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Hospitals Risk Management Workbook

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Hospitals Risk Management Workbook Powered By Docstoc
					RISKS
Failure to track and secure supplies Lack of adequate supplies

CONTROL1
perpetual inventory system just-in-time ordering system

CONTROL 2
locked/secure supply area

Lack of adequate equipment Failure to track and secure equipment

equipment maintenance plan

management knowledge of current technology

property inventory system

check-out log

Improper or inadequate maintenance of equipment properly trained technicians management knowledge of current technology

equipment maintenance plan budget for capital outlay & supplies

Lack of current technology

Lack of inventory controls over drugs (incl. disposal of expired drugs/wastage) perpetual inventory system

monthly check for any expired drugs supervisory oversight of distribution log

Failure to charge for drugs dispensed segregation of duties Lack of inventory controls over supplies Failure to charge for supplies

perpetual inventory system segregation of duties

limit access to supply area limit access to supply area

CONTROL 3
management oversight

CONTROL 4
periodic physical inventory counts

CONTROL 5

locked/secure area

periodic physical management oversight counts

drugs maintained in secure area

distribution log

periodic physical counts

RISKS
Inadequate number of staff

CONTROL1

CONTROL 2

predetermined staffing levels streamlined hiring process

Staff does not have proper licenses or credentials Failure to supervise and assess all other clinical staff

obtain copy of licenses prior to hire verify with licensing agency management supervisory training

periodic evaluations

Lack of on-going training and education

training policy adhere to Federal discrimination laws hiring incentives (money, schedule)

budgeting for training costs

Lack of a diverse workforce

Inadequate supply of nurses Failure to attract and maintain quality faculty (recruitment)

streamlined hiring process

up-to-date technology hiring incentives (money, schedule)

innovative environment

Inadequate supply of physicians

streamlined hiring process

Failure to apply tenure requirements consistently Lack of recruiting resources

Documented policy and procedures for granting maintain a tenure committee tenure budgeting for recruiting

Lack of time to recruit Failure to train employees in infection control, etc Lack of adequate radiological monitoring systems Failure to ensure employees have appropriate immunizations

dedicated staff for recruiting tracking mechanism (training database)

required training

Use of monitoring badges maintain and track up-todate shot records Documented hazmat waste hazardous waste containers management policies and in each room procedures l

Lack of appropriate disposal systems for contaminated waste

CONTROL 3

CONTROL 4

CONTROL 5

adhere to job qualifications requirements

job descriptions

training

Contract for removal of HazMat

RISKS Aging population

CONTROL1
maintain adequate facilities and staff to accommodate guidelines for what carriers to accept

CONTROL 2

Bad payer mix Declining reimbursements from carriers Lack of first rate clinical facilities

strategic planning

maintenance plan find alternate funding for the uninsured

Uninsured Loss of competitive advantage

turn them away

Complex regulatory environment

comprehensive competent compliance officer compliance plan

Bad contracts

hiring qualified contract personnel

training of contract personnel

Dissatisfied patients

send patient surveys and evaluate results

customer service training Monitor all payers for financial viability

Insurers going bankrupt Loss of productivity (tenure mix) Failure to recognize and assess changing demographics Failure to recognize revenue generating capacity of materials, etc not needed for patient care

maintain reserve fund productivity-based pay plan evaluation of external environment

Untrained employees Excessive use of temporary employees Failure to properly manage temporary agency employees

comprehensive training program and monitoring of completion

training budget appropriately for marketing needs

Lack of an adequate marketing program

Lack of adequate strategic planning process Lack of adequate governance process

formalized strategic strategic planning committee plan

Lack of effective compliance program

formalized compliance competent compliance officer policy and procedures

CONTROL 3

CONTROL 4

CONTROL 5

Defined level of charity services

policy regarding who is authorized to negotiate/accept employee incentives for good customer service

RISKS
Alienation of partner hospitals Lack of faulty marketing program

CONTROL1
monitor interrelated activities

CONTROL 2

Lack of faculty disciplinary program Failure to adequately monitor and document residency programs Failure to maintain adequate faculty/student/support ratios Failure to define faculty criteria for teaching, research, and clinical practice activities

formal disciplinary policy training for program requirements monitor and evaluate ratios well-defined job descriptions documented faculty grievance process

maintain accreditation

Lack of adequate faculty grievance system Failure to maintain adequate performance and financial monitoring systems over faculty activities

CONTROL 3

CONTROL 4

CONTROL 5

RISKS
Failure to supervise and assess students/residents

CONTROL1
training

CONTROL 2
policies and procedures

Failure to maintain accreditation Failure to maintain state/federal funding

training

policies and procedures

Lack of recruiting resources

budgeting for recruiting dedicated staff for recruiting continuous curriculum development

Lack of time to recruit Failure to maintain Medical Board pass rates Failure to comply with applicable animal care regulations Lack of an animal security program Lack of adequate monitoring of research activities

training

policies and procedures

centralized oversight of research

Lack of adequate review of research design by the IRB checks and balances Lack of a grant assistance program

Documented P&P

CONTROL 3

CONTROL 4

CONTROL 5

implementation of standards

department to oversee (IACUC)

RISKS
Info is not captured and organized to facilitate decision-making Lack of real-time patient information (interconnectivity)

CONTROL1
training

CONTROL 2

Info is not secured to ensure privacy and integrity training Info is unavailable when needed for patient care Info is improperly altered or deleted because of processing error Info is improperly altered or deleted because of unauthorized access

policies and procedures

Segregation of duties

Access controls/limitations

read-only access (where appropriate) segregation of duties Test business continuity plan access controls/limitations

No business continuity process or plan is create a business in place continuity plan Inappropriate access of information (HIPAA) management review Info is unavailable when needed for noncare purposes such as regulatory or research Unauthorized release of Health Information (HIPAA) Inefficient report functionality for providing healthcare information Failure to account for disclosure of information not requiring authorization (HIPAA)

training

periodic confidentiality statement

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 access

RISKS
Misuse or inappropriate use of controlled substances prescribed to patients Lack of a valid Bioethics/Clinical decision making function

CONTROL1
physical safeguards

CONTROL 2
perpetual inventory system

Giving preferential access, treatment, or billing to selected groups or individuals Improper billing (Fraud) Failure to prevent patient abuse Failure to provide a trusted mechanism for reporting and resolving abuse complaints Lack of an adequate system for tracking incurred but not reported or billed services Failure to properly identify and monitor hazardous materials

policies and procedures independent review of charts monitoring

training

hotline Documented P&P for non billed tracking policies and procedures hazardous waste containers in each room

training

Failure to properly store and dispose of hazardous materials 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

training

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 interactions

Insufficient control over organ donor list

CONTROL 3

CONTROL 4

CONTROL 5

exceptions to policy approved by management

policies and procedures

Contract for disposal

RISKS
Clinical data does not support billing Inaccurate coding

CONTROL1
independent review of charts training

CONTROL 2

Failure to maintain Charge Description Master Duplicate record of services created independent review of charts

Failure to capture all charges Failure to collect co pays and balances due at time of service Failure to comply with regulatory standards (Medicare, HIPAA, etc)

training

policies and procedures

training independent review of charts

policies and procedures

Failure to file a clean claim Failure to obtain required pre-certification or approval Inaccurate claims or billing due to system errors

training

policies and procedures

Failure to file a claim or bill the patient

reconciliation of records independent review of charts Review of credit policies and procedures balances Management approval policies and procedures required

Fraudulent claim or billing

Failure to manage credit balances

Failure to write-off uncollectible debts 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 counts

Improper 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 personnel

CONTROL 3

CONTROL 4

CONTROL 5

Review of billings and receivables

Reconciliations

Review of deposits and support documentation

Forced time-off

Documentation of policies and procedures

RISKS
Loss of external partners 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 programs

CONTROL1
Relationship Management

CONTROL 2

CONTROL 3

CONTROL 4

CONTROL 5

RISKS
Failure to adequately assess and reassess patient needs

CONTROL1

CONTROL 2

Failure to coordinate care 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

Effective communication

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 Failure to comply with regulatory standards Failure to monitor the quality of care provided Loss of unconditional JCAHO accreditation 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 care Training of JCAHO requirements Proper training

Policies and procedures

Misuse 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

Medical record request Drug interaction due to lack of patient info 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 Lack of adequate ancillary personnel Hiring Incentives

Failure to properly handle a patient death 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 room

Training

CONTROL 3

CONTROL 4

CONTROL 5

RISKS
Lack of an adequate Emergency Management Plan Failure to adequately test the EM Plan

CONTROL1

CONTROL 2

Inadequate functional space to meet patient utilize proper forecasting Prepare a master plan demand methods for facilities Failure to maintain facilities maintenance plan monitoring by the police department security cameras

Lack of security Unsafe or hazardous environment Lack of comfortable and welcoming environment Failure to plan for Business Continuity Lack of sanitation levels commensurate with patient needs Lack of an adequate infection control process Improper disposal of bodies Disastrous physical event destroys building(s) 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 Failure to properly identify and monitor hazardous materials Failure to properly store and dispose of hazardous materials

develop business continuity plan

Test business continuity plan

training outsource disposal

policies and procedures training test disaster recovery plan

disaster recovery plan

training

policies and procedures

training

policies and procedures

training

policies and procedures

Failure 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 Failure to keep patient areas, rooms, and supplies clean and appealing Failure to properly dispose of hospital based waste training patient shuttle service

policies and procedures

CONTROL 3

CONTROL 4

CONTROL 5

restricted access

Limited access

security cameras

contract for disposal of HazMat

fire drills

contract to dispose of waste


				
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