Sample Risk Management Plan (Page 5 of 9) in pdf

When a reportable incident is identified, the person with knowledge of the incident completes the

reporting form for the risk management program (Appendix B). These forms are available to staff in

each department of the facility. All reportable incidents are to be reported to the risk manager within

24 hours of discovery. Upon receipt of an incident report, the risk manager will enter the case in the risk

management log (Appendix C) for tracking through its completion.

Per KSA 65-4924: Impaired providers; if a report to a state licensing agency pursuant to subsection

(a)(1) of (2) of KSA 1986 Supp. 65-4923 or any other report or complaint filed with such agency relates

to a health care provider’s ability to practice the provider’s profession with reasonable skill and safety

due to physical or mental disabilities, including deterioration through the aging process, loss of motor

skill or abuse of drugs or alcohol, the agency may refer the matter to an impaired provider committee

of the appropriate state or county professional society or organization.

Identification of reportable incidents may be generated by, but not limited to the following method:

1) Personal Observations

2) Occurrence Screens

3) Infection Control Reports

4) Complication Reports

5) Death Reviews

6) Blood Usage Reviews

7) Tissue Reviews

8) Patient Satisfaction Surveys

9) Patient/Family Complaints

10) Medical Record Reviews

The risk manager shall have the authority to review all facility and medical policies, procedures, records,

committee minutes and actions, to make recommendations to administration and the medical staff, and

to initiate independent investigations to bring cases to satisfactory closure.

V INVESTIGATION OF OCCURRENCES

All clinical variance/incident reports will be investigated by the risk manager or the appropriate

department director/designee and will result in a specific standard of care determination. Separate

standard of care determinations shall be made for each involved provider and each clinical issue

reasonably presented by the facts. Resulting conclusions for standard of care determinations will be

documented on the investigational tool (Appendix D). The primary reviewer must sign and date the

investigational tool. Preliminary standard of care determinations are recorded on the risk management

log.

VI DULY AUTHORIZED RISK MANAGEMENT COMMITTEES

Results of the investigation are presented to the appropriate committee for final standard of care

determination. All reviewers and committees shall be considered peer review committees pursuant to

the provisions of KSA 65-4915.

The RMC (Risk Management Committee) functions as the nursing/ancillary staff peer review/risk

management committee. Members include department heads from ancillary services, outpatient and

nursing; quality improvement director; the risk manager; and the administrator. The risk manager is the

chairperson.

The MSEC (Medical Staff Executive Committee) functions as the physician/credentialed practitioner peer

review/risk management committee. It is composed of directors for surgery, anesthesiology, obstetrics

and emergency departments. The Chief of Medical Staff is the chairperson. Non-voting members

include the health information director and the risk manager. Names and titles of all medical staff

involved with risk management peer review are included on the signature page.

Sample Risk Management Plan Page 5

Related Articles

Related forms

Related Categories