SO OTHERS MIGHT EAT CLINIC RISK ASSESSMENT. Survey Area Evaluation Criteria Check One Weight Score

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1 SO OTHERS MIGHT EAT CLINIC RISK ASSESSMENT A. ADMINISTRATION 1. Is there an office manual outlining patient management policies and procedures? 2. Does the appointment schedule allow for same-day appointments? 3. If the practice has more than one provider in the same specialty, does the patient have the option as to who will treat him? 4. Is there an established procedure to follow-up missed appointments? 5. Is there an established procedure for staff to follow when terminating the physician/patient relationship? Review manual for policies and procedures addressing patient emergencies, diagnostic testing and results notification, patient consents, conscious sedation (if used), general anesthesia (if used), medications and drug samples, and general patient management procedures. manager and review of appointment schedules. manager. Interview with office manager and front office staff. Review appointment policies and procedures. Are all missed appointment, noncompliance issues and terminations documented in the medical record? manager and review policies and procedures. Is he patient notified by certified mail when the relationship is terminated? Does the termination letter clearly state the date on which the termination will become effective? Usually no less than 30 days from the date of the letter. Does the termination letter offer to help the patient locate a new provider? Does the termination letter indicate records will be made available to the new provider with proper patient authorization? So Others Might Eat 1

2 6. Do all contracts (with HMO s, PPOs, IPAs, maintenance companies, or hazardous waste removal companies) contain indemnity or hold harmless agreements? 7. Does an attorney review all contracts prior to signature or is a template approved by Legal used? 8. Has risk management education been given to staff within the last years? 9. Are all legal requests for patient records and subpoenas reviewed prior to release? 10. Is there on-going effort and initiatives in Patient Safety, Risk Management and Quality Improvement 11. Has someone been appointed as being responsible for risk management in the practice? 12. Has an incident reporting system been implemented for the practice 13. Has a relationship been established with the local hospital risk manager? Review contracts for indemnity or hold harmless agreements. manager and review of attorney contract review letters Review employee files for on-going education. Review outline Interview office manager Interview office manager and physician. If so, interview that individual Yes No NA 1 Not Known Yes X No NA 1 0 Review related P & P and report form. Interview with office manager and physician. Yes No X NA 1 N/A B. OFFICE STAFFING 1. Is the current office staffing by position sufficient enough to support the number of physicians in the practice? Does each physician have his own medical assistant or nurse? Are patients seen in a timely manner at the reception desk? Are callers put on long telephone holds? Are all call answered within 5 rings? Are all patients seen within 30 minutes of scheduled appointment time? 2. Are there personnel policies? Written policies that address orientation, progressive discipline, performance reviews, harassment, compliant procedures, PTO, pay and benefits reviewed in the last 2 years. So Others Might Eat 2

3 3. Is there a written documented orientation program for new employees? 4. Is there a written confidentiality policy given to all employees at orientation? 5. Are there current position descriptions for all employees? Orientation covers fire and safety issues, universal precautions, personnel policies, adverse event reporting, telephone triage, medication refills, confidentiality, and patient management. Orientation is documented in employee s personnel file. Policy should cover HIPAA requirements for privacy and security Does staff receive documented annual confidentiality training that includes signing a confidentiality statement? Copy of each employee s position description should be signed by the employee and supervisor and filed in the employee s personnel file. Are job responsibilities of licensed allied health personnel within the scope of practice permitted by state licensure and certification? 6. Are licensed and certified allied health personnel required to keep certification and licensure current?? 7. Do all staff members wear nametags that at a minimum provide first name and position? 8. Are agency relief staffs used for medical positions? Allied health personnel files should contain current a copy of their current license or certification. Is there a reminder system? Observe staff and determine if they are wearing nametags. Is there a current written agreement spelling out the specific duties to be preformed, availability of personnel, responsibility to report unusual events, insurance requirements for professional liability and workers compensation. Agreement should be readily available for review. XYes No NA 2 2 Yes X No NA 1 0 Yes X No NA Is staff ACLS or BLS certified? Review personnel files for copies of certification. 10. Is all staff taught the basics of customer service? Observe staff to see how they answer the phone, do they give their name, are they pleasant? So Others Might Eat 3

4 11. Has staff been given any training on violence in the workplace Interview office manager and see if staff has the basic skills necessary to recognize, diffuse and manage assaultive behavior. C. OFFICE SETTING 1. Office location readily identified Signage highlighting the physician or group name should be visible and clearly identifiable to patients and their family as they approach the office. 2. Handicap parking available, easily accessible to handicap entrance and clearly marked. 3. The building or office is readable accessible by the handicap, The required number of spaces are available and meet ADA requirements for the handicap Are there appropriate ramps at the curb and for change from one level to another? Can the elevators accommodate a wheelchair and are controls within easy reaching distance. Are floor #s easily readable in and outside the elevator Are they raised and in Braille. Is the office door wide enough tot accommodate a wheelchair 4. The walk from the parking lot or garage to the office is considered safe or has security. 5. Can staff visualize patients in the waiting room? 6. Can staff conversations and telephone calls be overheard in the waiting room? Parking lot is free of potholes, free of debris and has sufficient lightning. During inclement weather, floor mats protect the entrance and exits from slipping and tripping hazards. Snow removal service and salt deposits are plan for snow days. Ensure waiting room is visible to a staff member at all times. Review barriers to ensure patient privacy and conversation If possible, sit in the waiting room and listen for staff conversations and calls. So Others Might Eat 4

5 7. Can patients make appointments and converse with reception staff without being overheard in the waiting room? 8. Does the receptionist forward all clinical questions to a nurse or the physician? 9. Does the practice have a written policy on providing telephone advice? 10. Are all telephone calls with patient documented, even those after hours? 11. Is there an answering service /recording for after hour s calls? (recording with ability to go to employee directory, referred to 911 for emergencies) 12. Does a physician of the same specialty provide on-call coverage? 13. If an automated call distribution system is used, do patients have the ability to speak with someone immediately in case of an emergency or are they referred to 911? 14. Do exam room storage spaces have child-resistant closures or are they high enough off the ground that they are not a hazard? (Only adult care is delivered) 15. If there is a play area, is it visible from the front desk? Sit in the waiting room and listen for patient and staff conversations. Interview with receptionist and nursing staff Interview staff as to practice. Review P & Ps Medical record review and as above Interview office manager Does the service log all calls received? Interview office manager and physician Do physicians providing call coverage have access to patient s medical records? Call the office and listen to the message and routing of calls. Is this the first option? During office tour check exam room storage spaces for child-proof closures. Yes No X NA 1 N/A X Yes No X NA 3 3 Yes No X NA 1 NA Check visibility of the play area from the front desk. Yes No X NA 1 NA 16. Are toys cleaned regularly and in working order and safe for all ages? 17. Are entry and exit signs present and clearly marked? 18. Are floors clean and void of any tripping hazards? 19. Are hazardous waste containers labeled and properly placed? manager and check of the toys. Check toys to ensure they have no small parts, which might be swallowed or sharp edges Observe during office tour. Do all hallways and the waiting room have signs indicating the nearest exit? Observe floors during office tour looking for torn carpet, missing tiles or anything else that might be a tripping hazard. Observe during tour of the practice. Are they in areas where hazardous waste is generated? Yes No X NA 1 NA So Others Might Eat 5

6 20. Are sharp containers conveniently located, secure and not overfilled? 21. Hazardous waste is disposed of properly and in accordance with applicable statutes? 22. Are exam and procedure rooms situated to assure patient privacy? D EMERGENCY MANAGEMENT Observe during tour of the practice. Are they located in areas where sharps are used (preparation and administration of medication and where blood is drawn)? Review policies and procedures, contracts and interview staff on disposal procedures. Observe during tour of facility ensuring that people in the waiting room cannot look into these rooms. Also, ensure conversations in one area cannot be overheard in another. 1. Is there a written evacuation plan? Plan available 2. Are there documented emergency procedures (flood, hurricane, fire)? Documented and available and appropriate for the type of situations encountered. 3. Is airway support available? An ambu-bag or disposable pocket mask required OSHA Standard 4. Are emergency drugs available? Minimum of epinephrine available. Nitrosata should be available at a cardiology office. Should be checked after each use and at least monthly and logged. OSHA standard 5. Is O 2 available? O 2 available If tank, must be properly stored Gage on tanks should be checked and documented every 6months OSHA standard 6. Defibrillator available, if applicable? 7. Are there isolation procedures written and circulated to staff Located in building if stress testing or IV anesthetics administered In Practice 8. Is there a transfer plan for emergency situations? Review the plan for completeness. (Call 911) 9. Is there a crash cart or kit in the office? If so, is there a numbered tamper indicator tag attached? Who maintains it? Is a log kept and is it current? So Others Might Eat 6

7 10. Are emergency drills conducted on a regular basis? 11. Are fire extinguishers readily available and currently tagged with annual inspection date? 12. Does the office have a posted fire plan? Determine frequency of drills and who is involved. Review drill log or records. Look for extinguishers during office tour. Inspected annually with lag or on computer listing. Observe during the office tour. E. MEDICATION / DRUGS 1. Are sample prescription drugs dispensed from the office? 2. Are prescription pads kept secure, out of exam rooms and out of sight of patients? manager. Examine drug storage area for security and outdates. Review policies and procedures related to drug samples. If samples are dispensed are they documented in the patient s medical record? When samples are dispensed are they labeled? Are the samples dispensed by the physician? Are the samples kept in a locked cabinet if in a patient care area and inventoried by office personnel for outdates? Observe office practice during tour of office. 3. Are syringes and drugs kept secure, out of exam rooms and out of sight of patients? 4. Are narcotics and other controlled substances kept in the office? 5. If there is a medication refrigerator is it clean and free of food? 6. Does a provider approve all prescription renewals? Same as above. manager. Review narcotics log. If narcotics are kept in the office who has access? If narcotics are kept in the office are appropriate logs maintained? Yes No NA 2 NK During office tour ask to see the medication refrigerator. manager and physicians. Review policies and procedures manual. So Others Might Eat 7

8 7. Are renewals documented in the patient s medical record? Review of patient s medical records. 8. Medications disposed of properly when outdated 9. Multiple use vials are not used past the expiration date F. PATIENT RELATIONS Discarding in regular waste is not appropriate Discard in biohazard bag or sharps container or return to pharmacy Medication is not used past recommended date of manufacturer Rubber stopper is not torn or disrupted 1. Is there a New Patient pamphlet or office policy to introduce the patient to the practice, highlighting office hours, billing and prescription renewal procedures? 2. Are patient satisfaction surveys conducted? Review pamphlet or policy to determine if required items are included. English speaking patient population have forms and pamphlets been translated into the primary patient languages? Determine frequency, review survey, and use of results. 3. Is there a patient compliant policy that includes both medical and non-medical complaints? 4. When appointment delays occur, are patients informed how long they can expect to wait? Review compliant policy, complaints received and their resolution. Review policy. Interview reception staff and ask how they manage patients whose appointments have been delayed. Do patients have the option of rescheduling their appointment if the delay becomes excessive (more than 30 minutes)? Yes No X NA 1 N/A 5. Are interpretive services available? 6. Does the physician obtain the patient s informed consent prior to any procedure and document it? Interview with office manager. (Call DC Health Care Alliance Interpreter) Record review Are procedure specific consent forms utilized? Is the patient s informed refusal documented in the record if they refuse to consent for a procedure? 7. Do providers obtain HIV specific consent prior to testing? 8. Are new patient asked if they have an advanced directive. If so, is a copy obtained and placed in the patient s record Interview with office manager Yes X No NA 1 0 So Others Might Eat 8

9 9. Are patients aware of their right under HIPAA G. OFFICE PROCEDURES Review of P & P relating to HIPAAA and interview with office manager 1. Are laboratory tests done on site? If so, what type? Urine, wet-prep, ora/quick) 2. If lab tests are done on site is the lab CLIA accredited? (CLIA Waived lab) 3. Are patient identification procedures followed prior to all diagnostic tests? 4. Is pregnancy status always assessed prior to x-raying female patients? (only dental x-rays done ) 5. Does the office follow-up to make sure requested diagnostic test results have been received by the office? 6. Are patients informed when test results are expected and to call in by a certain date if they do not hear from the practice? 7. Do providers review and then initial and date all test results before they are filed in the record? 8. Are any of the physicians involved in any investigational or research projects? If so what type? 9. Have patients consented in writing to being part of an investigational or research project? 10. If conscious sedation is used in the office are there policies and procedures on its administration and patient monitoring? manager or physicians. manager or physicians. Review CLIA accreditation report. Yes No X NA 1 N/A Observe patient testing procedures. Review radiology patient procedures. Interview radiology personnel. Review office diagnostic test result procedures, review diagnostic test results polices and procedures. As above. (Most patients come in to receive results. If results are critical, staff attempts to contact patient by phone or in writing). As above and medical record review. Computerized format) manager and/or physicians. (Clinical /statistical research involving information that is redacted of all PHI) Review records of patients included in any project. (would be obtained if necessary by type of research) Review policies and procedures and medical records. Interview staff on conscious sedation procedures. Ensure staff is trained on how to monitor patients and what to do in the event of an emergency. Yes No X NA 2 N/A Yes X No NA 2 0 Yes No X NA 2 N/A Yes No X NA 2 N/A So Others Might Eat 9

10 11. If general anesthesia is used in the office are there policies and procedures on its administration and patient monitoring? 12. Do any of the physicians perform procedures in the office for which they don t have hospital privileges? If so, what are they? 13. Does a radiologist review and over read all radiological tests? (only dental x-rays are taken) 14. Does a cardiologists or internist review and interpret all EKG s? H. MEDICAL RECORDS Review polices and procedures and medical records. Interview staff on general anesthesia procedures. Ensure staff is trained on how to monitor patients and what to do in the event of an emergency. manager and physicians. Determine why this is occurring. manager and physicians. Review procedures for over reads and the time period in which they occur. manager and physicians. Review procedures for over reads and the time period in which they occur. Yes No X NA 3 N/A Yes No NA 2 NK Yes No X NA 2 N/A Yes No NA 2 N/ K 1. Are records retained as required by statute? Review record retention policies. (retained 7 years) 2. Is there a formal written policy on the release of medical records that conforms to HIPAA and state requirements? 3. Original medical records are never removed from the office? (Staff not allowed to take laptops home) 4. Is an electronic medical record system used? ( early adopter eclinicalworks through DCPCA) 5. Are appropriate security procedures in place for all electronic media, i.e. fax, billing, electronic medical records, cell phones, etc?? 6. Does a covering physician send documentation of any patient contact? (all patient seen on site. All after r hours calls are logged in electronic record) 7. Is it verified and documented the patient kept all referral appointments? Review medical record release policy. manager. Hard copy/electronic manager. Review security policies, interview with office manage and staff questioning security measures used. Interview with office manager. Is this documentation filed in the medical record after the patient s physician has reviewed it? Medical record review. Appointments are generally made for the patients So Others Might Eat 10

11 8. Is a transcription service utilized? Used Transcription Express up until May 1, 2008 discontinued) 9. Are all patient instructions documented and provided in writing to the patient? 10. There is a policy addressing approved and unapproved abbreviations manager. How are transcribed reports received? Does the method used protect patient confidentiality and conform to HIPAA? Does the dictating physician review and sign his reports prior to them being filed? Yes No X NA 1 N/A Look at sample instruction sheet Review policy There is a process to verify compliance I. OSHA REQUIREMENTS 1. Is there a written hazard communication plan? manager. Review plan. 2. Has staff received documented training on this plan? 3. Are MSDS (material Data Sheets) current and readily available listing all hazardous chemicals used in the practice? 4. Are spill cleanup procedures established? 5. Has staff received documented training? J. EQUIPMENT manager and review training records. Review MSDS sheets. OSHA standard manager and review procedures. manager and review training records. 1. Does the practice have policies on testing, cleaning, and annual bio-med checks on equipment? (SOME uses a contract service provider for all biomedical equipment) 2. Are inspections of equipment requiring regular inspection documented? Interview with office manager, P & P review and review of maintenance logs As above So Others Might Eat 11

12 3. Equipment shared with other practices/sites? 4. Is biomedical equipment subjected to incoming safety and performance testing? 5. Sterilized instruments are wrapped and labeled with expiration date. 6. Autoclaved and sterilized items are kept in a clean dry place 7. Is a cold sterilizing solution/high level disinfection solutions, like Cidex, used appropriately and container labeled? 8. Are quality assurance test conducted as required? Interview office manager If so, is a responsible person assigned for its maintenance and operating condition? Review P&P s for shared and transferred equipment As above If so, who performs these inspections and is it documented? Review policy Autoclaved instruments used on broken skin or membranes must be sterile Non-disposable speculums must be sterilized Preserves sterility Glutaraldehyde solutions (Cidex, Omnicide or Metrocide) are used according to manufacturer s directions OSHA Standard manager and review testing logs Yes X No NA 2 2 Yes No X NA 3 N/A Yes No X NA 2 N/A So Others Might Eat 12

13 ASSESSMENT RESULTS SUMMARY Criteria (Score) Results Criteria (Score) Results A. ADMINISTRATION C.OFFICE SETTING (cont.) 1. Office Manual (1) 1 10.Are all call documented (2) 2 2. Same-day Appointments (1) Answering service used (1) 1 3. Physician Option by Pt. (1) Provider same specialty call (1) N/A 4. Missed appt. procedure (2) Automated call system (3) 3 5. Patient Termination (3) Child closure exam rooms (1) N/A 6. Protective contract language (1) NK 15. Play areas visible to staff (1) N/A 7. Attorney Review (1) Toys cleaned and safe (1) N/A 8. RM education in past year (3) Clearly marked entrance/exit (2) 2 9. Legal Request /Subpoenas (1) Clean, hazard free floors (1) 1 10.Pt. Safety, RM, QI Initiatives (3) Waste labeled & located (2) 2 11.RM Responsibility Assigned (3) Sharps containers (2) 2 12.Incident Reporting System (3) Hazardous waste disposal (1) 1 13.Relationship Hospital RM (1) N/A 22. Exam room private (2) 2 Office Setting Score 31 Administration Score Total Possible (35 minus 4 NA/NK 21 scores = Total Possible ( 24 minus 1 NA/ 1NK Compliance 22 scores = 22) 100% Compliance 95% D. EMERGENCY MANAGEMENT B. OFFICE STAFFING 1. Written evacuation Plan (1) 1 1. Sufficient staffing (3) 3 2. Document Emergency Proc. (3) 3 2. Personnel policies (1) 1 3. Is airway support available (2) 2 3. Written orientation program (3) 3 4. Emergency drugs available (3) 3 4. Confidentiality policy (2) 2 5. O 2 available (3) 3 5. Position descriptions (2) 2 6. Defibrillator available (3) 3 6. Current licensure/certification (2) 2 7. Isolation procedures ((1) 1 7. Name tags- first name/position(1) 0 8. Emergency transfer plan (1) 1 8. Agency staff used (1) 1 9. Crash cart (1) 1 9. ACLS / BLS/ CPR (2) 2 10.Emergency drills (1) Basics of customer service (1) 1 11.Fire extinguisher tag/inspect (2) Employee violence training (1) 1 12.Posted fire plan (2) 2 Office Staffing Score 18 Emergency Management Score 23 Total Possible ( 19 minus NA/NK scores =19) Total Possible (23 minus NA/NK scores Compliance 95% Compliance 100% C. OFFICE SETTING E. MEDICATION/DRUGS 1. Location readily seen (1) 1 1. Sample drugs dispensed (1) 1 2. Handicap access - parking (2) 2 2. Rx pads secured (2) 2 3. Handicap access building (3) 3 3. Syringes/drugs secure (2) 2 4. Access is safe (2) 2 4. Narcotics security (2) NK 5. Waiting pts visualized (1) 1 5. Medication refrigerator (2) 2 6. Privacy of staff conversations (2) 2 6. Rx renewal Provider approve (2) 2 7. Privacy of pt. conversations (2) 2 7. Rx renewal documented (3) 3 8. Referral of clinical questions (1) 1 8. Outdated medication (2) 2 9. Providing telephone advice (1) 1 9.Multiple vials use (2) 2 So Others Might Eat 13

14 E. MEDICATION/DRUGS (CONT.) H. MEDICAL RECORDS Medication/Drugs Score Retained by statute (1) 1 Total Possible (18 minus 2 NA/NK 2. Release of records (3) 3 16 scores 16) Compliance 100% 3. Removal of original records (2) 2 4. EMR used (1) 1 F. PATIENT RELATIONS 5. Security for electronic media (3) 3 1. New Patient information (1) 1 6. Documentation covering MD (1) 1 2. Pt. satisfaction surveys (1) 1 7. Referral documentation (2) 2 3. Pt. complaint policy (3) 3 8. Transcription services (1) N/A 4. Appointment delays (1) N/A 9. Document patient instructions (1) 1 5. Interpretive service (3) 3 10.Abbreviation policy (3) 3 6. Informed consent obtained (3) 3 7. HIV testing consent (2) 2 Medical Records Score Advanced directives (1) 0 Total Possible (18 minus 1NA/NK scores =17 9. Pts rights under HIPAA ( 3) 3 Compliance 100% Patient Relations Score 16 I. OSHA Total Possible (18 minus 1 NA/NK 1. Written Hazard Plan (2) 2 17 scores= 17) Compliance 94% 2. Documented training (2) 2 3. MSDS current & available (2) 2 G. OFFICE PROCEDURES 4. Spills clean-up procedures (2) 2 1. Laboratory test (1) 1 5. Documented training on spills (2) 2 2. Lab CLIA accredited (1) N/A 3. Pt. ID prior to test (3) 3 OSHA Score Pregnancy status prior to x-ray (2) N/A Total Possible (10 - NA/NK scores Dx testing received in office (2) 0 Compliance 100% 6. Pt. informed of test results (2) 2 7. Test results reviewed & initialed(2) 2 J. EQUIPMENT 8. Research done drug/device (1) 1 1. Bio-medical equipment (2) 2 9. Written consent for research (1) 1 2. Equipment inspections (2) 2 10.Conscious sedation P&P (2) NA 3. Shared equipment with others(2) 2 11.General anesthesia P&P (3) N/A 4. Safety & performance testing (2) 2 12.MD procedures (2) NK 5. Sterilized instruments labeled (3) N/A 13.Radiologist over reads (2) N/A 6. Sterilized safely stored ( 3) Does cardiologist /internist 7. Cold sterilization safety (2) N/A N/K reread all EKG (2) Office Procedure Score Quality assurance testing (2) 2 Total Possible (26 minus 10 NA 4 NK scores = 12) 10 Equipment Score Compliance Total Possible (18 minus 5 NA/NK 83% scores = 13) 13 Compliance 100% So Others Might Eat 14

15 OVERALL SCORE FOR INDIVIDUAL OFFICE PRACTICE Area Total # Compliance Average A. Administration % B. Office Staffing C. Office Setting D. Emergency Management E. Medication/Drugs F. Patient Relations G. Office Procedures H. Medical Records I. OSHA J. Equipment Total Score % % % % % % % % % % 90% or higher no action required 80 89% action plan required Less than 80% action plan required and possible revisit % Compliance = actual score / total possible score X 100 Score: 96% Site: Date: Reviewer: So Others Might Eat 60 O Street NW Washington DC Monday, June 23, 2008 PM Roberta Carroll, RN, ARM, MBA, CPCU Aon Healthcare So Others Might Eat 15