Risk Management: Phase II
Through this phase, Princeton Insurance’s healthcare risk consultants help each facility examine four factors that frequently contribute to the difficulties in defending malpractice claims.
The four contributing factors focused on during this phase are:
- Credentialing
- Documentation
- Patient Experience
- Informed Consent
Credentialing
Credentialing is the administrative process for validating the qualifications of physicians and assessing their background. Primarily, it’s the role of the medical staff coordinator to gather all pertinent information for each physician every two years, and present it to the facility’s credentialing committee. Many documents and additional information are reviewed and confirmed during the credentialing process, including letters of reference, colleges and/or medical schools attended, residency, copy of driver’s license, confirmation of certifications, etc.
Our consultants review the facility’s existing credentialing files to assess their current procedures, and then provide recommendations based on their findings. Many “winning points” were also identified for each participating facility, serving as recognition for exemplary practices that are in place.
Common findings during the credentialing assessment include:
- Deficiencies in verifying insurance coverage (many facilities accept copies or faxed documents from the physician as a sole means of verifying coverage)
- Lack of verification of competency for physicians privileged in performing new procedures
- Forms for the delineation of privileges often include the use of check marks to designate the procedure (in fact, the initials department chairperson should be written into this column on the form)
- Legibility was a concern involving various documents, including licenses, applications and references
- Documents were found to be altered through the use of white correction fluid, and several files contained information that was edited without being initialed by the individual making the correction
- Professional references were obtained from the physician’s practice partners, which can be construed as a conflict of interest
- Copies of reference letters were accepted rather than original letters
Documentation
Documentation issues present many problems when defending a professional liability claim on behalf of a facility and its employees. At each hospital, the risk managers and the clinical leaders are urged to focus on the areas that pose serious risk for the nurses, other clinical staff and the physicians, including: 1) following and documenting the appropriate chain of command; 2) documenting discussions with team members; 3) including date and time for all entries; 4) improper alterations; 5) completeness of information and forms.
While facility staff are familiar with conducting record audits for other purposes, the Princeton-developed audit tool includes additional items to review, such as inappropriate editing or erasing of information, illegible entries and date and time of entries. This audit tool can be added to the facility’s existing audit tools to avoid duplication of effort.
Common findings during the documentation portion of this phase include:
- Illegible entries by both nursing staff and physicians
- Patient identifiers missing from documents
- Pre-printed forms not fully completed, i.e. leaving numerous blank spaces, which could be interpreted by a plaintiff attorney as an oversight
- Blank lines were not properly stricken in progress notes to prohibit late entries
- Re-assessments were not completed in a timely manner for pain management and/or falls assessment
- Minimal or lack of discharge planning information, such as patient teaching regarding medications, follow-up treatments, wound care, etc.
- Frequent use of unapproved and/or inappropriate abbreviations
Patient Experience
In this portion of Phase II, Princeton’s healthcare risk consultants review information from the hospital to better understand the level of patient involvement in their own care at each facility. Most facilities have a patient advocate/representative, whose job is solely dedicated to this function. However, in rare instances, the risk manager may serve as the patient advocate, which could be construed as a potential conflict of interest.
Princeton’s Healthcare Risk Management team also encourages the development of a Patient-Family Council at each facility. Members of this council – former patients, hospital administration, nursing staff, physicians, community leaders, etc. – discuss ideas relative to improving the safe delivery of health care. This council may also include a patient or family member of a patient who has experienced an adverse event during their hospitalization. While still a relatively new concept for New Jersey healthcare institutions, facilities in other states have successfully implemented such a council.
Other areas of review in the patient experience phase include:
- Patient education and health-literacy programs
- Types of brochures and information provided to patients
- Video tapes or DVDs used for teaching purposes, such as a video for patients newly diagnosed with diabetes or hypertension
- Whether healthcare documents and literature are written at the standard 5th grade reading level – especially consent forms, educational brochures, etc.
- How patients are encouraged to participate in their care, and if they are provided the necessary tools to foster participation
As anticipated, all facilities were found to have a designated patient representative and to conduct patient satisfaction surveys on a regular basis.
The broad finding is that the facilities are concentrating their efforts on improving the patient’s hospital experience.
Common patient experience findings include:
- Many of the hospital programs are specific to the culture of the patient population
- Most facilities use the patient survey results to enhance the patient programs, and improve the overall patient experience organization
- The patient advocate/representative often has additional responsibilities within the organization
- Patient-Family Councils have not been established (but in some cases, it is under consideration)
- Written policies should be developed to specifically address resolution of billing disputes and processes for directing patient concerns and obtaining resolution
Informed Consent
During this portion of Phase II, the healthcare risk management consultants review practices, policies, procedures, and other documents, including the numerous consent forms currently in-use by the facilities.
The purpose of this component is three-fold:
- to identify potential deficiencies in the documents that could impact the defense of a claim
- to identify policy redundancies which may contradict each other
- to identify key elements that may have been inadvertently omitted from a document
Phase III 