I RISK MANAGEMENT ^177 ^197

Risk management is an approach that aims to minimize the risk of patient injury and subsequent lawsuits through the following actions:

• Developing algorithms, policies, and procedures to decrease medical error

• Changing practice patterns to obtain quality care

• Showing clinicians how to document records properly to include all events that occurred

Risk management cannot always prevent a lawsuit.

The goal of risk management is quality medical practice. For the prac­titioner, risk management involves excellent communication skills, atten­tion to the process of informed consent, and thorough documentation practices. Risk management is also a team effort, and all participants, including staff members, must understand that the acts of one individual reflect on the entire team and easily can lead to liability for everyone. Communication breakdown among team members can be a major source of patient injury.

Risk Reduction

A program of risk management should be developed and maintained, with an emphasis on patient safety. This program should have the following elements:

• A person responsible for the risk management program and, if applicable, the risk management committee

• Periodic review of clinical records and clinical care policies

• Education in risk management activities for all staff within the insti­tution or office

• Methods to identify incidents and adverse occurrences that arise in the practice setting

The risk management program should address important clinical care issues, which may include, but are not limited to, the following:

• Procedures for communicating with patients about confidentiality issues, follow-up of abnormal tests or other results, and missed appointments

• Procedures for communicating with other physicians, hospitals, laboratories, and diagnostic imaging facilities to ensure efficient handling and follow-up of clinical information

• Methods for maintaining a realistic patient schedule and allowing for emergencies

• Periodic review for legal and medical accuracy of any forms used for informed consent

• Review of all incidents and complaints reported by employees, visitors, and patients

• Review of all deaths, trauma, or adverse outcome events

• Procedures for disclosure and discussion of adverse outcome events with patients and family members

• Periodic review of patient office records

• Periodic review of liability insurance policy coverage and exclusions in comparison to clinical activities performed

• Procedures for how and when to communicate with the professional liability insurance carrier

• Review of obligations under managed care contracts to ensure that proper procedures are followed

• Procedures for complying with applicable state and federal laws and regulations

• Procedures for addressing relationships with competing health care organizations so as to avoid antitrust and restraint of trade concerns

• Procedures for dealing with inquiries from government agencies, attorneys, consumer advocate groups, and the media

• Procedures for transfer of medical information at the patient’s request to other health care providers

• Procedures by which a patient may be dismissed from care or refused care

• Periodic performance reviews of employees and allied health personnel

• Procedures for managing situations in which a physician becomes acutely incapacitated during a medical or surgical procedure

• Identification and management of the impaired or disruptive health care providers

• Procedures for complying with contractual agreements

• Procedures for the prevention of unauthorized prescribing and the use of drugs

• Protocols for introducing the use of new technologies, devices, or medications

Practice Coverage and Referrals

Practice Coverage

Practice coverage outside normal business hours should be established and documented.

When a physician is not available for any reason, a qualified substitute practitioner should be identified and made available to patients. The office staff, hospital, and answering service need to be advised of the treating physician’s absence, along with the name and contact information for the covering physician.

Referrals

The obstetrician-gynecologist often serves as a primary medical resource and counselor to the patient and her family for a wide range of medical conditions. However, all clinicians, regardless of the extent of their train­ing, have limitations to their knowledge and skills and should seek con­sultation at appropriate times for reproductive and nonreproductive care.

Physicians may be reluctant to obtain a consultation and refer patients to a specialist for the following reasons:

• Unrealistic perception of one’s own level of expertise

• Belief that training is adequate to treat the patient’s condition

• Lack of recognition of limits of knowledge

• Lack of understanding of limits of skills

• Belief that knowledge base is sufficient to answer all questions personally

• Pressure from managed care plans not to refer patients

• Limited patient finances

• Concern that patient will leave the practice

• Physician’s moral beliefs or religious convictions

Once a physician is aware that a patient’s medical needs may fall out­side the realm of his or her expertise or present a conflict of conscience, appropriate care should be arranged. The physician should discuss the situation with the patient and make a referral to a competent specialist. Responsibilities for referrals and consultations are outlined in the “Human Resources” section later in Part 1.

Retirement or Office Closure

Patients should be given adequate notice that a medical practice is clos­ing. The period that constitutes adequate notice may vary from state to state. Usually, 30-60 days’ notice is sufficient. Patients should be given the names of other obstetrician-gynecologists or the telephone number of the local medical society. To expedite the transfer of care and reduce inconve­nience to the patient, an authorization form to transfer copies of the medi­cal record to the patient’s physician of choice, which is compliant with the Health Insurance Portability and Accountability Act, can be included with the letter of notification. The original record, all correspondence, and all authorization forms should be retained by the original physician. In gen­eral, only copies of records are transferred.

Considerations regarding how long to maintain medical records include the obligation to make records available for the patient’s future medical care, requirements of the Centers for Medicare & Medicaid Services, state rules for retaining business records, and state statutes of limitation for malpractice actions that involve adults and minors. The longest of these retention requirements should be followed. The physician should consult his or her attorney, county medical society, or liability insurance carrier for record retention guidance.

Billing

A billing system should be established to ensure reimbursement for ser­vices rendered. Payment and reimbursement requests should comply with all third-party payers and meet federal and state standards and guidelines. Physicians should develop a program to ensure that office visits, consul­tations, inpatient visits, and procedures are coded and billed accurately. Unpaid accounts should be reviewed before referral to a collection agency.

Federal scrutiny of Medicare claims has increased. To reduce the possi­bility of an allegation of fraud and abuse, it is wise to develop a compliance plan. Compliance plans are not currently required for physician practices by the U.S. Department of Health and Human Services. However, estab­lishing and following a compliance plan could reduce the anxiety and pos­sible acrimony that can be associated with a federal audit.

Adverse Events, Litigation Stress, and Physician Behavior

Among the many stressors encountered by physicians in clinical practice is the constant threat of adverse outcome events, with or without subse­quent medical professional liability litigation. Common responses to both adverse events and medical liability litigation include feelings of shock, denial, anger, anxiety, guilt, shame, and despair. These distressing emo­tions can disrupt relationships with patients and colleagues and potentially increase risk of error. Because a professional liability case in obstetrics and gynecology can take several years to resolve, coping is an ongoing, complex process in which physicians often must struggle to regain a sense of per­sonal identity, professional mastery, and control of their clinical practices. Residents, as young physicians in training, may be particularly vulnerable to this psychologic and emotional upheaval. A program of risk manage­ment should include education about the potential effect of adverse events and litigation stress on physician behavior and practice. Physicians should be made aware of resources and supportive mechanisms available to them.

Bibliography

American College of Obstetricians and Gynecologists. Coding responsibility. ACOG Committee Opinion 249. Washington, DC: ACOG; 2001.

American College of Obstetricians and Gynecologists. Professional liability and risk management: an essential guide for obstetrician-gynecologists. 2nd ed. Washington, DC: ACOG; 2008.

Coping with the stress of medical professional liability litigation. ACOG Committee Opinion No. 551. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:220-2. [PubMed] [Obstetrics & Gynecology]

Disclosure and discussion of adverse events. Committee Opinion No. 520. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012; 119:686-9. [PubMed] [Obstetrics & Gynecology]

Informed consent. ACOG Committee Opinion No. 439. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:401-8. [PubMed] [Obstetrics & Gynecology]

Professional liability and gynecology-only practice. Committee Opinion No. 567. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013; 122:186. [PubMed] [Obstetrics & Gynecology]

Seeking and giving consultation. ACOG Committee Opinion No. 365. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;109:1255-60. [PubMed] [Obstetrics & Gynecology]

Resources

Accreditation Association for Ambulatory Health Care. 2014 Accreditation hand­book for ambulatory health care. 2014 ed. Skokie (IL): Accreditation Association for Ambulatory Health Care; 2014.

American College of Obstetricians and Gynecologists. From exam room to court­room: navigating litigation and coping with stress [CD-Rom]. Washington, DC: ACOG; 2006.

American Congress of Obstetricians and Gynecologists. Healing our own: adverse events in obstetrics and gynecology [DVD]. Washington, DC: American Congress of Obstetricians and Gynecologists; 2012.

Hartnett J, Ginsburg K. Closing down a medical practice: guidelines and consid­erations. Washington, DC: American College of Obstetricians and Gynecologists; 2009. Available at: http://www.acog.org/About_ACOG/ACOG_Departments/ Practice_Management_and_Managed_Care/Closing_a_Practice. Retrieved July 16, 2013.

Office of Inspector General. Self-disclosure information. Available at: http://oig.hhs. gov/compliance/self-disclosure-info/index.asp. Retrieved August 13, 2013.

OIG compliance program for individual and small group physician practices. Office of Inspector General. Fed Regist 2000;65:59434-52.

OIG supplemental compliance program guidance for hospitals. Office of Inspector General. Fed Regist 2005;70:4858-76.

Publication of the OIG compliance program guidance for hospitals. Office of Inspector General. Fed Regist 1998;63:8987-98. [PubMed]