Overview

It is a common practice among behavioral health organizations in today’s litigious and ever-changing environment to develop a Written Risk Management Plan in order to manage hazards and reduce the severity of loss. Certainly having an established Written Risk Management Plan makes good business sense. Possessing a written plan also provides staff members with information and knowledge about the organization’s risk exposure and steps it is taking to reduce risk. Typically the organization’s Fiscal Director, Quality Improvement Manager, Corporate Compliance Director, or legal counsel carries out risk management functions.

Accreditation Requirement(s)

To be in conformance with these accreditation standards, the organization’s Risk Management Plan must show evidence of the following:

• Identification of any known loss exposures
• Analysis of those exposures
• Addressing of how the exposures will be managed
• Implementation of actions to reduce risk
• Monitoring of the results of the actions taken
• Reporting on the results of actions taken to reduce risk
• Inclusion of risk reduction in performance improvement activities

Implementation Tips

Some Implementation Tips provided, in part, by Robert Johnson at: www.accreditationnow.com.

• Having a Risk Management Plan in writing can also be a part of, or referenced in, the organization’s performance improvement and/or financial plan. The Risk Management Plan can provide guidance and direction to staff in the event of a known loss exposure. The complexity of the plan will depend on the organization’s size and structure. The structure to implement the plan (a person versus a committee) is also determined by the organization’s size, style, and culture.
  
  
• Examples of potential risks may include:
  
  
  • Changes in funding streams
  • Security issues
  • Facility problems
  • Workers’ compensation
  • Adequate insurance coverage
  • Medication errors/sentinel events
  • Improper billing
  • Fraud, waste, and abuse
    
    
• The Risk Manager, with the assistance of appropriate staff members, should educate clinical employees on the importance of clearly documenting the course of treatment in the client record. The importance of documented informed consent should also be emphasized.
  
  
• The Risk Manager, or his or her designee, should provide clinical staff with written guidelines on how to handle patient injuries, including how to communicate with injured patients or their family members and how to formally document such discussions.
  
  
• The Risk Manager should meet periodically with the person(s) in charge of facilities management to identify and proactively manage any potential risks associated with building security and facility hazards.
  
  
• The Risk Manager must respond to significant changes in funding streams and estimate, after discussion with senior staff, the impact of such changes on the Risk Management Plan. For instance, the Risk Manager should anticipate any additional insurance needs associated with a significant change in the persons served or the services offered by the organization.
  
  
• The Risk Manager should meet periodically with the Compliance Officer (if not the same person) to ensure that risks associated with fraud, waste, and abuse of funds, including billing errors, are minimized.
  
  
• Potential types of benchmarking data to be used in preparation of the annual Risk Management Summary (if such a document is prepared by the organization) include:
  
  
  1. Number of incident reports filed, including a comparison with previous year(s)
  2. Number of incidents that occurred in "high-risk" areas, as identified by the Risk Manager
  3. Number of active lawsuits and lawsuits resolved, including method of resolution (settlement, dismissal, etc.)
  4. Number of active government investigations and investigations resolved, including any fines paid
  5. Portion of the organization’s budget spent on resolution of lawsuits and government investigations
  6. Expenditures on insurance, as compared with previous year(s)
  7. Workers’ compensation costs, as compared with previous year(s)