in University Clinics

Donald A Vogel, AuD, CCC-ADirector, Hunter College

Center for Communication Disorders

Risk Management

Vogel Bio:

Audiologist, Clinic Director for Hunter College-CUNY, and, member of Metropolitan New York Council of University Clinic Directors in Communication Sciences and Disorders (that’s a mouthful for ya!)

Many thanks to my co-authors –Dr. Sue Wortsman, AuD, CCC-ADr. Paul Cascella, PhD, CCC-SLP

Bio & Disclosures

Disclosure I:

I am employed by Hunter College-CUNY and will receive travel reimbursement for attending CAPCSD.

I am not paid for, nor do I have a vested interest in, promoting any product, software, hardware, or saleable good that may possibly be discussed during this presentation.

Bio & Disclosures

Disclosure II:

I am not a lawyer, credentialed risk management professional or university administrator.

I am a SIMPLE professor employed by the City University of New York who has an interest in sharing what I do as clinic director with this audience.

Bio & Disclosures

Learning Objectives:Define risk management activities in a

university clinicAssess risk issues in their own settingsCoordinate a risk management

committee at their clinics

Bio & Disclosures

At the conclusion of this session, [I’m hoping] you will have some tools to develop guidelines to create a viable supervisor-faculty-student RMP appropriate to the university clinic setting.

Bio & Disclosures

Basic information – what is risk management?

Risk management in healthcare is the examination and implementation of procedures and policies that will reduce harm to patients and employees

Literature & Survey

What does the literature say?Hospitals and service industry

instruct their employees about RMThere is a paucity of research in

this topic We need to train future professionals

about why this is important and not rely on the medical community to prepare our own professionals

Literature & Survey

We did a survey (thank you for participating!)

Our primary goals were: 1. Determine what RM activities are

conducted2. Recognize any trends across the

country3. Determine if professional experience

relates to RM4. Additionally, we wanted to assess

how RM is monitored and used as an educational tool

Literature & Survey

Risk management programs (RMP) High priority in healthcare settings and academic

institutions administrationsHowever, RMP survey of 280 CSD programs showed

need for growth in this area of interest (response rate of 35%)

Literature & Survey

AdministrationClinical supervision EnforcementMediationParenting Patient careResearchServiceTeaching

Balancing Acts

University CD’s balancing act:

When performing a balancing act, RM gets deprioritized!

In your clinic, do you have a Risk Management Committee?

Answer Response %Yes 11 11%No 91 89%

Balancing Acts

Answer Response %

My institution's administration includes our department in their overall risk management activities

31 34%

Lack of personnel to add this task to their work load 31 34%

The need for a risk management committee is unclear 26 29%

Lack of knowledge about risk management 20 22%

Lack of time 19 21%

A Risk Management Committee has never been considered

19 21%

Insufficient resources to pay for a risk management committee and its programs

10 11%

Other 9 10%

What are the barriers?

Balancing Acts

Who sits on your RM Committee?Answer Response %

Clinic director 10 83%

Clerical staff 6 50%

CSD academic faculty 5 42%

Clinical educator(s) 5 42%

Graduate student(s) 3 25%

Other 3 25%

Business manager 2 17%

Associate dean or other college administrator 1 8%

Undergraduate student(s) 1 8%

Representative from your institution's H & S dept. 1 8%

Assistant clinic director 0 0%

Client(s) 0 0%

RM consultant from outside of college/university 0 0%

Balancing Acts

Risk Management CommitteeHunter College Center for Communication Disorders

Balancing Acts

Frequency of RM monitoring activities

Question Once a semester

Once a year

Every other year

Never

Document audits 46 29 6 20

Fire drill attendance 32 33 0 36

Equipment audits 29 54 1 17

Policy and procedure manual updates 20 70 8 3

Safety drill attendance 19 27 1 54

In-service program attendance 17 41 2 41

Chemical and Material Safety Data Sheet (MSDS) reviews

8 31 0 62

Balancing Acts

Has your clinic RMP resulted in any of the following?

Answer Response %

We do not have a risk management program. 52 51%

We had one or more incident(s) for which we were appropriately prepared.

22 22%

Our legal department and/or administration has utilized clinic's documentation.

17 17%

We have not seen a positive or negative impact from having a risk management program.

12 12%

We had one or more incident(s) for which we were unprepared.

2 2%

Balancing Acts

With a clear understanding of risk management, CDs can integrate appropriate aspects of it into their clinic’s routine protocols.

Balancing Acts

How does RM affect my clinic? “Risk management refers to strategies that reduce and minimize the possibility of a loss.”1 It’s very clear for healthcare:

e.g., bloodborne pathogens = use glovesand ePHI = HIPAA compliance tools

But for us there’s more:Student: safety; FERPA; credentialingFaculty: safety; credentialing Staff: safety; trainingAccreditation

1Risk Management and Medical Liability, American Academy of Family Physicians, AAFP Reprint No. 281, retrieved 3.31.14 from: http://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Reprint281_Risk.pdf

Affects on clinic

How does RM affect my clinic?

Need – the who, what, where, when and why

Commitment of time and resourcesAcademic benefitsHarm reductionTeaching tool

Affects on clinic

What incidents have you recorded?Answer Response % Answer

Response %

None; we did not record any risk management incidents

36 35%

Infection control (e.g., not cleaning materials, reusing speculae, not using gloves, etc.)

8 8%

Client/patient chart documents (e.g., missing data, misfiled charts, breach of privacy)

36 35%Asthma and/or respiratory allergy problems

7 7%

Public safety (e.g., falls in clinic, assault, threats, etc.)

23 23% Lockdown, university wide 5 5%

Externship contracts issues (e.g., sending student to site with expired or no contract)

17 17%Abuse (e.g., elder, emotional, physical, sexual)

5 5%

Credentialing documentation (e.g., expired license, certification, liability insurance)

14 14% Other 5 5%

Privacy (e.g., breach of HIPAA and privacy rules)

14 14%Food allergies (e.g., reaction to food exposure)

4 4%

Fire safety (e.g., any type of fire incident)

12 12%Chemical (e.g., expiration, spills, etc.)

3 3%

Patient satisfaction (e.g., unresolved complaint)

9 9% Lockdown, in clinic only 2 2%

Other: Workman’s comp; altered mental status; falls

Affects on clinic

University clinic RMPIs it not as important as:

Clinical duties and service? Teaching?Research?

Affects on clinic

What drives risk management? Charge of the risk management committee must

be a comprehensive oneUniversity administration looks to avoid adverse

events thus reducing harm and liabilitiesFinancialStudentsClientsFacultyStaffPhysical plant

Affects on clinic

Key elements of an RMP include

Risk Management Program

Education

Awareness

Action

Key elements of RMP

Knowledge of these tools assists university clinic managers in the initiation of an RMP in a fairly effortless, and [somewhat] less time-consuming manner.

Key elements of RMP

Education Education about risk management

helps reduce harm to clients, students, faculty and staff.

Educating students about risk management philosophy and how it is conducted adds to the pedagogical element of clinical education.

Key elements of RMP

Awareness Individuals walking into clinic know the

risks, measures and how to avoid them. Awareness of the risks takes place on

multiple levels and interactions: EnvironmentEnvironment to peoplePeople to people

Key elements of RMP

Action

RMP takes charge to secure harm reduction

ProtocolsDrillsAuditsInspections

Reinforces the commitment by the university clinic to reducing the risks

Key elements of RMP

What do we wish to impart on our students, faculty and staff?The elements creating a unique risk management program in the university clinic setting:

Pedagogical aspects of client/patient care Measures that reduce risks for clients,

students, staff and faculty who attend clinic

Environmental monitoring

Key elements of RMP

The other elements that make it workGovernanceRisk AssessmentCompliance

Key elements of RMP

Governance Directive from administration that a task

needs to be performedEnsures that the directive was completed Managing risks of safety and liability to

clients, students, faculty and staff are the goals

Governance will often lend financial support to the RMP [if they bring it up first!]

Key elements of RMP

Risk Assessment

Examines the gravity and control of various hazards exposing those entering the sphere of the university clinic setting:

ClientsStudentsFacultyStaff

Key elements of RMP

Compliance Mechanism by which Governance and

Risk Assessment are adheredIndividuals appointed as compliance

officers are typically the “turn to” person and held responsible for ensuring the various goals of risk management program have been met

Key elements of RMP

Steps to creating a RM committee

1. Committee mission2. Committee members

Clinical educatorsFacultyStudentsStaff

3. Frequency of meetings4. Generating specific goals and directives

Create a committee

Steps in running the committee: 1. Elect/Assign committee chair (with every fiber of

your being, resist taking command of this role)

2. Allow the new leader to define and delineate the center’s risks

Classify if the risks are in the purview of the committee or some higher authority

3. Allow the new leader to assign responsibilities to complete tasks

4. Allow the new leader to design activities which will ensure compliance

Create a committee

Leadership: Clinic director assumes these roles:Advisor: function as an advising

member/participantMentor: allow other faculty members or

staff to serve as leader, because:CD is released from dutyAdvocate for professional development

of a peer

Create a committee

CD guides through important issues (may be overlooked with the less experienced eye):

Abuse: elder, emotional, physical, sexual Chemical/Environmental Documentation and credentials Hazardous waste Infection control Privacy Proper identification Supervision Training Transferring patients

Create a committee

Review issues from these perspectives:

EnvironmentPatient carePedagogy

Important issues

What areas of RM does committee consider?Compliance to Privacy Policy 11 92%

Client/patient documentation (e.g., charts, notes, raw data, etc.) 10 83%

Fire safety plans 10 83%

Patient privacy (HIPAA) 10 83%

Public safety plan (emergency preparedness) 10 83%Credentialing documentation (e.g., license, certification, liability insurance, etc.) 9 75%

Infection control protocols 9 75%

Chemicals (e.g., cleaning solutions) 7 58%

Equipment calibration 7 58%

Patient satisfaction 7 58%

Abuse issues (e.g., elder, emotional, physical, sexual) 6 50%

Externship contracts 6 50%Transfer for patients (e.g., walker to stationary chair, wheelchair to washroom, etc.) 5 42%

Asthma and respiratory allergies 4 33%

Food allergies 3 25%

Other 0 0%

Important issues

Identifying risk areas is critical: Privacy and security Infection control Safety Allergens

Important issues

Assessing Risk in 5 Steps2

Step 1: Identify the hazards (what can go wrong?)

Step 2: Decide who might be harmed and how (what can go wrong? who is exposed to the hazard?)

Step 3: Evaluate the risks (how bad? how often?) and decide on the precautions (is there a need for further action?)

Step 4: Record your findings, proposed action and identify who will lead on what action. Record the date of implementation.

Step 5: Review your assessment and update if necessary

2Health Risk Assessment Made Easy, National Patient Safety Agency (NSPA), 2007, London, UK (http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59825)

Important issues

What metric surveys are conducted?Answer Response %

Credentialing review (e.g., valid insurance, license renewal, etc. 9 75%

Chart audits 8 67%

Patient satisfaction survey 8 67%

Equipment calibration (e.g., biologic monitoring, electro-acoustic calibrations, etc.) 8 67%

Monitoring of cleaning (e.g., toys, ear probes, counter tops, etc.) 8 67%

Externship contract validity 7 58%

Fire drills (frequency and attendance) 6 50%

Chemical expiration date monitors (e.g., ultrasonic cleaning solutions, ear mold materials, etc.) 3 25%

Other 2 17%

Safety drills (frequency and attendance) 1 8%

Majority of these tasks are done by different personnel in our department and not conducted as a part of a formal Risk Management Committee; None of the above are completed by myself as coordinator of clinical services, not as part of the risk management team.

Important issues

About EHRAnswer Response %

We do not maintain electronic health records at this time and have no plans to move towards electronic health records within the next 12 months.

51 50%

We do not maintain electronic health records at this time but we do plan to move towards electronic health records within the next 12 months.

35 34%

We currently maintain electronic health records. 16 16%

Answer Response %

Documentation and privacy risks remain unaffected. 9 56%

Documentation risks have decreased. 4 25%

Additional privacy and documentation risks have resulted. 3 19%

EHR and documentation

Important issues

Environmental issues

ChemicalFire safetyPublic safetyStructural

Important issues

Environment issuesWrite down RM tasks important to environmental issues

Chemical

Carbon Monoxide

Cleaning solutions

Allergens

MSDS sheets

Gloves

Insect/rodent droppings

Important issues

Fire Safety

Exit signs

Fire extinguishers

Fire drills

Flammable materials

Fire hazards - closets

Fire hazards – hoarding

Public Safety

Locking doors

Adequate exits

Signs to contact security

Safety drills

Toys as weapons

IT security

Patient/Client care issuesWrite down RM tasks important to client issues

Important issues

Patient Care

Abuse

Documentation

Food allergies

Asthma triggers

Infection control

Patient Care

Privacy

Transferring patients

Falls

Safe use of wheel chairs and walkers

Student issues Abuse Documentation Food allergies and

asthma triggers Infection control

Privacy Safe use of wheel chair

and walkers Transferring patients Falls

All of the above, and,• Clinical knowledge and skill• Credentialing (e.g., liability insurance)

Important issues

Supervision issuesAbuseDocumentationFood allergies and

asthma triggers Infection controlPrivacyFalls

Safe use of wheel chair and walkers

Transferring patientsClinical knowledge

and skillCredentialing (e.g.,

liability insurance)

Same as students and:• FERPA

Important issues

PedagogyNot necessarily a risk (but just in case,

you can get rider on your liability insurance)

Student involvement is a critical component of this program as it enables them to learn about issues often left to learn at externship or real-world experiences

Pedagogy

RM as teaching tool Answer Response %

Risk management is embedded in at least one course in our curriculum.

63 62%

We discuss risk management subjects during student meetings outside regular classes.

38 38%

We require students to attend risk management program activities.

35 35%

Risk management is not embedded in any form in our curriculum.

19 19%

Other 8 8%Students have the option to attend risk management program activities.

2 2%

Orientation are required and include risk management information; Students sign confidentiality agreements that incorporate HIPAA regulations; Only HIPAA - BBP training; risk management issues are addressed in student orientation and student meetings; on--line training; HIPAA in-service training is conducted yearly at student orientation

Pedagogy

How do you confirm your students’ knowledge of RM issues?

Answer Response %

Students' knowledge is confirmed via assessment tool. 52 51%

Students’ knowledge is not confirmed via assessment tool. 40 40%

Students perform self-evaluation of risk management knowledge.

7 7%

Other 6 6%

There are multiple assessment tools; Assessment is done via multiple class exams and vis web-based certificate course; Certificates given for above; Some items confirmed via assessment

Pedagogy

Risk Management Program Activities

Document risk management activities thus ensuring the mission of the committee is accomplished

Activities are:Active PassiveCombined

Doing so crosschecks for compliance

RMP activities

Active Activities

Risk Management DayAuditsDrillsInspections

RMP activities

Educational activities in your RMP: Answer Response %

Fire drills 50 50%

Signage 46 46%

In-service programs 40 40%

Safety/evacuation drills 35 35%

Web-page information 31 31%

We offer no activities 20 20%Educational brochures 16 16%Other 10 10%

Approved Continuing Education (CE) events 9 9%Risk Management Day (i.e., a designated time of activities dedicated to risk management awareness)

8 8%

Computer based learning modules; Department Clinical Staff, Faculty and Practicum Students take web-based HIPAA certificate course; Safety manual on Blackboard for Students; HIPAA training provided by the UH General Counsel Office; E-mail updates; Orientation sessions; Formal course on Moodle that University administers; Addressed in professional issues courses

RMP activities

Passive ActivitiesEducational brochuresSignsWebpage updates

RMP activities

Tools to help youNational Institutes of Health (NIH) Listserve: https://list.nih.gov/

OCR-Privacy listserve Lots of other information

Department of Health and Human Services Security Risk Assessment Tool

Download iPad App (search for HSS SRA) Windows tool:

www.healthit.gov/providers-professionals/security-risk-assessment

NIH: Patient Safety and Quality http://www.ncbi.nlm.nih.gov/books/NBK2651/

NHS – National Health Service (UK) http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59825

Tools to help

What can go wrong, will!

What can go wrong, will

What can go wrong, will

What can go wrong, will!

What can go wrong, will

What can go wrong, will

What can go wrong, will

What can go wrong, will

ConclusionA clinic director is responsible for so many areas of her or his facility’s function, inclusive of safety and risk.

Managing risk through committee will inevitably ease the director’s various work tasks, improve quality of care for clients, reduce financial and safety risks, while teaching students management, organization and clinical skills not often discussed in the classroom.

Conclusion

Risk Management Resources: