Cphrm

Front 1

Types of Event Identification

Back 1

Incident Reporting, Generic Screening, IHI Trigger Tools (occurence screening), RCA, FMEA.

Front 2

Risk Assessment Factors

Back 2

Likelihood: Frequency of event.
Impact: Severety of event.

Front 3

Sarbanes Oxley

Back 3

Signed into law July 30th, 2002.
To enhance corporate responsability, financial disclosures, and combat corporate and accounting fraud. Overseen by PCAOB.

Front 4

Enterprise Risk Management (ERM)

Back 4

Designed to ID potential events that may affect the entity, and manage risk to be within its risk apetite.

Front 5

L- Negligence

Back 5

Claims of general or professional liability. Most common cause of action among civil law claims and allegation against Health care providers.

Front 6

L-Breach of Duty

Back 6

Such as allowing hazards to exist.

Front 7

L-Cause of Injury

Back 7

Must suffer injury

Front 8

L-Damages

Back 8

Plaintiff must show legally cognizable damages as a s result of the injury sustained.

Front 9

General Liability

Back 9

Premise liability, slips, falls, defamation.

Front 10

Medical Professional Liability

Back 10

Malpractice- Negligence for patient care activities. Acts of omission that result in injury.

Front 11

Duty

Back 11

Standard of Care.

Front 12

Concept of Standard of Care

Back 12

Measured by the degree of care and skill possesed by other HC Professional withing the same or similar circumstances.

Front 13

Expert Testimony

Back 13

Must be licensed.

Front 14

Admisability of Expert Testimony

Back 14

Daubert: Supported by appropriate validation.
Frye: Principle and method underlying opinion is generally accepted by scientists active in the relevant field.

Front 15

Negligence Perse

Back 15

Adopt a statute as defining the standard of care.

Front 16

Informed Consent

Back 16

Two different varieties and difference is made by the determination of what constitutes a "material risk" of the procedure.
Traditional: Physician must disclose the risks that a "reasonable physician", under the same or similar circumstances, would have disclosed.
Affirmative misrepresentation of the nature of the procedure: The patient might have expressly consented to the performance of an appendectomy, after which the surgeon performed a hysterectomy.

Front 17

Peer Review

Back 17

Way of medical profession (Physicians) police its own activities. Protected under privacy and privilege information and generally protected from criminal and civil liability.

Front 18

Patient Confidentiality

Back 18

Communications between a physician and that physician's patients are private and confidential.
The improper disclosure of information (PHI) violates state confidentiality statutes, which generally provide criminal or civil penalties.

Front 19

Respodeat Superior Liability (Vicarious Liability)

Back 19

"let the master answer" Legal doctrine under which an employer may be liable for wrongful acts of its employee that are done within the scope of that employee's job. The hospital is vicariously liable for the actions of its employees who the hospital had a duty to supervise.

Front 20

Staff Credentialing

Back 20

Careful selection, review, and evaluation of health care providers. Courts have held health care institutions vicariously liable for the negligent acts of independent Physicians through the doctrine of apparent agency or ostensible agency (See respondeat superior)

Front 21

Agency by Estoppel (not permitted)
Ostensible or Apparent Agency

Back 21

A hospital may be held vicariously liable for the acts or ommisions of independent contractors. Under this theory, a hospital may be viewed liable if the patient looked to the institution rather than the individual Physician for care.

Front 22

Corporate Negligence

Back 22

A hospital has a non-delegeable duty to the patient to ensure the patient's safety and well being while a patient in the hospital. To prevail the plaintiff must prove:
1. That the hospital knew or had reason to know of a defect in its procedures: and
2. That the defect was a substantial factor in bringing about injury to the patient.

Front 23

Long-Term Care Liability - OBRA

Back 23

The Omnibus Budget Reconciliation Act of 1987 is the basis for the uniform regulations that govern the care and assessment of nursing home residents. Including in OBRA is the Federal Nursing Home Reform Act. To participate in Medicare adn Medicaid the SNF must survey and certify every 9 to 15 months:
1. Survey of the quality of care
2. Review of adequacy written care plans.
3. Audit of accuracy of residents asssesments.
4. Review of compliance with resident's rights.

Front 24

Types of Liablity

Back 24

Vicarious, Corporate, Claims

Front 25

Duty to Warn - Tarasoff

Back 25

A psychiatrist or licensed Psychologist cannot disclose information acquired while rendering proffesional services to a patient without the written consent of the patient. However, individuals may waive this privilege by placing their psychiatric state at issue in a lawsuit. An exception to the above includes the release of information if the patient poses a danger of violence to another individual to protect the intended victim against such danger.

Front 26

Integrated Delivery Systems

Back 26

An IDS consolidates a variety of professional, lab, and technical services to control costs. This may include:
1. Preadmission review
2. Discharge Planning
3. Utilization Review: Controls allocation of HMO resources.
4. Individual case management.
5. Second opinions.
6. Appeal Process: To contest case management decisions.

Front 27

HMO

Back 27

Health Maintenance Organization is an IDS that provides the financing and delivery of comprehensive health care services to participants for a prepaid fee. Common to the HMO is the PCP (Primary Care Physician) who acts as the gatekeeper. 4 types:
1. Staff Model- HMO directly employs staff physicians and other providers. Also occasionally own or lease their own healtcare facilities.
2.Group Model-HMO contracts with independent medical groups.
3.Network: HMO contracts with different groups of physicians who are permitted to continue to treat non-HMO patients.
IPA-Individual Practice Associations. Contracts on a capitation basis with IPA which in turn contract with individual private practitioners in their own offices.

Front 28

PPO Preferred Provider Organization

Back 28

A PPO consists of Physians hospitals, and other medical providers who contract to provide medical care to a defined group of patients on a negotiated, discounted fee-for-service basis.

Front 29

Point of Service

Back 29

POS: combines basic features of and HMO and PPO. The covered person may treat with a non-network provider but at a reduced level of benefits.

Front 30

Exclusive Provider Organization

Back 30

EPO - Similar to a PPO, and EPO consists of a group of participating providers with contractual agreements to an insurer or other sponsoring group to provide services.

Front 31

Physician Hospital Linkages

Back 31

Venture between a hospital(s) and a group(s) of physicians, generally the hospital's medical staff and other ancillary providers, who have streamlined their services to act as an integrated whole.

Front 32

Tradional PHO

Back 32

Serves as the contracting agent for multiple HMO's and PPO's.

Front 33

Management Services Organization

Back 33

MSO assumes the financial risk associated with health care management by purchasing the assets of a proffesional corporation and then leasing the assets back to the group.

Front 34

Foundation Model

Back 34

Corporation that is organized by a hospital, a group of hospitals, or a group of non-profit doctors with a common parent organization. The foundation thus provides the physical plant, administrative and marketing services, and non-medical personnel. For the most part, physicians have little control in a foundation model.

Front 35

Integrated Health Organization

Back 35

IHO in an organization that requires a separate legal entity, such as a parent corp., with at least two subsidiaries (such as a hospital and a management services organization), and often a third such as an educational or research foundation.

Front 36

Employee Retirment Income Security Act - ERISA

Back 36

passed in reaction to widespread concern regarding the integrity of nationwide employee benefit or pension plans.

Front 37

The United States of America Court System

Back 37

It has fifty-one distinct court systems. There is a federal court system, that can draw upon state or federal law, and there are fifty different state court systems. Although each is different, there are certain similarities inherent in each system.

Front 38

Court Jurisdiction

Back 38

All courts must have jurisdiction over the parties and the subject matter of the dispute to render a competent judgement in any particular case. (Although "jurisdiction" is often used a short hand term for the geographical area over which a particular court may have the power to hear cases, the term actually refers to a court's power to hear and decide cases.)

Front 39

Lawsuit

Back 39

All potential plaintiffs must have standing to bring a lawsuit. This generally means that they must have suffered and injury that may be redressed (set right; remedy or rectified) by the law, or they may be threatened by or in fear of an injury that could be prevented by legal means.

Front 40

Forum non conveniens

Back 40

All actions must be brought in the proper venue. Venue is determined by statute and generally is concerned with issues of fairness, efficiency, and judicial economy.

Front 41

Elements of Negligence

Back 41

To prevail the plaintiff will be required to show:
1. the existence o fa duty running from the defendant to the plaintiff
2. Breach of that duty
3. Injury caused by the breach of the duty;
4. Damages as a result of the injury.

Front 42

Res ipsa Loquitur

Back 42

"the thing speaks for itself" :
Event or outcome is one that does not normally occur in the absence of negligence. 3 elements involved:
1.Accident must be of a type that does not normally occur in the absence of negligence
2. The instrumentality must have been entirely within the control of the defendant.
3. The plaintiff must not have had any responsability, through voluntary action or contribution, for the event. The most common claim in Health Care in the case of RFO (Retained foreign body) following surgery.

Front 43

Strict Liablity

Back 43

Attaches when society will not permit a defendant to mount a defense against the allegations of liability made by the plaintiff. e.g: allowing dangerous animals to run free.

Front 44

Intentional Torts

Back 44

Arise out of actions taken by the defendant with the intention of causing the outcome that resulted.

Front 45

Assault

Back 45

Civil:Occurs when one places another in a position in which the other fears that a battery will occur. Thus lunging at someone with a knife, but with no contact, is an assault.
Criminal: subsumed into the crime of battery to the point where the two words have become virtually a single term.

Front 46

Battery

Back 46

Simple tort. It merely requires the touching of another person's body without that person's consent. One must show injury or damage of some sort if one wishes to prevail in a lawsuit. However, it is possible to make a showing of damages based upon a psychological or emotional injury.

Front 47

Consent

Back 47

General Consent: will suffice for non-invasive, relatively low-risk procedures.
Informed consent: will be required in any situation where the proposed procedure or treatment carries a material risk of harm.

Front 48

Essential Responsibilities of a Hospital Board

Back 48

Patient Safety, finances, improvements, new services, Better patient outcomes, a patient-friendly hospital

Front 49

Basic legal duties of Health Care Trustees

Back 49

Many not-for-profit corps. use the term trustee because many early not-for profit corps. began as charitable trusts. Trustee therefore may mean directors. Management presonnel who support the governance of a Health Care Org. must understand the two basic duties of trustees: The duty of care and the duty of loyalty.

Front 50

Duty of Care

Back 50

Duty to act in good faith, with the care that an ordinarily prudent person in a similar position would use under those circumstances.

Front 51

Acting in the best interest of the corporation

Back 51

Duty of reasonable care, meaning that the board members have the duty to explore all options before they make an important decision--To "do their homework", so to speak.

Front 52

Duty of loyalty

Back 52

No competing with the corporation, No disclosure of confidential information, no usurping corporate opportunity, no personal enrichment at corporate expense.

Front 53

Risk Management and the Board

Back 53

Duty to prevent or minimize corporate loss from legal liability. This may involve developing systems to prevent adverse events and attempting to handle events that occur in such a manner that the organization's financial and reputation cost are minimized.

Front 54

Ethical Principles adn Moral Obligations

Back 54

The basic ethical principles that are more relevant to clincal bioethics are:
1. Beneficence, which creates an obligation to benefit patients and other people, and to further their welfare and interests
2. A principle of respect for patient's autonomy
3. Nonmaleficence, which asserts an obligation to prevent harm or, if risks of harm must be taken, to minimize those risks.
4. Justice, which is relevant to fairness of access to health care and to issues of rationing at the bedside.

Front 55

Clinician Moral Obligations to Patients

Back 55

1. To respect the Pt's privacy and maintain a process that protects confidentiality
2. To communicate honestly about all aspects of the Pt's dx, tx and Px.
3. To determine whether the Pt is capable of sharing decision-making
4. To conduct and ethically valid process of informed consent throughout the relationship.

Front 56

Ethics in research

Back 56

For the most part governed by the IRB(Institutional Review Boards) which maintains strong safeguards for the safety of human subjects in medical research is a paramount obligation of clinical investigators and their institutions.

Front 57

Patient Self-Determination Act

Back 57

Federal Act. Requires institutional health care providers who receive federal funds to inform Pt's of their right to make health care decisions.(Usually at time of admission). DNR is part of this self determination.

Front 58

Definition of Insurance

Back 58

a system by which a risk is transferred by a person, business, or organization to an insurance company, which reimburses the insured for covered losses and provides for sharing of costs or losses among all insured.
An organization can retain risk or transfer its risk to another organization.

Front 59

How insurance is regulated

Back 59

Highly regulated industry. Most regulation is mandated at the state level. Nearly all states give their insurance dpts. the power to regulate rates, to license insurers and insurance company reps, to approve policy forms, and to respond to consumer complaints.

Front 60

Insurance company financial security

Back 60

The financial stability of an insurance carrier should be a key consideration in an insured's decision to transfer risk. If an admitted carrier fails, its insureds may have access to the state guaranty fund (usually limited).

Front 61

Insured obligations

Back 61

Provide promt notice of loss.
Cooperate with the insurer in investigation and settlement of loss.
Obligation to pay the premium in a timely manner.
Conditions under which the policy may be canceled or non-renewed.
Insurer's right to inspect the premises.
Coverage territory of the policy.
Applicability of limits, deductibles, and defense expenses.

Front 62

How Insurance is Purchased

Back 62

Most Health Care Risk Managers gain access to the commercial insurance market by using an insurance broker or independent agent.

Front 63

Drafting Coverage Specifications

Back 63

Risk Management Professionals often have the resposiblity of securing cost-efficient, comprehensive insurance coverage.
Process must begin at least 6 mos. before policy inception.
This application is called Undewriting submission. These include:
Description of operations and org. chart.
Listing of named insured.
Retroactive dates.(If claims-made)
Location listing
Current hx exposure info.
Current valued hx loss experience.
Large loss detail for any claim > 100,000.
Signed apps
Current annual report or other financial statements.
Description of risk management dpt. procedures including loss prevention, QI,Patient safety initiatives, and claims mgmt.
Current actuarial report.
Trust,Captive, or undelying coverage docs.
TJC or other accreditation report
Description of desired coverage-limits, deductible, coverage extensions, underlying coverages, pricing guidelines, policy period, key coverage terms, or services.

Front 64

Insurance Hard and Soft Markets

Back 64

Insurance industry is cyclical. It is characterized by periods of low premium, flexible terms, and generous capacity(SOFT) followed by periods fraught with escalating premiums, strict underwriting procedures, and limited availability of coverage(HARD).

Front 65

Do not resuscitate (DNR) orders

Back 65

Self determination act

Front 66

Brain Death Criteria

Back 66

look up

Front 67

Withdrawal of life support

Back 67

look up

Front 68

How to Develop a Risk Management Plan

Back 68

Program description;
Scope of program/components
RM role/ Integration
Policies & Procedures

Front 69

Risk Management Metrics

Back 69

Total number of claims, PCE's, Cost of Risks, Average defense cost of particular type of claims-Incurred but not reported (IBNR)
*Caution with using benchmarking (not a good source of data)

Front 70

Key Elemements of a Risk Management Program (Must memorize these)

Back 70

Coordination with key stakeholders:
C-suite,Medical staff,finance dpt,Medical records,Quality Improvement,Pharmacy,Infection Control,Materials Management,Patient relations,Public relations,Nursing,Worker's Comp,Billing,Education(GME,Clinical),Medical library

Front 71

Key Elemements of a Risk Management Program

Back 71

Authority, Visibility,Communication,Coordination,Accountability.

Front 72

Claims made coverage

Back 72

Provides coverage for a claim that occurred after the inception of retroactive coverage date of the policy and is reported to the insurance company while the policy or any replacement policy is still in effect.
To change claims-made carriers one can:
Maintain original retro date (nose)
buy an extended reporting endorsement (tail) from existing carrier and establish a new retro date with the new carrier (good for Retiring physicians)
The retro date will usually predate the effective date on the policy

Front 73

Occurrence Coverage

Back 73

Provides coverage for a claim that occurred during the policy period regardless of when the claim is reported to the insurance company

Front 74

Claims-Made coverage (retroactive date)

Back 74

The date defining the beginning of the coverage period for the claims-made policy; this date is retained on an indefinite basis if one remains with the same carrier

Front 75

Claims-made coverage (nose)

Back 75

Period of time between an insured's retroactive date and the current policy period

Front 76

Claims made Tail coverage

Back 76

Permits an insured to report claims that are made after a policy period has expired or has been canceled, provided the wrongful act giving rise to the claim took place during the policy term.
Provides coverage for a claim which occurred after the inception or retroactive coverage date of the policy and is reported to the insurance company while the policy or any replacement policy is still in effect.

Front 77

Ethics commitee Risk Manager Role

Back 77

Be a neutral party during the discussion
Serve as a facilitator
Act as a consultant on legal issues
Develop ethics consultation mechanism

Front 78

HR Issues

Back 78

At will doctrine
Erosion of the application has resulted from new statutes and laws

Front 79

EEOC Equal Employment Opportunity Commision

Back 79

Fed agency responsible for investigating charges of discrimination. 180 days limit.

Front 80

Workers Comp

Back 80

Promotes study of causes
Provides single remedy and reduces court delays and legal fees
Encourage max employer interest in safety and rehab

Front 81

OSHA RULES

Back 81

Be familiar w OSHA 300,301,300A,needle stick prevention act,

Front 82

Human capital risks

Back 82

Absence and productivity mgmt

Front 83

Data management

Back 83

Med record is the PRIMARY comm medium for planning,coord,and orchestrating patient care.

Front 84

Documentation

Back 84

Fed and state statutes
Professional practice standards
Specific hospital
Accredit bodies
Third party payers

Front 85

Contract definition

Back 85

An agreement between two or more persons that creates an obligation to do or not do to a particular thing

Front 86

Five legal essentials

Back 86

Parties to contract are competent
Mutual understanding
Consideration for legal value
Contract is documented in writing
Purpose or object of contract is legal

Front 87

Directors liability

Back 87

Mergers acquisitions and diversitures

Front 88

Stock acquisitions

Back 88

Normally the acquiring company assumes all legal liabilities

Front 89

Asset purchase

Back 89

Normally there is no transfer of liability

Front 90

Successor liability

Back 90

The acquiring company can be held liable for the torts of the target companies previous owners

Front 91

Advertising liability

Back 91

Avoid statements about success rates or outcomes, creating apparent agency relationships,representations about high quality

Front 92

Sentinel Event

Back 92

Any unexpected ocurrence involving death or seriuos physical or psych injury, or the risk thereof.

Front 93

FMEA

Back 93

Method used to ID those risks inherent in care delivery.
Proactive model to ID weak points, incidents or events before they occur

Front 94

Risk Priority Number

Back 94

Ocurrence*detection*severity
Where:
Likelihood of ocurrence 1-10
". ". of detection 1-10
Severity. 1-10

Front 95

HRO high reliability orgs

Back 95

Preocupation with failure,reluctance to simplify,sensitivity to ops, commit to resilince,deference to expertise

Front 96

Human Factors

Back 96

Why humans make mistakes: cognitive concepts:
Slips tend to occur with routine acts
lapses memory failure
mistakes judgement failures

Front 97

Human error reduction strategies

Back 97

Simplification, standardization,forcing functions,reduce reliance on memory and vigilance,use of protocols and checklists, avoid and reduce fatigue, heighten awareness of error prevention through communication and training

Front 98

Just culture, Why?

Back 98

2-3% errors reported in general
HC workers would report only what they could not hide
Errors are viewed by hospitals and the public as acts of carelessness

Front 99

Insurance

Back 99

System by which a risk is transferred to an insurance company, which reimburses the insured for covered losses and provides for sharing costs of losses among all insureds

Front 100

Risk retention groups

Back 100

Insurance co that provides liability to its members and owners; members must be similar or related entities with respect to the liabilities to which they are exposed.
Reciprocals and purchasing groups

Front 101

Insurance Policy

Back 101

Legal contract. Standard elements:
Declarations page
Insuring agreement
Conditions
Exclusions

Front 102

Excess insurance

Back 102

Sits over specific primary insurance to afford additional limits of liability

Front 103

Umbrella liability

Back 103

Sits excess over several lines of liability coverage:
Professional liability
Commercial general
Employers
Automobile
Aircraft heli

Front 104

The process of reviewing loss runs include?

Back 104

$ amt. established in reserves for each claim.

Front 105

Negligence 4 D's

Back 105

Duty to exercise reasonable care "standard"
Duty breached
Direct proximate causation injury
Damages resulted

Front 106

Defend vs settle

Back 106

Meritorius vs frivolous
Alternative dispute resolution avoids cost delay
Binding/nonbinding
Arbitration
Mediation
Negotiation

Front 107

Arbitration

Back 107

Binding most of the time

Front 108

Mediation

Back 108

3rd trained non partial mediator. Non binding

Front 109

Negotiation

Back 109

Informal with atty present to negotiate settlement

Front 110

Advantages of ADR alternative dispute resolution

Back 110

Economical quick less hostile more private

Front 111

Settlement

Back 111

Negotiation agreement dismissal guardian ad litem
Reporting is required to national practioner data bank NPDB
State licensing agency

Front 112

Litigia process

Back 112

Assignment of counsel
Acknowledge receipt-default judgement
Answer cross claims or joinders
Investigation medical reviews
Discovery interrogatories depositions subpoenas or subpoenas duces tecum

Front 113

Potential liabilities related to credentialing

Back 113

Negligent credintialing
Economic credintialing
Corporate liability
Breach of patient privacy
Violation of the ADA

Front 114

RM functions and PI basic principles

Back 114

Requires senior management support
People do not malfunction, process do
Reducing process variation reduces the potential for error and inefficiency
All process and outcomes must be measurable
Problem solving must include multidisciplinary approaches that empower all employees to participate in the quality process.
REMEMBER: PDSA (IHI Model)

Front 115

Benchmarking as a Quality Improvement tool

Back 115

Is a comparative porcess used by org. to collect and measure internal or external data that might ultimately be used to develop, implement, or sustain quality improvements.
Bld. Concensus, collect and analyze data, Implement and monitor process improvement activities.
System Barriers to Benchmarking: Technical, stuctural, psychosocial, managerial, cultural.

Front 116

Ethics Principles

Back 116

Autonomy: Ability to make decisions w/o undue influence.
Beneficence: To do good and protect from harm
Non-maleficence: To avoid causing harm or prohibition against cruel tx.
Justice , fairness and equal distribution.
Non-discriminatory care.

Front 117

Ethics Issues

Back 117

Created by the collision of :
Law, Medicine, Biotech, Business,Philosophy,Religion.

Front 118

Advance Directives

Back 118

legal document that communicates and individual's medical decisions or appoints someone else to make decisions on that person's behalf (Agent) shoudl the individual become incapacitated and either permanently unconscious or terminally ill. Two types: Living wills-wishes within a period of time prior to the patient's anticipated death.
Durable power of atty:Usually allows a surrogate (agent) to make decisions on the Pt's behalf whenever the Pt is incapacitated, regardless of imminence of death. Governed at the state level. No uniform doc. Preferably written, but can be verbal. Specify what to or not include. Pt. can change mind at last minute.

Front 119

Do not Resuscitate

Back 119

Requires a Dr's Order to withhold life saving treatment, and intended to end or prolong the agony of dying. Does not require an advance directive as a pre-condition. May be rescinded for surgical interventions.

Front 120

Surrogate

Back 120

Individual who is legally authorized to make HC decisions on behalf of a patient who cannot make or communicate decisions d/t incapacity. These include common in law next-of-kin or an individual designated by the patient in a DPA.

Front 121

Institutional Review Boards (IRB)

Back 121

Roles:
ID risks of the research
Minimize risks as much as possible
ID probable benefits
Eval the risks in relation to the benefits.
Determine intervals or periodic review and mechanisms for monitoring data collection.
Ensure that research subjects have the right to accept, reject, or terminate participation.

Front 122

Case Law: Stanford Hospital Vs. Vega (1995)

Back 122

Jehovah's Witness refused a blood transfusion: Was transfused against her will by court order.
A healthcare facility cannot
presume to substitute its
own judgment for that of the
patient, or make decisions
on behalf of the State, or
take action simply to preserve
its own notions regarding
the integrity of the
medical profession.
A healthcare facility may go
to court as a neutral party
seeking guidance. As a
practical matter, the law
must allow a healthcare provider
the opportunity to seek
guidance from the legal system
before going ahead, either
to disregard a patient’s
rights, or to allow a patient’s
life to expire without attempting
a standard medical
intervention.
SUPREME COURT OF CONNECTICUT, 1996.

Front 123

Case Law: Karen Ann Quinlan 70 NJ 10 (1976)

Back 123

The state had promised to prosecute anyone who terminated Quinlan's life support because such an act would constitute homicide. The New Jersey Supreme Court, however, rejected this consequence because the resulting death would be from natural causes. The court stated:

The exercise of a constitutional right, such as we have here found, is protected from criminal prosecution.… The constitutional protection extends to third parties whose action is necessary to effectuate the exercise of that right.…

Front 124

Case Law: Cruzan v. Director, Missouri DPH (1990)

Back 124

The Court ruled that the State of Missouri could prohibit the Cruzan family from removing feeding tubes from Nancy because there was no clear evidence that she would have wanted medical treatment stopped.

After the Court upheld the right of Missouri to demand “clear and convincing evidence,” a new hearing was held before a Missouri court to determine Nancy Cruzan's fate. After hearing testimony, a State judge authorized the disconnecting of the feeding tubes. Nancy Cruzan died several days later.

Front 125

Case Law: Schiavo v. Schiavo (2005)

Back 125

Patient with anoxic brain injury. Husband wanted to remove feeding tubes, but Terry's parents opposed. They requested to have husband removed as guardian. Case involved 14 appeals endind on the order for removal of feeding tubes. Terry expired after removal of life support.
Conflicting interests .

Front 126

Capacity (Ethics)

Back 126

Patient must be: Of age (varies greatly by state and circumstances)
Able to understand the nature of the situation and the consequences of the decision.
Able to communicate the wishes of the caregiver.
Capacity normally is determined by the physician.
*Capacity is not determined based on patient's disagreement with Physician's care. HINT: Psych consult.

Front 127

Futile Care

Back 127

Quality of life is defined by the patient's values, not by the surrogate or caregiver's.
Physicians are not required to violate their own ethical or religious beliefs.
Clinical staff may decline only for reasons of "conscience".
Do not abandon Pt. Arrage for xfer.
Have appropriate policies.
Avoid court as much as possible.
Negotiate with Pt and family.
Use Ethics Commitee.

Front 128

Culturally appropriate care

Back 128

The National Quality Forum endorsed 45 best practices. Issues addressed:
Communication, Community engagement, workforce training.

Front 129

Ethics Commitee

Back 129

Chairperson should be well educated or trained in ethical issues.
Appropriate medical and clinical staff should be included.
There should be a clerical representative from the religious community.
A layperson from the community shoud be a member.
Decisions are nonbinding _ Consulative only.

Front 130

Topics for Ethics commitee

Back 130

Abortion and reproductive rights.
End of life or futile care.
Quality of life.
Surrogate decision-making.
Advance Directives.
DNRs.
Medical Resources.
Staff rights that conflict with patient's wishes.

Front 131

Loss Prevention

Back 131

Risk control technique reduces the likelihood of an untoward event occuring and focuses on reducing the frequency of loss. Core of most Health Care RM programs. Proactive in nature, and includes staff education, policy, and procedure review and revision. These interventions aim to control the # of adverse events w/o unduly eliminating potentially risky activities.

Front 132

Under what circumstances should I use an ethics committee?

Back 132

You should consider asking for a consult when two conditions are met:

you perceive that there is an ethical problem in the care of patients, and
resolution does not occur after bringing this to the attention of the attending physician.
Most "ethical problems" turn out to be problems due to lack of communication. However, sometimes a true ethical dilemma occurs, frequently because there is a conflict between principles (autonomy, beneficence, justice) or between principles and outcomes.
At most hospitals, anyone may request an ethics consultation including the patient or family. Please check the hospital's policies to learn how to request an ethics consultation.

Front 133

Risk Management

Back 133

The process of making and carrying out decisions that will assist in prevention of adverse consequences and minimize the adverse effects of accidental losses upon an organization. Making these decisions requires the five steps in the decision process (ARM)

Front 134

Steps in Risk Management Process (MUST KNOW)

Back 134

ID and analyze loss exposures (New and existing services)
Examine alternative risk management techniques (Risk Control and Risk Financing)
Select the best risk management technique or combinations of techniques.
Implement selected techniques.
Monitor, evaluate, and improve the RM progam. (I Eat Sugar In the Morning)

Front 135

Risk Identification Definition

Back 135

Identification of problems or potential problems that can result in loss:
Type of value exposed to loss.
Potential cause of loss (peril)
Extent of the projected financial consequence of the loss.

Front 136

Purpose of the Medical Record

Back 136

provides a database for planning, evaluation, and treatment
allows for continuity of care
documents the patient's day-to-day condition
documents communications between the primary care provider and other health care professionals involved, and
provides written evidence that can be used to protect the legal interests of the hospital and/or health care provider(s).

Front 137

Systems for Risk ID

Back 137

Informal: Claims data,MR requests,Member complaints,Standard surveys and questionares, Personal inspections and walk arounds, commitee minutes, survey or regulatory reports,Recall notices,Experts (internal,ext)Hotline or grapevine,Collab relationships.
Formal: Incedent reports,Ocurrence reports and screening,Sentinel event tracking,FMEA,Device reporting adn tracking logs, Security reports,QA reviews, Peer review data,RCA,Never events tracking.

Front 138

Net Income Losses (the bottom line)

Back 138

Revenue + Gains - Losses(expenses).
e.g Cardiac program had revenue of 750,000 dollars -operation costs of 100,000 (insurance, .

Front 139

The COP’s that are found within the Medicare regulations (42 C.F.R. Sec. 482 et. seq.) are:

Back 139

Conditions Of Participation that must be met by the respective provider programs in order to participate in the Medicare program (Ch. 38 Statutes, Standards and Regulations)

Front 140

EMTALA is best described as a(n):

Back 140

Non-discrimination statute that was enacted in response to hospital ED’s (Emergency Department) that refuse service to patients who lack the ability to pay (Ch. 38 Statutes, Standards and Regulations)

Front 141

The Newborns’ and Mothers’ Health Protection Act of 1996 is a law that says:

Back 141

health plans and health insurance issuers may not restrict covered hospital benefits for a mother and her newborn to less than forty-eight hours following vaginal delivery or ninety-six hours following cesarean section (Ch. 38 Statutes, Standards and Regulations)

Front 142

ERISA (29 U.S.C. Sec 1001) is:

Back 142

The Employee Retirement and Income Security Act that establishes a nationwide standard for administrative functions of employee welfare benefit plans and a federal preemption of state laws that cover plan benefits. (Ch. 38 Statutes, Standards and Regulations)

Front 143

The Anti-Kickback Statue (42 U.S.C. Sec. 1320a-1327a) :

Back 143

Prohibits a provider from knowingly or willfully soliciting, receiving , offering or paying remuneration for services paid for under any federal health care program (Ch. 40 Corporate Compliance)

Front 144

Safe Harbor Regulations

Back 144

Lists certain types of transactions that are immune from federal prosecution

Front 145

Stark I, the Ethics in Patient Referrals Act

Back 145

Prohibits physicians from referring Medicare or Medicaid patients to clinical labs in which the physicians has a financial interest

Front 146

Which of the following coverages generally will respond for losses arising from valet parking operations?

Back 146

Garagekeeper’s liability,General liability

Front 147

Which of the following should be included in an institution’s contract with a vendor for biomedical equipment?

Back 147

a) The responsibilities of each party regarding preventative and ongoing maintenance of the particular biomedical equipment.
b) A guarantee of equipment “uptime” or prompt provision of a substitute acceptable to the facility for biomedical equipment critical to patient care.
c) A procedure for the vendor to directly notify the institution regarding identified product hazards or recalls.

Front 148

On a steamy summer afternoon, an 86 year old female was walking toward the entrance of a physician’s private practice office. There had been a light rainfall two hours before. As she stepped from the parking lot to the sidewalk, she slipped on the curb and tore her dress and stockings. The lady sought reimbursement for her damages when she later heard that a portion of the sidewalk near the door needed to be replaced the day after she fell. Which of the following defenses could reasonably be employed to deny this claim?

Back 148

The sidewalk that was replaced the day after her fall was not he proximate cause of her fall.There was no breach of duty.

Front 149

During an operation on an 18 year old male in a JC accredited hospital, an electrocautery device ignited the surgical drapes. The fire was quickly extinguished by the operating room staff; however, the patient suffered second degree burns to his right thigh. Based on all applicable state and federal laws and regulations, the best course of action for the risk manager is to:

Back 149

Secure the device until it can be examined independently. (chapter 45)

Front 150

Which of the following DOES NOT pertain to first party insurance?

Back 150

Automobile liability (chapter 22)

Front 151

Workers Compensation laws vary from state to state. The objective(s) below that best describe(s) the underlying intent of Workers Compensation laws is/are:

Back 151

It provides a reasonable income and medical benefits to work-accident victims, or income benefits to their dependents, regardless of fault.It provides a single remedy and reduces court delays, costs and workloads arising out of personal injury litigation.It eliminates payment of fees to lawyers.It encourages maximum employer interest in safety and rehabilitation of their employees.It promotes frank study of causation of accidents

Front 152

There are many state variations in the methodology used to compute workers’ compensation insurance premiums, but generally the premiums are based on the following considerations:

Back 152

b) Statistical data as provided by the NCCI (National Council on Compensation Insurance)d) Covered payrolle) Covered employee’s risk classificationsf) An experience modifier

Front 153

OSHA (The Occupational Safety and Health Act of 1970 (revised in 2001) requires employers with :

Back 153

Ten or more employees to collect information on the type, number and severity of employee injuries on in an OSHA 300 log (CH. 36)

Front 154

One common definition of ergonomics is:

Back 154

The science of designing work tasks to fit the employee (Ch. 35)

Front 155

Risk Managers should consider the following in developing an effective risk control and loss prevention program and promoting a culture of workplace safety:

Back 155

a) Everyone is held to the same standard for personal protection (such as gloves, masks, etc.)
b) Objectively measuring safe attitudes and behaviors of staff and linking successful attitudes and behaviors to rewards
c) No one, at any level, perceives it as unacceptable to bring a violation of safety standards to managements’ attention
d) All levels, from executives to part-timers, know and understand the company accident prevention plan and the goals set for it

Front 156

A PCE is a:

Back 156

Potentially Compensable Event

Front 157

A PCE may include:

Back 157

an unexpected event causing injury or potential injury that has occurred in the course of a patient or member’s treatment
a denial of treatment
an expression of dissatisfaction or perceived injury by a patient or family
events a risk manager would predict would give rise to a demand for compensation or lawsuit(Ch. 9 Claims and Litigation Management)

Front 158

The first thing a risk manager should do when a PCE is reported is:

Back 158

Ensure that the patient continues to receive prompt care (Ch. 9 Claims and Litigation Management)

Front 159

A PCE should be reported to:

Back 159

The claims manager/insurance company by the risk manager as soon as is reasonably possible (Ch. 9 Claims and Litigation Management)

Front 160

The risk manager, when investigating a PCE, should do the following:

Back 160

Ascertain the facts
Interview the involved providers and staff
Evaluate the need to report to appropriate regulatory bodies (eg. state Department of Health Services, FDA, etc.)
Secure any and all evidence that may be pertinent to the effective defense of a future claim and define a chain of custody for all sequestered evidence
Direct staff to complete the medical record as soon as possible after the event
Sequester appropriate expired insurance policies in effect at the time of the event and determine limits of coverage
Secure and copy all relevant policies and procedures in effect at the time of the event
Keep an ongoing confidential file and diary to update at regular intervals

Front 161

What does MDQR stand for?

Back 161

Medical Directors’ Quality Review

Front 162

In ethical decision-making, the most accurate definition of a “surrogate” is:

Back 162

The individual who is legally authorized to make health care decisions on behalf of a patient who is unable to make or communicate decisions on his or her own behalf due to incapacity (Ch. 30 Ethics and Patient Care)

Front 163

In a recent court decision, In Re K.I. nos. 98-FS-1683 and 98-FS-1767m 1700-1742 (D.C. App. 1999), the court recognized that parents have a fundamental constitutional right to the care, custody, and management of their child that is:

Back 163

not absolute, but must yield to the best interest and well-being of the child (Ch. 30 Ethics and Patient Care)

Front 164

In the event of a disagreement between clinician and surrogate as to the appropriate course of action for a patient who lacks decisional capacity; the best course of action for the risk manager to recommend is:

Back 164

Internal mechanisms to resolve the matter, including an ethics committee consultation (Ch. 30 Ethics and Patient Care)

Front 165

There are three basic ethical principles that are particularly relevant to the ethics of research involving human subjects. They are:

Back 165

respect, beneficence and justice (Ch. 30 Ethics and Patient Care)

Front 166

A group of surgeons, anesthesiologists, O.R. leaders and Patient Safety leaders have submitted a proposal to the Institutional Review Board (IRB) to study behaviors of O.R. teams and link them to clinical outcomes with the intent of establishing an evidence base for Human Factors training. The proposal was approved by the IRB. Two months into the study, the researchers decided to change the methodology from videotaping the teams to having trained observers in the Operating Room to observe the teams.

The IRB is backlogged for months and the researchers fear their revised proposal would take months to be re-evaluated by the IRB. 5. The alternate course of actions for the researchers would be to:

Back 166

Suspend the study until they can obtain an opinion from the IRB. (Ch. 30 Ethics and Patient Care)

Front 167

The Risk Manager should assess organizational risk related to research in the following areas:

Back 167

a)whether the institution has an internal monitoring system to verify that investigators are complying with research protocols
b)whether the institution’s research meets regulatory requirements (such as the Nuclear Regulatory Commission for research conducted in nuclear medicine)
c)whether the institution is following the OIG’s (Office of the Inspector General) and the DOJ’s (Department of Justice) requirements that all federal funds obtained for research are properly obtained and there is no basis for prosecution under fraud and abuse laws
d)whether the research protocols are adequately considering the new HIPAA requirements for protection of PHI (Protected Health Information