SAMPLE
Physician Practice Group
Risk Assessment
Risk Management Objectives
- To introduce physicians, office managers and staff to a systematic
review to identify strengths and weaknesses in a physician practice.
- To identify practices that place physician offices at risk of liability,
recognition of patient safety issues that could lead to patient harm,
to help provide safer and better care, and limit risk of medical
malpractice.
- To promote patient safety commitment among physicians and staff.
- To collect baseline information which will allow comparison of
physician practices for benchmarking purposes.
- To create baseline comparisons so that practices are able to monitor
themselves following implementation of improvement strategies.
- To reduce the likelihood of system breakdowns and errors in patient care.
Risk Assessment Plan
The Risk Assessment Tool for physician offices is a tool to help identify strengths and weaknesses in a physician practice. The survey is organized into key areas. It allows staff within the various settings to provide input by completing the survey. Surveys are completed over a two to three week time frame. All self-assessments will be followed up by a Clinical Risk Specialist who will do an on-site survey.
Assessment reports will be generated within 3 weeks of completion. The report will include strengths and identify opportunities for improvement. The assessment will help to identify and prioritize areas most in need of improvement and risk reduction.
There is no scoring system. The options for responding to the statements are Always/ Yes, Sometimes, Never/NO, and NA. The ideal response to each statement is Always /Yes or N/A. Any other response indicates an area of potential risk in the practice and should be addressed and resolved.
The Risk Assessment Tool includes the Enterprise or whole system approach. The Risk Management team will focus on Clinical Issues and consult additional departments as needed for assistance/ follow up. (Such as Infection Control Issues or Environment of Care Issues). Clinical areas (high-lighted in yellow) will be the primary focus of the Clinical Risk Specialists.
After an assessment, the Clinical Risk Specialist will analyze the findings and develop the Assessment Report. The report will be generated within 3 weeks of completion. The report will include the strengths and identify opportunities for improvement. The assessment will help to identify and prioritize areas most in need of improvement and risk reduction. A copy of this report will be provided to the following:
Following the risk assessment, the Practice Manager should review the results with physician leaders. Together they can define goals, develop and implement strategies to meet the goals. Areas for risk reduction and safety can be prioritized and goals made into an action plan.
The Practice Manager will return the action plan to the Clinical Risk Specialist within 3 weeks of receiving the assessment report.
- New acquisitions will be audited as follows to establish an initial baseline, to ensure patient safety and to decrease risks.
- Within one month of purchase
- 6 Month Audit
- Annual Risk Assessment
- Established practices will be audited as follows:
- Initially by completion of the self-assessment utilizing the Risk Assessment Tool.
- Verification of self-assessment will be completed by a Clinical Risk Specialist completing
an on-site evaluation.
- Annual Risk Assessment
Table of Contents
Objectives ...... 2
Risk Assessment Plan ...... 3
Practice Assessment Checklists ...... 5 - 22
Human Resources ...... 5
Advance Directives/ Patient’s Rights ...... 5
Cultural Competency ...... 6
Medication Use and Safety ...... 6 - 9 Physician Progress Notes ...... 9
Procedure Consents ...... 9
Respiratory Isolation Practice ...... 10 - 11
Safety ...... 8
Credentialing/Competency ...... 11 - 12
Office Procedures ...... 12 - 13
Telephone Procedures ...... 14 - 15
Health Information Management / Documentation ...... 14 - 16 Confidentiality ...... 16 - 18
Communication and Teamwork ...... 18 - 19
Americans with Disability Act ...... 19 - 20
Clinical Laboratory Improvement ...... 21
Risk Management / Quality Improvement ...... 19 – 20
References ...... 21 - 22
Corrective Action Form ...... 23
TRACER FINDINGS RECORDING FORM
Date: ______Office Reviewed: ______Reviewer(s): ______
Topic / Findings: Checked Items Indicate Compliance / Always/ Yes / Sometime / Never/ NO / Practice Action PlanHuman Resources / Number of Providers ____
Number by Title:
Physicians _____
Nurse Practitioners _____
Physician Assistants _____
Other (List):
Type and Number of Staff Employed:
Registered Nurses ____
LPN/LVN ______
Medical Assistants _____
Nurse Aides______
Receptionists ______
There are current job descriptions for all positions.
There is an orientation process for new staff members.
Staff members do not perform tasks beyond their scope of licensure, certification or training.
Advance Directives, Patient Rights / Questions about advance directives are completed during the initial screening process
If the patient has an advance directive, there is a current copy on the chart, with the health care agent name and contact information listed
If there is an advance directive but no copy on the chart, the patient has been instructed to provide one
Charts and patient-sensitive information is stored and kept in a manner that protects the patient’s privacy
Patients in the waiting area cannot overhear telephone conversations
Advanced Directives and Patient
Rights / If there are open areas that cannot be structurally changed, there is an area where sensitive and confidential issues can be discussed so that others cannot hear. (Use of white noise machines? Yes or NO
Abuse/neglect screening completed
Cultural Competency / Preferred language in which to discuss medical information is documented in the record, if applicable.
Language Line use is documented w/ operator number.
Medication Use and Safety / Current list of medications is documented in the record, including over-the-counter and herbal supplements. List should include medication dose and frequency.
Medication list is updated each office visit.
Allergies are listed and displayed prominently; updated as necessary.
Immunization status is documented
Medications are prepared in a clean area.
Vaccine administration is documented including date, dose, expiration date, manufacturer and lot number.
Vaccine Information Statement given to patient (most recent date)
Vaccines are either entered into vaccine log or, if electronically documented, history of same may be accessed electronically.
If samples are held in the offices:
Is there a drug sample control program that includes inventory, monthly checks of expiration dates and a recall system?
Medication Safety and Use / Sample tracking logs are utilized when samples are dispensed.
Samples are dispensed directly by the physician, or, if dispensed by the MA, correct patient, drug, dose, route and frequency are verified by the physician prior to handing to patient.
Sample closet is secured to prevent diversion of medication
Stocked medication is stored per manufacturer’s guidelines, including refrigerated/frozen vaccines.
Medication refrigerator temps are checked at least daily; if out of range temps are documented, appropriate corrective action is undertaken, documented and follow-up temp is done.
There is a monitoring process in place so that if the temperature of the med refrigerator went out of range off-hours, the staff would be aware of it upon return to the office.
If the med refrigerator is found to be out of range, the staff know what to do about it.
Medications - only - are stored in med refrigerators (no chemicals, oral contrast, lab reagents, food, etc.)
Stocked medication including biological and samples, prescription pads and syringes are stored in a secure area; inventoried, and controlled? should not have unsecured meds in patient rooms
Process for administering medications includes proper patient identification and drug orders verified before administration of medications in the office and follows law and regulations for MA administration?
Single dose vials are used for one patient only and discarded after one use (CDC guidelines on Safe Injection practices are followed.)
Multi-dose vials are dated with a 28 day expiration date, unless manufacturer’s expiration date precedes that date.
Medications from multi-dose vials are drawn up with a clean needle and syringe each time the stopper is pierced. If the same needle or the same syringe is used, the vial is considered to be single patient use and is discarded after the patient leaves.
Medication and Safety Use / Meds drawn up from a multi-dose vial in a non-patient care area should be labeled with the drug name, dose/concentration unless taken directly to the patient and injected.
Does the physician review every request for prescription refills personally?
Is patient information readily available to providers when ordering medication/writing prescriptions?
Is a copy of all medication orders and prescriptions maintained in the patient’s office record?
Are all medications that are dispensed from the office properly labeled? ( Check competency skills checklist for medical assistants for administering medications)
Are medications and biological prescribed and administered only by qualified providers and by staff within their scope of practice
Do policies prohibit the use of pre-signed and /or postdated
prescription forms?
Are there protocols for handling patient requests for prescription renewals? (Is there protocol listing of what can and cannot be done and by whom)
Is there a policy that requires a “read back” of the complete order by the person taking verbal or telephone medication orders to confirm that they are correct?
Is a complete drug history – including prescription and over-the-counter medications, herbal products/nutritional supplements, and illicit drugs – obtained and documented at the initial patient encounter and updated periodically?
Medication and Safety Use / Are two patient identifiers confirmed and drug orders verified before administration of medications in the office?
Is a current medication list maintained in the records of all patients on drug therapy?
Is there a process for handling drug recalls?
If a crash cart or emergency tackle box with medications exists in the office, the box is checked monthly for expired medications.
Physician Progress Notes / Completed with office visits
Legible
Each entry is dated and signed
Is there a protocol for physician referral on specific abnormal findings?
Please specify.
Procedure Consents / Informed consent obtained by physician; risks, benefits, alternatives in progress notes or physician signature on all invasive procedures or treatments (surgical/ special procedures) permit
If invasive procedures are performed in the office, are discharge instructions provided to the patient/ family in writing?
Is a copy placed in their chart?
Any conscious sedation ever utilized? If so, who is using it? Who is monitoring? What are they monitoring?
Are informed-consent discussions documented by the physician in the patient’s office medical record?
Is patient consent obtained and documented for the taking of photographs, videotapes, or other individually identifiable images of patients?
Procedural or surgical consents are dated and timed
Respiratory-Specific Isolation Practice
n/a / Suspected flu or Ebola patients are placed into private room with door closed and patient mask applied
Suspected TB or Ebola patients are placed into private room with door closed and patient mask applied
Patients with respiratory symptoms should be offered a mask if it is expected that they will be in the waiting room for any period of time.
Have selected personnel been fit-tested for use of a NIOSH approved TB respirator mask ( N-95, HEPA)?
Safety
Safety / Specimens are labeled in the presence of the patient with at least two identifiers (name and DOB), date, time and signature of staff
Are children seen in the office?
Do you have appropriate equipment for children (e.g., BP cuffs, etc)?
Are bariatric patients seen in the office?
Do you have appropriate equipment for bariatric patients (e.g. BP cuffs, wheel chairs, etc)?
Are mock emergency drills conducted periodically, and is the adequacy of the response evaluated
Are procedures in place to identify and handle patients who may be pregnant?
Are patients identified and the site of the procedure verified before the start of any procedure
Do policies provide for the use of a chaperone during intimate patient examinations? (Male: Female and same sex)
Are patients assessed and monitored before, during, and after office procedures according to medical need and standard of practice?
Is the use of sedation or any other nonlocal anesthesia governed by
Policies and procedures
Is there a policy and procedure for handling emergencies that arise in the office?
All equipment is functioning properly and staff is properly instructed in its use.
Does all equipment at the physician practice site undergo periodic inspection, testing, and preventive maintenance?
Are inspection and preventive maintenance procedures documented?
Are office personnel instructed on what to do if a device malfunctions?
Do all office-based users of medical devices receive adequate training before use on patients?
Is the above training documented?
Credentialing/Competency
Credentialing and Competency / Is there a formal credentialing and periodic re-credentialing process For all providers (e.g. physicians or other licensed independent or dependent practitioners) associated with the office practice?
Is there a mechanism for periodically reassessing each provider’s and each employee’s clinical competence?
Is this evaluation documented?
Are there current, written collaborative practice agreements for midlevel providers (e.g. physician assistants, nurse practitioners) as applicable?
Do unlicensed assistive personnel (e.g. medical office assistants) function under the supervision of a licensed healthcare professional?
Are there scheduled quality review meetings with staff to review cases?
Is there a formal office orientation program with periodic (annual, at minimum) educational updates for all providers and staff?
Are all clinical staff certified with cardiopulmonary resuscitation (CPR)
and trained in emergency-response procedures?
Are all office providers and staff trained in the use of office equipment during orientation and on all new devices before the devices are placed into use?.
Office Procedures
Office Procedures
Does the practice use clinical practice guidelines that are base either on evidence from recognized sources or on current professional knowledge by board-certified /eligible practitioners?(If the physician does not use the standard, does he document why not – does he give a rationale?)
Is there a policy regarding missed appointments or cancelations that includes permanent documentation and notification of the provider to determine action on rescheduling?
Does the practice have a system for triaging telephone calls?
Is the system based on physician –approved protocols by appropriate-level staff?
Lengthy voice mail, with various options, is not used to screen calls. It is easy to access a person to answer a phone. In other words there is a shortcut to get a person on the phone.
Are callers allowed to speak before they are put on hold?
If an automatic call distribution system is used, does it include an option for patients to speak to someone in the event of a real emergency?
Does the physician practice have a written policy on telephone advice protocols? (Is it posted where people can see it?)
Is a system in place to monitor staff compliance with the protocols?
Do nurses and other staff who give telephone advice have specific training, experience and documented competence in telephone assessment techniques?
Is staff instructed to consult a physician whenever they have doubts about proper instructions or advice?
Are physicians instructed to be receptive to questions by office staff regarding patient calls?
Is there a consistent procedure for handling phone-in lab reports?
Does this include a policy addressing how to relay “panic values” to the physician?
Is an answering service used during off hours?
If no, can messages be retrieved and addressed promptly at all times?
If yes, are the service’s policies and procedures for answering physician office calls regularly reviewed?
Is the caller immediately informed that he or she is dealing with an answering service?
Does the service verify the caller’s name and telephone number?
Is the service provided with an emergency procedure in case the physician on call cannot be reached?
Is there documentation in the patient’s record of after hour calls?
Are the test calls placed periodically to assess the performance of the answering service?
Is dictation, transcription, and filing of reports timely (e.g., within 24 to 48 hours)?
Health Information Management / Documentation
Health Information
Management/
Documentation
Health Information Management/ Documentation / Are transcribed reports authenticated by signature of the responsible provider in a timely manner (e.g., within 48 to 72 hours)?
Are medical records readily available to providers when needed (e.g., when treating patients in the office or over the telephone)?
Is drug, food and other allergy information documented prominently in the paper or electronic record?
Are all charting entries signed and dated (by hand or electronically)?
Is patient education regarding health problems, medications and plan of care documented?
If pain is part of the visit complaint, pain score is documented using 0-10 scale or faces pain scale (in the case of children)
Do patients receive written instructions and information regarding self-care and follow-up?
Are instructions given to patients documented in the medical record?
Are written instructions provided both in English and in languages that represent the largest limited-English speaking groups?
Is patient noncompliance and/or informed refusal of recommended treatment documented?
Are all telephone calls in which a provider or staff member provides treatment orders or advice documented?
Does this documentation include:
Patient name?
Caller name (if different from patient)
Physician name?
Date and time of call?
Reason for call (caller’s statement as he/she relayed it)?
History of complaint, including effect of any interventions taken at home?
Follow – up, if applicable?
Advice given/treatment ordered?
Initials or signature of the staff member taking the call?
Do you use off-site storage? (For electronic records, do you have backup systems?)
Are charts thinned?
If yes, by whom? ______
What criteria are used? ______
Is a random selection of medical records assessed periodically for illegibility, inaccuracies, omissions, alterations, or other red flags indicative of poor charting practices?