Sample Risk Management Plan (Page 7 of 9) in pdf

Monitoring Frequency: Data relevant to reported variances/incidents will be compiled

by the risk manager in a statistical summary and will be presented quarterly to the

Quality Assurance Performance Improvement Director to be used for indentifying trends

in practice and patient care. The Quality Assurance Performance Improvement

Committee will analyze the frequency and causes of incidents and pursue measures to

minimize recurrence through the active cooperation of facility staff, medical staff and

administration. Statistical data and summaries will also be reported to the governing

board at least quarterly.

Facility Actions: Internal facility actions may be taken as a result of investigation and

data compilation and will be in accordance with facility policies and procedures and

bylaws of the medical staff bylaws and governing board.

IX PLAN

A copy of the current risk management plan will be included in the employee policy manual and the

bylaws of the governing board and medical staff. The plan will be reviewed and approved by the

governing board annually and whenever amended. All amendments will be submitted to the Kansas

Department of Health and Environment Risk Management Program Director for approval prior to

implementation.

X CONFIDENTIALITY

Any person or committee performing any duty pursuant to this plan shall be designated as a peer review

officer or committee pursuant to KSA 65-4915 and amendments thereto.

All reports and records made pursuant to KSA 65-4921 et seq, and amendments thereto, shall be

confidential and privileged. Such reports and records shall not be subject to discovery, subpoena or

other means of legal compulsion for their release to any person or entity and shall not be admissible in

any civil or administrative action other than a disciplinary proceeding by the appropriate state licensing

agency.

No person in attendance at any meeting of an executive or review committee or a medical care facility

or of a professional society or organization while such committee is engaged in the duties imposed by

KSA 65-4923 shall be compelled to testify in any civil, criminal, or administrative action, other than a

disciplinary proceeding by the appropriate licensing agency, as to any committee discussions or

proceedings.

No facility personnel, medical staff member or board member shall disclose information concerning

reportable incidents except to their superiors, administrator, risk manager, the appropriate facility and

medical staff committee or the licensing agencies, unless authorized to do so by the risk manager.

XI INTERFERENCE WITH RISK MANAGEMENT PROCESS AND RETRIBUTION FOR REPORTING

Attempts by any employee of the facility or medical staff member to inhibit or prevent

any other employee or medical staff member from reporting what they believe meets

the definition of an incident, shall not be tolerated, and will result in reprimand,

suspension, or termination of any person who tries to inhibit or prevent.

Pursuant to KSA 65-4928, the facility will not discharge or otherwise discriminate against

any employee for filing an incident report, or the facility may be subject to civil suit by

the employee for so doing.

XII RETENTION OF RM DOCUMENTS

Incident reports, investigation tools, minutes of risk management committees, and other

documentation of clinical analysis for each reported incident shall be maintained by the facility for not

less than one year following completion of the investigation.

XIII RESOURCE ALLOCATION

Facility X will provide necessary resources for a full-time risk manager (if part time, specify number of

hours) and other staff support necessary to fulfill the risk management program. The facility

administrator will designate individuals as necessary to complete data and to provide other identified

support for the risk manager.

Sample Risk Management Plan Page 7

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