Risk Management and Patient Safety Program

Lāna`i Community Health Center Policy and Procedure Title: Effective Date: Risk Management and Patient Safety Program June 21, 2011 Revised Date:...
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Lāna`i Community Health Center Policy and Procedure

Title:

Effective Date:

Risk Management and Patient Safety Program

June 21, 2011

Revised Date:

Executive Director Signature

Board Approval Signature:

Date: June 21, 2011

Date: June 21, 2011

Page 1 of 9

As a non-profit, Lāna'i Community Health Center (LCHC) has established this policy to ensure a comprehensive, proactive risk assessment process to evaluate the potential adverse impact of direct and indirect patient care processes, buildings, grounds, equipment, occupants, and internal physical systems on the safety and health of patients, staff, and other people coming to LCHC. This proactive risk assessment process is used to identify, rate, and prioritize risks and or hazards. Based on this risk assessment, policies, procedures, and controls may be put into place to manage the risks as appropriate to the organization, with the intent of reducing them to the lowest possible level. This program applies to all direct and indirect patient care processes, departments, and facilities of LCHC. RELATED POLICIES AND PROCEDURES See also Quality Management Plan, Incident Policy, Peer Review Policy, Provider Privileging, and Provider Credentialing. Additional related policies: HazCom Training, TB, PPE, Emergency Prep, Fire Safety, BBP, Environmental Safety, Hep B, Infection Control, Home Safety, PostExposure. Proactive Risk Assessment LCHC conducts proactive risk assessments to identify and evaluate the potential of adverse impacts of direct and indirect patient care processes, buildings, grounds, equipment, occupants, and internal physical systems on the safety and health of patients, staff, and other visitors. Risk assessments are performed on identified hazards and proposed changes to new or

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existing processes. Examples of proposed changes include automated or manual work processes and equipment or other technology. The goal of performing risk assessments is to reduce the likelihood of or mitigate the impact of incidents or other negative experiences that have the potential to result in injury, accident, or other loss to patients, visitors, staff, or assets. It is important to understand that no process, activity, or system can ever be made completely risk free. Some level of risk is always present. The concept of risk assessment involves examination of the risks and making a determination as to what level of risk is acceptable to the organization. With limited resources, the object of risk assessment is to manage the risks in a prioritized fashion. Results of the risk assessment process and other potential safety issues are reported and discussed in the Corporate Quality Committee-Safety Committee meetings. In the Risk Management and Patient Safety process, recommendations on management of the issue at hand are reached based on the committee’s evaluation of the situation and the pertinent data. This information may be used to create or revise policies, procedures, and practices, as well as develop orientation and education programs and performance monitors. Continuing Education: In addition to risk assessment, continuing education, including medical malpractice/risk management training is provided to all staff. Many of these trainings are provided by Altres HR, the company LCHC contracts with for human resource, payroll and risk management services. Based upon the staff member's position and duties, they may be required to attend training and/or maintain certification in the following areas. (Supervisors will be subject to additional training not listed here.) All Employees • Back Safety/Ergonomics • Critical Thinking Skills • Emergency Preparedness & Evacuation • Fire Safety • Hazard Communication (including MSDS and OSHA) • HIPAA/Confidentiality of Patient Records • People Skills • Personal Safety and Awareness (also Workplace Violence) • Sensitivity and Diversity • Stress Management Clinical Employees (These items may also be required if the employee is a nonclinical employee but working in the clinical area.) • Bloodborne Pathogens (with Universal Precautions) • CPR/BLS (including AED) • Personal Protective Equipment (Respiratory Protection and Program may also be required as applicable) • TB Awareness 2

Non-Clinical Employees • First Aid (unless trained in CPR/BLS above, either by requirement or optional election) The preceding lists are not exhaustive and are subject to change; LCHC may require additional training due to industry regulation, funding mandate, or managerial decision. Most training will be required upon hire and annually. Employees who do not live on Lana‘i and who may not be attending training in person, will be permitted to train via alternate means (e.g., by conferencing in via phone or computer, by completing an online module, or by attending training offered on the employee's home island, where applicable). LCHC will pay for staff time at any required training and for the training itself, as applicable. Failure to attend mandatory training and/or to maintain required certifications may result in disciplinary action, up to and including dismissal. Professional Development: LCHC values the professional development and continuing education of its employees and realizes that this education will also result in risk reduction. So, in addition to ongoing internal educational training sessions, LCHC may elect to pay for appropriate professional development opportunities and/or continuing education for non-provider staff, contingent upon business needs, eligibility requirements, and the availability of funds. (Providers are responsible for maintaining continuing medical education, or CME, credits on their own; however, leave time may be provided to do so.) All staff members are responsible to keep a log of all internal and external training and educational programs attended each year (whether required or optional) and submit this log with their annual performance appraisal. If LCHC requires the employee to attend a continuing education meeting, tuition/registration costs will be paid for by LCHC and the employee will receive his/her regular rate of pay for the time spent in class. All employees are welcome and encouraged to explore continuing education opportunities with their supervisor. In addition, can apply for educational assistance through ALTRES for any professional development or continuing education tuition/ registration costs not otherwise covered by LCHC.

Procedure for proactive risk assessment: 1. The first step of the risk assessment process involves identifying potential risks to be the subject or target of the assessment process. Risks may be discovered as a result of incident reports, near misses, and environmental tours which are used to uncover environmental deficiencies, hazards, and unsafe practices. Potential hazards that are identified and do not involve simple corrections are candidates for risk assessment. Additional sources of potential risk identification may include: • Issues reported to or identified by the Director of Quality or Safety Officer • Observations by any staff member • Published reports in the healthcare literature • New regulatory issues • Sentinel events alerts • Product recalls • Inspections from outside agencies, insurance carriers, consultants • Internal events /Incident reports: injuries, accidents • A staff member concern that is brought to the attention of their supervisor, the Director of Quality, Safety Officer or any Corporate Quality Committee-Safety Committee member • Any source that identifies a potential risk 3

2. The LCHC Safety Officer will schedule risk assessments by determining if any areas not scheduled for an initial assessment in a given year have had significant changes that would indicate the need to conduct a risk assessment in that area. 3. Once a potential risk is identified, the Safety Officer will present the issue for discussion at the next Corporate Quality Committee-Safety Committee meeting. The Committee will discuss the risk and if appropriate, appoint a risk assessment team, to analyze the risk and report their findings at the next Committee meeting. 4. The Safety Officer is responsible for identifying and reporting on all Risk Management and Patient Safety activities of the Corporate Quality Committee-Safety Committee, and provides and conducts proactive risk assessment. As a small organization, LCHC does not have a standing risk assessment team, but the Safety Officer will identify additional team members as necessary to assist with assessment and corrective actions. 5. The Safety Officer will conduct an inspection of the area being assessed for risk or observe the process being assessed for risk in action. If the process or area is clinical, the LCHC Medical Director will work with the Safety Officer. The Safety Officer (and Medical Director when appropriate) will document findings on the “LCHC Proactive Risk Assessment Worksheet” (Attachment A). To determine the appropriate score for each identified risk, the reviewer will consider information obtained through a physical tour of the facility, review of annual incident and accident statistics, review of at least the past twelve (12) months Corporate Quality Committee-Safety Committee meeting reports, hazard surveillance reports, interviews with employees and supervisors. A proactive risk assessment may require more than one visit. In the event there is significant risk, visit frequency will be determined on an individual basis. 6. The Safety Officer (and Medical Director when appropriate) will review results and determine the risk score based on the probability and impact on the organization. The report will also include possible controls or other methods to reduce the risk to the lowest possible level. The report is to include estimated costs associated with the implementation of the suggested controls and the Safety Officer's recommendations. 7. The Safety Officer's findings will be presented at the next Corporate Quality Committee-Safety Committee meeting and analyzed. If necessary the committee will make recommendation(s) to the Director of Quality for action in managing the risk or control implementation. Management of the risk can occur in several ways: • Risk Reduction: Implement controls to reduce severity or probability. • Transfer: Insure against the risk • Avoid: Stop performing the process. • Accept: Perform the process despite the risk Using the Risk Assessment Matrix on the LCHC Proactive Risk Assessment Worksheet, the potential risk is assigned a score of 1 to 16. Scores of 1 – 4 are considered “Low Risk” and are monitored and the risk re-assessed annually. Potential risks with scores of 6 – 9 are defined as being “Medium Risk” and are addressed by establishing controls to minimize this risk. “High Risk” areas or processes 4

receive scores from 12 – 16 points and are subject to immediate risk reductions strategies and required action. Only the Director of Quality and Executive Director can make the decision to accept any given level of risk. 8. The Corporate Quality Committee (QMP) and Safety Committee (EMP) will review the Safety Officer's report, determine if the risk assessment is acceptable, and, if so, using Risk Assessment Tracking System (Attachment B), define: • The specific risk reduction strategies to be implemented; • An accountable individual to manage the implementation of the risk reduction strategy; • Timeframes for the implementation of each step in the risk reduction plan; and • A process to monitor implementation of the risk reduction efforts. • Whether interim actions are indicated to mitigate the impact of the identified risk while the risk reduction efforts are being implemented and, if so, the specific nature of these interim actions. The QMP-EMP Committee will also specify the frequency with which they expect reports from the Safety Officer (and Medical Director when appropriate) on the implementation status of risk reduction efforts. 9. The QMP-EMP Committee will also determine a schedule for a reassessment of the identified risk to verify that risk reduction strategies were implemented and are being followed. Frequent reassessment of the area or process will also continue until necessary policies and procedures have been written, the area is in compliance with policies, procedures, and appropriate regulations, and the QMP-EMP Committee is convinced that the risk level has been lowered to an acceptable level. 10. The QMP-EMP Committee will assess whether an area that was considered high risk in a previous year requires an annual proactive risk re-assessment or is now a low or medium risk.

Should any situation(s) that constitute an imminent danger be discovered during the course of the risk assessment, they will be reported immediately to the Safety Officer (and Medical Director when appropriate) for appropriate follow-up action to resolve the identified issue(s). Documentation of this risk assessment process will be found in the QMP-EMP Committee reports.

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ATTACHMENT A Lana'i Community Health Center RISK ASSESSMENT WORKSHEET HAZARD/RISK: ________________________________________________________________________ Location of Hazard/Risk: ________________________________________________________________ Potential Risk (Impact) if hazard is not addressed: ___________________________________________ Means of Identification: _________________________________________________________________ _____________________________________________________________________________________ Assessment Team: _____________________________________________________________________ _____________________________________________________________________________________ Date of Identification: _____________ Date of Assessment: _________________ Description of Hazard: (Attach additional sheets as necessary)

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ATTACHMENT A Lana'i Community Health Center RISK ASSESSMENT WORKSHEET RISK ASSESSMENT MATRIX RISK = PROBABILITY SCORE x IMPACT SCORE Risk Element Description

Probability Impact

PROBABILITY DEFINITIONS:

IMPACT DEFINITIONS:

1

Not likely to ever occur

1

Minor or no injury

2

Possibly can occur in a year

2

Minor injury or illness

3

Probably will occur in a year

3

Severe injury/illness

4

Very likely within one year

4

Loss of life

Risk Score:

1-4 6-9 12 - 16

Risk Score (P x I)

Low Risk Medium Risk High Risk

Monitor and assess annually Establish controls to minimize risk. Immediate risk reductions strategies and action required

SUBJECTIVE ASSESSMENT OF RISK:

RECOMMENDED RISK REDUCTION STRATEGIES OR PROPOSED CONTROLS: (attach separate sheet as necessary)

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ATTACHMENT B Lana'i Community Health Center PROACTIVE RISK ASSESSMENT RISK REDUCTION TRACKING SYSTEM Status as of: 8/7/11 Page 1

Nature of Proactive Risk Assessment Conducted: ___________________________

Date Proactive Risk Assessment Conducted: ________________________________

Assessment Team:

__________________________________ LCHC Safety Officer

_________________________________ LCHC Medical Director (if applicable)

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ATTACHMENT B Lana'i Community Health Center PROACTIVE RISK ASSESSMENT RISK REDUCTION TRACKING SYSTEM Page 2 Risk Identified

Risk Level Classification (H/M/L)

Risk Reduction Strategy

Approvals: ________________________________ LCHC Safety Officer

Accountable Individual

Timeframe for Completion

Current Status of Risk Reduction Strategy Implementation

__________________________________ LCHC Medical Director (if applicable) 9

Interim Action(s) to Mitigate Risk (if Indicated)