cannot be reached with a critical result.
It is important to still have comprehensive tracking policies even if you use an electronic
health record for tracking purposes.
Some examples of what may be included in policies related to electronic health records are listed
on the slide.
The components listed on the previous slide, such as tracking ordered tests and documenting
results, communicating all results to patients, and documenting patient notification should
also still be included in policies when the health center uses an electronic health record.
The test tracking and follow-up toolkit, available on the Clinical Risk Management Program website,
includes a sample policy on test tracking and follow-up that you can download and use
in your health centers, sample test tracking logs, a sample letter to the patient about
test results, and other resources and tools that can help you develop appropriate policies
and practices related to test tracking and follow-up.
Important components of policies on hospitalization tracking appear on this slide.
Policies should outline how you will educate patients and families to notify the health
center when they have been hospitalized and how you will document patient hospitalizations.
There are two resources available on the Clinical Risk Management Program website, a sample
policy guide and a hospital admission and emergency visit log, that can help in your
development of complete policies and procedures on hospitalization tracking.
This slide lists components of a policy on tracking patient referrals.
It is important that your policies state what information should be documented, including
all patient referrals, communication with patients including communication that patients
were informed of the importance of keeping the referral appointments and the risks if
they chose not to keep the appointment, and follow-up with patients who miss appointments,
including the health center’s methods for following up with the patient, whether the
patient was reached, and how many attempts were made to reach the patient.
A frequently asked question related to the Risk Management Systems portion of the FTCA
application appears on this slide.
The question is, what is required to provide sufficient response to question 2 under the
Risk Management section of the FTCA application, identify policies and procedures implemented
regarding appropriate supervision of clinical and non-clinical staff?
The answer to this question is that the health center should provide a brief summary of the
policies that it has in place that delineates how it provides supervision to clinical support
staff such as registered nurses, licensed practical nurses, and medical assistants.
The health center should also describe what it has in place for supervision of mid-level
providers such as collaborative agreements or supervisory agreements.
The next question is, what is a hospitalization tracking policy?
A hospitalization tracking policy should include procedures for tracking patients who have
been hospitalized once the health center discovers they have been hospitalized and ensuring that
the patient is brought back in to the health center for follow up care.
So how do you get to all the resources we just referred you to?
In order to access the Clinical Risk Management website, go to the address listed on the slide,
www.ecri.org/clinical_rm_program.
You’ll need to log in with your username and password; you can see the red circle on
the slide where you enter your log in information.
If you don’t yet have a username and password, please contact ECRI at the contact information
listed on the slide and we’ll get you set up.
In addition, if you need any help finding the resources referred to during this presentation
or any other resources, please contact us.
If you have any questions on the deeming process or application process, please contact HRSA
at the contact information listed on this slide.
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