RISKS CONTROL1 CONTROL 2 Failure to track and secure supplies perpetual inventory system locked/secure supply area Lack of adequate supplies just-in-time ordering system Lack of adequate equipment equipment maintenance plan management knowledge of current technology Failure to track and secure equipment property inventory system check-out log Improper or inadequate maintenance of equipment properly trained technicians equipment maintenance plan Lack of current technology management knowledge of current technology budget for capital outlay & supplies Lack of inventory controls over drugs (incl. disposal of expired drugs/wastage) perpetual inventory system monthly check for any expired drugs Failure to charge for drugs dispensed segregation of duties supervisory oversight of distribution log Lack of inventory controls over supplies perpetual inventory system limit access to supply area Failure to charge for supplies segregation of duties limit access to supply areaCONTROL 3 CONTROL 4 CONTROL 5 management oversight periodic physical inventory counts locked/secure area management oversight periodic physical counts drugs maintained in secure area distribution log periodic physical countsRISKS CONTROL1 CONTROL 2 Inadequate number of staff predetermined staffing levels streamlined hiring process Staff does not have proper licenses or credentials obtain copy of licenses prior to hire verify with licensing agency Failure to supervise and assess all other clinical staff management supervisory training periodic evaluations Lack of on-going training and education training policy budgeting for training costs Lack of a diverse workforce adhere to Federal discrimination laws Inadequate supply of nurses hiring incentives (money, schedule) streamlined hiring process Failure to attract and maintain quality faculty (recruitment) up-to-date technology innovative environment Inadequate supply of physicians hiring incentives (money, schedule) streamlined hiring process Failure to apply tenure requirements consistently maintain a tenure committee Documented policy and procedures for granting tenure Lack of recruiting resources budgeting for recruiting Lack of time to recruit dedicated staff for recruiting Failure to train employees in infection control, etc required training tracking mechanism (training database) Lack of adequate radiological monitoring systems Use of monitoring badges Failure to ensure employees have appropriate immunizations maintain and track up-todaat shot records Lack of appropriate disposal systems for contaminated waste hazardous waste containers in each room Documented hazmat waste management policies and procedures lCONTROL 3 CONTROL 4 CONTROL 5 adhere to job qualifications requirements job descriptions training Contract for removal of HazMatRISKS CONTROL1 CONTROL 2 Aging population maintain adequate facilities and staff to accommodate Bad payer mix guidelines for what carriers to accept Declining reimbursements from carriers Lack of first rate clinical facilities strategic planning maintenance plan Uninsured turn them away find alternate funding for the uninsured Loss of competitive advantage Complex regulatory environment competent compliance officer comprehensive compliance plan Bad contracts hiring qualified contract personnel training of contract personnel Dissatisfied patients send patient surveys and evaluate results customer service training Insurers going bankrupt maintain reserve fund Monitor all payers for financial viability Loss of productivity (tenure mix) productivity-based pay plan Failure to recognize and assess changing demographics evaluation of external environment Failure to recognize revenue generating capacity of materials, etc not needed for patient care Untrained employees comprehensive training program and monitoring of completion Excessive use of temporary employees Failure to properly manage temporary agency employees training Lack of an adequate marketing program budget appropriately for marketing needsLack of adequate strategic planning process strategic planning committee formalized strategic plan Lack of adequate governance process Lack of effective compliance program competent compliance officer formalized compliance policy and proceduresCONTROL 3 CONTROL 4 CONTROL 5 Defined level of charity services policy regarding who is authorized to negotiate/accept employee incentives for good customer serviceRISKS CONTROL1 CONTROL 2 Alienation of partner hospitals monitor interrelated activities Lack of faulty marketing program Lack of faculty disciplinary program formal disciplinary policy Failure to adequately monitor and document residency programs training for program requirements maintain accreditation Failure to maintain adequate faculty/student/support ratios monitor and evaluate ratios Failure to define faculty criteria for teaching, research, and clinical practice activities well-defined job descriptions Lack of adequate faculty grievance system documented faculty grievance process Failure to maintain adequate performance and financial monitoring systems over faculty activitiesCONTROL 3 CONTROL 4 CONTROL 5RISKS CONTROL1 CONTROL 2 Failure to supervise and assess students/residents training policies and procedures Failure to maintain accreditation training policies and procedures Failure to maintain state/federal funding Lack of recruiting resources budgeting for recruiting Lack of time to recruit dedicated staff for recruiting Failure to maintain Medical Board pass rates continuous curriculum development Failure to comply with applicable animal care regulations training policies and procedures Lack of an animal security program Lack of adequate monitoring of research activities centralized oversight of research Lack of adequate review of research design by the IRB checks and balances Documented P&P Lack of a grant assistance programCONTROL 3 CONTROL 4 CONTROL 5 implementation of standards department to oversee (IACUC)RISKS CONTROL1 CONTROL 2 Info is not captured and organized to facilitate decision-making training Lack of real-time patient information (interconnectivity) Info is not secured to ensure privacy and integrity training policies and procedures Info is unavailable when needed for patient care Info is improperly altered or deleted because of processing error Segregation of duties Access controls/limitations Info is improperly altered or deleted because of unauthorized access read-only access (where appropriate) segregation of duties No business continuity process or plan is in place create a business continuity plan Test business continuity plan Inappropriate access of information (HIPAA) management review access controls/limitations Info is unavailable when needed for noncaar purposes such as regulatory or research Unauthorized release of Health Information (HIPAA) training periodic confidentiality statement Inefficient report functionality for providing healthcare information Failure to account for disclosure of information not requiring authorization (HIPAA)CONTROL 3 CONTROL 4 CONTROL 5 management review/monitoring Review of audit trail Management monitoring/review audit trail review management review policies and procedures Need-to-know accessRISKS CONTROL1 CONTROL 2 Misuse or inappropriate use of controlled substances prescribed to patients physical safeguards perpetual inventory system Lack of a valid Bioethics/Clinical decision making function Giving preferential access, treatment, or billing to selected groups or individuals policies and procedures training Improper billing (Fraud) independent review of charts Failure to prevent patient abuse monitoring Failure to provide a trusted mechanism for reporting and resolving abuse complaints hotline Lack of an adequate system for tracking incurred but not reported or billed services Documented P&P for non billed tracking Failure to properly identify and monitor hazardous materials training policies and procedures Failure to properly store and dispose of hazardous materials training hazardous waste containers in each room Failure to properly train all staff in the use of hazardous materials Failure to assure that staff has adequate sleep and is not otherwise incapacitated Lack of a proper incident alerting mechanism Lack of an adequate peer review mechanism Failure to take action on peer review findings tone at the top Lack of an adequate system to analyze incidents and develop institutional memory Lack of an adequate patient safety program Lack of patient info for managing drug interactionsInsufficient control over organ donor listCONTROL 3 CONTROL 4 CONTROL 5 exceptions to policy approved by management policies and procedures Contract for disposalRISKS CONTROL1 CONTROL 2 Clinical data does not support billing independent review of charts Inaccurate coding training Failure to maintain Charge Description Master Duplicate record of services created Failure to capture all charges independent review of charts Failure to collect co pays and balances due at time of service training policies and procedures Failure to comply with regulatory standards (Medicare, HIPAA, etc) training policies and procedures Failure to file a clean claim independent review of charts Failure to obtain required pre-certification or approval training policies and procedures Inaccurate claims or billing due to system errors Failure to file a claim or bill the patient reconciliation of records Fraudulent claim or billing independent review of charts Failure to manage credit balances policies and procedures Review of credit balances Failure to write-off uncollectible debts policies and procedures Management approval required Inconsistent collection effort by payer mix Untimely billing of services provided Not being paid in accordance with contracts contract monitoring Cash theft Segregation of duties Cash countsImproper allocations back to departments Inaccurate info given to dept administrators Failure to follow P&P training Not utilizing software to capture financial transactions training knowledgeable personnelCONTROL 3 CONTROL 4 CONTROL 5 Review of billings and receivables Reconciliations Review of deposits and support documentation Forced time-offDocumentation of policies and proceduresRISKS CONTROL1 CONTROL 2 Loss of external partners Relationship Management Image negatively impacted by external partners Wrong patient mix between indigent and paying Incomplete or unenforceable contracts with partners Failure to comply with contract terms (including resource capacity) Failure to consider all costs Lack of competitive intelligence for decision making Bankruptcy of external partners Lack of security of patient's property Provide poor quality services Failure to provide adequate employee safety programsCONTROL 3 CONTROL 4 CONTROL 5RISKS CONTROL1 CONTROL 2 Failure to adequately assess and reassess patient needs Failure to coordinate care Effective communication Failure to develop a plan of care Failure to document treatment and services provided Failure to follow care plan Lack of services and treatment that meets patient needs Lack of timely access to treatment or services Failure to address the need for continued treatment after discharge or transfer Failure to educate and train patients regarding their care and treatment Failure to share information with other providers Errors or negligence in patient care Proper training Failure to comply with regulatory standards Failure to monitor the quality of care provided Loss of unconditional JCAHO accreditation Training of JCAHO requirements Policies and procedures Failure to adhere to ethical practices (patient advance directives, culture diversification) Failure to provide/monitor the patient complaint process Failure to control infectious diseases Practice outside the standard of careMisuse of controlled substances Improper handling of hazardous materials Training Mismanagement of patient records Training Policies and procedures Improper patient information release Training Policies and procedures Drug interaction due to lack of patient info Medical record request form Insufficient controls on organ donor list Lack of an adequate discharge and termination process Lack of control over the laboratory, pathology, and other diagnostic services Lack of adequate nursing staff Hiring Incentives Lack of adequate ancillary personnel Failure to properly handle a patient death Training Failure to adjust bed/service allocation to demand Failure to obtain accurate patient info Failure to obtain accurate patient info Failure to comply with 72 hour rule Failure to protect patient's valuables Lack of a system to ensure compliance with EMTALA in emergency roomCONTROL 3 CONTROL 4 CONTROL 5RISKS CONTROL1 CONTROL 2 Lack of an adequate Emergency Management Plan Failure to adequately test the EM Plan Inadequate functional space to meet patient demand utilize proper forecasting methods Prepare a master plan for facilities Failure to maintain facilities maintenance plan Lack of security monitoring by the police department security cameras Unsafe or hazardous environment Lack of comfortable and welcoming environment Failure to plan for Business Continuity develop business continuity plan Test business continuity plan Lack of sanitation levels commensurate with patient needs Lack of an adequate infection control process training policies and procedures Improper disposal of bodies outsource disposal training Disastrous physical event destroys building(s) disaster recovery plan test disaster recovery plan Inefficient space allocation and/or layout Inefficient transport mechanisms Patient waiting spaces not adequate Failure to maintain adequate physical access security Lack of security over chemical, bioagents, and gases training policies and procedures Failure to properly identify and monitor hazardous materials training policies and procedures Failure to properly store and dispose of hazardous materials training policies and proceduresFailure to properly train all staff in the use of hazardous materials Failure to maintain fire code training policies and procedures Failure to maintain certifications for boilers, elevators, heliports, incinerators, etc Failure to update public areas to stay competitive Lack of adequate signage Lack of appropriate private spaces for counseling/emotional needs Failure to ensure that equipment in public view is perceived to be state-of-the-art Failure to maintain grounds and parking Lack of adequate and accessible parking patient shuttle service Failure to keep patient areas, rooms, and supplies clean and appealing Failure to properly dispose of hospital based waste training policies and proceduresCONTROL 3 CONTROL 4 CONTROL 5 restricted access Limited access security cameras contract for disposal of HazMatfire drills contract to dispose of waste