Role of Risk Management

Transport services are well aware of the value of the preventive maintenance and flight checklists that must be used to keep their aircraft in safe operation. Similar attention to the medical-legal component through risk-management activities likewise prevents quality, compliance, and legal issues from imperil­ing the operation.

The risk-management role has many aspects that might be assigned to different members of the team and administration rather than to a single risk manager, but the elements still need to be covered to ensure the long-term survival of the service as a viable business entity so that critical public safety needs can be met.

Credentialing

A critical factor in managing risk is attention to the credentialing of members of the transport team. Aggressive and well-documented follow-up is necessary on all applications to ensure that the team members are prop­erly licensed, functionally competent, and free of significant loss histories that warn of possible future issues. It is not sufficient to rely solely on the fact that a hospital has granted privileges to a provider to enable privileges in an independent transport system. On the other hand, hospital-owned and -operated services might reasonably use the hospital credentialing office because they are part of the same entity.

Direct contact with previous employers, instructors, and team mem­bers is recommended to help identify personnel who might not be ideal for a transport team position. Assessment of personal proficiencies should be documented before placing a person on a team, and ongoing assessment of competencies of all team members should be documented in their person­nel files. Ongoing tracking of certification renewals, continuing education, and performance reviews is necessary to document that the system has not allowed an unqualified or incompetent provider on the transport team.

Policies, Procedures, and Protocols

Transport services should have detailed job descriptions, policies, and proce­dures, which may be modeled after those of an ED or critical care unit. As a risk-management objective, it is important to realize it is difficult to defend a practice if people do not approach events in a similar manner. Policies and procedures are useful and necessary to help create a systematic (ideally evidence-based) and defensible process.

The policies and procedures can be “care paths,” protocols, guidelines, or other treatment algorithms. These may be legally necessary to allow hospital-based flight nurses, physician assistants, paramedics, or other non­physicians to provide critical care outside the hospital. Continuing educa­tion, training, competency, and quality review need to be documented to ensure that the team members remain qualified to perform necessary services and procedures. There is an increasing emphasis on simulation as a means of improving both communication skills and patient safety. Deviation from protocols eases a plaintiffs burden of showing that transport team person­nel were negligent and shifts the burden to the team to justify the variance from protocol.

Risk managers, in conjunction with clinical and legal leadership, are typically involved in the creation and drafting of policies, procedures, and protocols. They help clarify language for regulations or standard of clinical care, focus on potential risks in the process, and review documentation to ensure that it supports the care provided.

Quality Measures

One of the most important risk-management tools is ongoing quality reviews of the records of transports. These reviews set specific standards for mea­surement and audit and track compliance. The information provided by this process helps identify the potential vulnerabilities or inadequacies of indi­vidual team members and of the system as a whole, thereby allowing the risk manager to focus training, compliance efforts, and counseling to close the vulnerable spots in the medical-legal operations of the team.

All team members should be aware of exactly which quality indicators are being monitored, and they should be informed of both team performance as well as their individual evaluation to help motivate improvement.

Incident Management

An incident can include unplanned deviations from protocol, complaints, internal concerns, adverse outcomes, a medical records request from a law­yer, or any other circumstance that triggers a review of the facts, potential legal issues, and potential ways to prevent the issue from arising again in the future. The actual management of the incident may include factual investiga­tion, communication with the parties to contain the situation, preparation of information and notification of the insurance company, or recommendations for systems or performance improvement by the staff or team.

Ongoing issues in a system may not receive a primary focus for a vari­ety of reasons. Competition among systems, problems with client hospitals, issues with getting paid by insurance companies, and lawsuits typically receive priority attention because they must be addressed at that time. On the other hand, many of these situations may have had warning signs for a period before the event and could have been managed with favorable outcomes at these early stages. Risk-management responsibilities include identifying warning signs and ensuring corrective action early in the pro­cess, ideally before harm has ensued.

Litigation Support

If a transport service is involved in a litigated case, a great deal of effort will be expended in responding. The insurance company and defense lawyers will require the service and team members to be sources of information, documents, and records. A risk manager can provide oversight to the defense team and help keep team management informed on the progress of the case.