Sample Risk Management Plan Template (Page 4 of 9) in pdf

I PURPOSE

The risk management program of FACILITY X is designed to assure that the standard of care by the staff

is maintained at the acceptable level, to reduce the risk of patient injury as a consequence of that care,

and to minimize financial loss to the facility.

II OBJECTIVES

The risk management program is designed to:

1) Identify areas of risk in the clinical aspects of patient care and safety

2) Identify criteria for screening assess with risk potential regarding clinical aspects of patient care

and safety

3) Establish the investigative and evaluative process applied to cases with risk potential

4) Assure timely intervention in events below standard of practice

5) Develop policies and programs to reduce risk in clinical aspects of patient care and safety

6) Establish communication between risk management and quality assurance/improvement

functions in the facility

7) Report risk management activities to the Kansas Department of Health and Environment and

other appropriate licensing agencies, as mandated by law

III GOVERNING BODY AUTHORITY

The governing board duly authorizes the Risk Management Committee and the Medical Staff Executive

Committee* as the committees which are responsible for investigating and determining applicable

standards of care as required by state risk management laws, KSA 65-4921 et seq. These committees

are established for the purposes of compliance with the risk management statutes; to evaluate and

improve the quality of health care services and peer review act found at KSA 65-4915(a)(3). The

governing board has the final responsibility and authority for the risk management program of FACILTY

This plan was developed in accordance with provisions of the aforementioned Kansas statutes.

Responsibility for implementation of this plan is delegated to the Risk Manager.

*Larger facilities may find it appropriate to establish more than two committees while the smaller

facilities may need only one committee. Those facilities that have one committee should ensure that

the committee is multi-disciplinary, such as: two physicians, two registered nurses, a representative

from ancillary services etc. Appropriate consulting physicians may also be appointed to this committee.

IV REPORTING OCCURRENCES/INCIDENTS

In accordance with KSA 65-4921 et seq, all employees, health care providers, and medical care facility

agents are required to report any “reportable incident” to the risk manager, the chief administrative

officer, and/or the chief of medical staff. KSA 65-4921(f) defines the term “reportable incident” as:

An act by a health care provider which: (1) is or may be below the applicable standard

of care and has a reasonable probability of causing injury to a patient; or (2) may be

grounds for disciplinary action by the appropriate licensing agency.

Health care providers who are subject to statutory risk management include: medical care facilities,

doctors of medicine/osteopathy, chiropractors, optometrist, podiatrist, pharmacists, dentists, licensed

dental hygienists, physical therapist, physical therapy assistants, occupational therapist, occupational

therapy assistants, respiratory therapists, radiology technologists, athletic trainers, naturopathic

doctors, registered nurses, licensed practical nurses, mental health technicians, psychologists, social

workers, and professional counselors.

Per KSA 65-4927(c), the willful failure of a healthcare providers and/or medical care facility employee to

report, as required by law, is punishable as a Class C misdemeanor.

Sample Risk Management Plan Template Page 4