Step-by-step process helps assess ambulatory care risk

Risk managers must investigate potential exposures with a critical eye, especially when the area in question is a new acquisition for the organization, says Donna Young, CPHRM, FASHRM, vice president of risk management services with Mutual Insurance Co. of Arizona in Phoenix. Young says self-assessments are particularly important when a new physician practice, clinic, or other type of operation is acquired by the organization, but she notes that the same step-by-step process can be used to study the risks posed by any department or the organization as a whole.

To conduct a self-assessment, Young uses an ambulatory care setting to offer this advice:

1. First obtain the loss history of the facility, department, or organization. Include the loss history of the physicians involved. The carrier currently providing insurance will have a loss history. Review the history to look for any potential problem areas.

2. Using that information, develop an audit plan that includes these key areas:

• Medical record documentation. Look for legibility, proper corrections, and whether allergies are prominently displayed and updated. Are baseline history, chief complaint, findings, and planned treatment well documented? Is the follow-up time frame documented? "Failure-to-diagnose claims often are related to treatment plans that called for a patient to be monitored for six months, and then the patient is seen in the office two or three times over the next year with no indication that the problem was monitored," Young says. "Is there a system in place to flag those patients and make sure that doesn’t happen?"

Are diagnostic and consultative reports in the chart with physician initials and date? Are no-shows and cancellations documented? What about prescription refills/proper approval, medication summaries, evidence of communication between providers, and all phone calls (including after hours)? "That is another area of weakness that can complicate defense of any claim," Young says.

Is patient noncompliance and/or informed refusal of recommended treatment documented? "That information can be vital in defending future claims," she points out. Are informed consent discussions/forms in place, including a discussion about risks, benefits and alternative treatments? Is patient education regarding health problems, medications, and plan of care documented? "Often we will see the record with that says, Risks and complications discussed.’ That, quite frankly, is not what you want to see," she says.

Walk around to see risks

• Systems. System failures play a big role in failure-to-diagnose allegations, so look for a system that tracks diagnostic test results and consult reports, a patient reminder system for important follow-up appointments or preventative screening, and a follow-up system for no-shows. Is the telephone triage system based on protocols approved by the physician? If nurse practitioners and physician assistants work with patients, is there a system in place for physician supervision? Is there a system that will notify patients of abnormal lab results? Is there a system for discharging patients from the practice?

3. Do a walkabout. Look at the office environment, premises safety, appropriate signage, privacy notices, HIPAA compliance, handicap accessibility, prescription pad security, syringes, medications secured, and staff using nametags with appropriate designations. "My experience is that you’ll learn the most about a facility by doing a walkabout on any given day," Young says. "It’s risk management by walking around. You do it in your hospitals and you can learn a lot by doing it in ambulatory care or any other area you’re assessing."

4. Call the office or department. Call as if you were a patient and see how well the systems work from that perspective. How accessible to patients is the physician? Is the answering system live or electronic? Do you get lost in a loop of automated choices? How long do you wait on hold? Are same day appointments available for emergencies and emergency department follow-up? Is there an office protocol for when the doctor returns calls?

Check procedure for collections

5. Look at billing and coding. Are account receivable procedures lawful and professional? Is physician approval necessary before turning an account over to a collection agency? Is accurate coding assured? Are midlevel providers being billed appropriately? "Do the coders understand how to avoid pitfalls that could lead to allegations of fraud and abuse?" Young asks. "Check to see if the physician reviews the medical record prior to the business office sending the claim to collections. It’s been my experience that several claims can be avoid if this occurs."

6. Develop an action plan. Make sure time lines are in place and reasonable. Include staff and physician education. Focus on communication skills as well as the basic risk management issues. Don’t forget that physicians should be required to attend education programs because their attitudes often set the tone for the entire practice or department.

"Education programs are excellent ways to improve communication and explain to doctors and staff the how’s and why’s of steps that will improve the system," Young says. "You may also want to remind that improving documentation and management of clinical information not only improves clinical care and patient outcomes, but also reimbursement from the health plan."