68 AE Fall 2010

Specialty Practices Ambulatory Surgery Centers

Arisk management planshould include systems toidentify potential hazardsand processes to handleevents and incidents that

do occur in ways that minimize theeffects and costs of these events.

This plan is more than a docu-ment that sits in a policy and proce-dures manual. The written plan iscombined with facility policies,tracking indicators, surveys, andinspections. It assures there areprocesses in place to minimize riskand reduce your exposure to finan-cial and operational losses.

In order to achieve compliancewith CMS, your risk managementplan must be in writing, approved by

your governing body, and evaluatedon an annual basis. The implementa-tion responsibilities must be clear toassure accountability. The governingbody typically delegates the riskmanagement functions to a specificposition within the ASC, such as theclinical director. Education about riskmanagement efforts must be provid-ed to your personnel and medicalstaff.

Risk Assessment and ReductionThere are many areas of potentialrisk in all ASCs. Examples of sourcesof risk assessment or exposureinclude• credentialing compliance

• outside contract review and evalu-ation

• policy/procedure review • facility/equipment inspections• peer review• safety issues • patient complaints • patient satisfaction questionnaires • licensing/certification/accredita-tion results

• compliance auditsA risk assessment involves look-

ing at potential issues in all riskareas. For example, assume you con-sider credentialing at your facility athigh risk due to issues surroundingpractitioners who may not have fullcredentials or who may have practiceissues such as “excessive” malprac-

Risk Management for ASCs Debra Stinchcomb, RN, BSN, CASC

A comprehensive risk management plan helps

not only to minimizeany financial/legal

exposure but also to improve

patient outcomes.

AE Fall 2010 69

tice history, or a history of loss orsuspension of a partner’s medicallicense.

In order to minimize the poten-tial risks associated with credential-ing, you develop and implementcomprehensive credentialing poli-cies—and processes to ensure thesepolicies are followed—at your facili-ty. For example, periodic review ofphysician files would be performedto assure compliance with the policy.

If you did not put these process-es into place, your exposure mightinclude patient injury and incomeloss due to a liability claim orMedicare decertification.

In addition to reducing risk inanticipated risk areas, your planshould reduce risk in response toerrors. For example, assume a sen-tinel event occurs in your facility.Your facility should have processesin place to track/trend the error, per-form a root cause analysis as applica-ble, make the patient aware of theevent, and notify your malpracticecarrier, as appropriate.

Risk Management ActivitiesFollowing are four specific risk man-agement activities that help ensurethat your risk management plan iscomplete. They include (1) incidentreports, (2) compliance plans, (3)compliance audits, and (4) insurancecoverage.

Incident reports. It is importantnot only to create a work atmos-phere where incident reporting isnon-punitive, but it is also importantto track, trend, and report incidents.Tracking the incident reports pro-vides data on frequency and severity.When safety trends are noted, actioncan be taken and processes changedor developed to minimize occurrenceof future incidents.

Incident reports should bereported through your committeestructure, all the way up to yourBoard. Be sure to check with youraccrediting body and state depart-ment of health to determine if you

are subject to any mandatory report-ing of incidents.

Compliance plans. The adop-tion of compliance plans is a grow-ing trend in the ASC industry. Theplan should be used to educate youremployees and medical staff on ethi-cal and legal responsibilities in pre-venting, detecting, and determiningcriminal conduct or unethical behav-ior. The plan should include proce-dures that allow safe reporting meth-ods (such as a hotline) and prompt,thorough investigation and correc-tive action to any misconduct. Acompliance officer should beappointed to oversee the program.

A compliance plan shouldaddress the following items:• Regulatory issues such as the StarkAct, Medicare/Medicaid fraud andabuse, and HIPAA

• The responsibility to refrain fromillegal conduct, accept gratuities,and improperly benefit fromemployment or association withthe ASC

• Disclosure of conflict of interest ofself or family members

• FMV (fair market value) for allmaterial relationships such aslease or equipment purchases

• Ethical coding and billing prac-tices

Compliance audits. Complianceaudits are used to monitor compli-ance and assist in the reduction ofidentified problem areas. Considerthe use of an outside auditor to com-plete this.

The audits should focus on thefollowing:• Items that have substantive expo-sure to government enforcementactions, such as laws governingkickback arrangements and otherrules or policies that are a focus ofparticular attention from Medicarecarriers, OIG, and law enforce-ment initiatives

• Claims development, submission,and reimbursement

• Adequacy of the accounting sys-tem

• Confirmation of accuracy ofaccounts receivable

• Verification of the existence ofassets

• Verification of bank balancesInsurance coverage. Appropriate

insurance coverage minimizes finan-cial risk in your facility. There are sev-eral types of insurance available. YourBoard should determine which wouldbe most beneficial for your ASC:• Directors and officers (D&O)• Property (business and personal)• Commercial general liability (fire,damage, terrorism)

• Professional liability (malpractice)• Workman’s compensation• Business disruption insurance• Key man insuranceIt is important to know the details ofyour plans thoroughly. For example, • What is your total cost?• Does your malpractice insurancecover all procedures performed inyour facility or are there excep-tions? Who, specifically, in yourfacility does your malpracticecover?

• Does D&O cover employees oronly directors and officers?

• What, specifically, do the coverageand exclusion clauses address, andare they appropriate for your facil-ity?

Bottom LineRisk management is an importantcomponent in assuring safety inyour ASC. A comprehensive planhelps not only to minimize anyfinancial/legal exposure but also toimprove patient outcomes. AE

Debra Stinchcomb, RN, BSN,CASC (dstinchcomb@progres-sivesurgicalsolutions.com), is aconsultant with ProgressiveSurgical Solutions LLC, anASC development and consult-ing firm based in San Diego,Calif.