Sample Risk Management Plan (Page 6 of 9) in pdf

With respect to each reported incident. The committees must determine: (1) whether individual health

care providers met applicable standards of care expected in the facility; (2) if not, whether failure to

meet those standards caused injury or had a reasonable probability of causing injury to a patient; and

(3) whether any action by a health care provider might be grounds for disciplinary proceedings by the

appropriate licensing agency. A list of the acts (Appendix E) which are grounds for disciplinary action by

a health care provider licensing board is available to the risk management committees and all health

care providers, facility employees and facility agents through the office of Risk Management.

The activities of each risk management committee shall be documented in its minutes. Meetings are

held at least quarterly. The meeting minutes demonstrate that the committee is exercising overall

responsibility for finalization of all standard of care determinations. All standard of care 1 and 2

determinations, made by individual clinicians or subordinate committees shall be approved by the

designated risk management committee on at least a statistical basis. This approval will be documented

in the risk management committee minutes.

The minutes of the foregoing committees shall, also, document a specific standard of care

determination along with conclusions/rationale for all incidents with standard of care determinations of

3 and 4. Additionally, the minutes will document all incidents for which the standard of care has been

changed by the duly constituted committee and rationale for the change. Standard of care

determinations are recorded in the log.

The risk management committees may call upon the expertise of any facility personnel or medical staff

member in fulfilling their functions. All facility personnel, administration, and medical staff members

shall be obligated to cooperate with the risk management committees in acknowledgement of the joint

responsibility of the medical staff, facility personnel, and administration for risk management pursuant

to Kansas law.

Quality review-contractors/consults; all patient services including those services provided by outside

contractors or consultants shall be periodically reviewed and evaluated in accordance with the plan.

(Please specify how this review is accomplished in your facility).

The risk manager shall have the responsibility for filing quarterly reports (Appendix F) with the Kansas

Department of Health and Environment and reportable finding reports with the appropriate state

licensing agencies. The risk manager is also responsible for notifying the provider when a reportable

finding has been reported to their licensing agency.

VII STANDARD OF CARE DETERMINATIONS

Each facility shall assure that analysis of patient care incidents complies with the definition of a

“reportable incident” per KSA 65-4921(f). This facility shall use the following categories:

(1) Standards of care met

(2) Standards of care not met, but with no reasonable probability of causing injury

(3) Standards of care not met, with injury occurring or reasonably probable*

(4) Possible grounds for disciplinary action by the appropriate licensing agency*

*Categories 3 and 4 are reportable findings and by law must be reported to the appropriate licensing

agency.

VIII MINIMIZING OCCURRENCES

Facility X has established the following mechanisms to minimize occurrences:

Education: All new employees will receive information mandating their obligation to

report reportable incidents to the risk manager. The purposes of risk management and

how to report in this facility will also be explained. The Risk Management plan will be

reviewed at this time. Each employee will receive risk management in service on an

annual basis, thereafter. A copy of the Risk Management plan and a printed handout

explaining the risk management law will be provided to each medical staff member and

each board member at the time of appointment and annually, thereafter. Any time the

plan is amended, medical staff members, employees, and governing board members will

be informed of the changes.

Credentialing and Performance Evaluation: All Standard of Care determinations will be

applied to medical staff credentialing and employee performance evaluation. In

addition, reportable findings will be reported to the appropriate licensing agency.

Sample Risk Management Plan Page 6

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