Risk Management Manual and Implementation Strategies - the Payne Medical Center - Case Study Example

Risk Management Manual Name Institution Contents Executive Summary The Payne Medical Center seeks to expand its physical facilities and services offered to the community of Roma. The management hopes to add more specialties to have a comprehensive center where individuals can be treated for a variety of diseases. The hospital shall adopt the COSO 2013 Framework to guide its operations. The structure consists of internal control processes that the hospital has adopted to improve efficiencies. Covered are the center's vision, mission and values and how the control environment will be managed. It also lists the functions of its board of directors, human resource management strategies, risk assessment, information and communication and monitoring activities. Risk Management Manual Introduction Located about 480km west of Brisbane, the Payne Medical Center is a small medical practice serving a regional population of about 15,000 people. Dr. Maurice Payne established the healthcare facility in 2001. Dr. Patricia Hart in 2004 and Dr. Veejay Sharma later joined him in 2010. With the need to grow the facility, Subsequently, Dr. Payne made the two directors and shareholders in ‘Payne Medical Pty Ltd.' As of now, the medical center has four full-time doctors, a manager, a full-time registered nurse, and two full-time administration staff. Although the center has undergone changes to its building to allow for expansion, they are not enough and are creating operational inefficiencies. After much deliberations, the directors have opted to construct a larger facility at the same site. Part of the plan to have an integrated service by having a podiatrist, a psychologist, and a physiotherapist join it. The center is planning to have a pharmacy. Among the changes to be implemented include: 1. Eight medical specialists 2. A treatment room with four beds 3. Associated amenities 4. Four nurses 5. Six administration personnel 6. Three supporting staff members 7. A pharmacy The management has already hired an architect to come up with concept plans and the total cost which he has placed at $3 million. Control Environment Most failures in business, financial and healthcare sectors are attributed to serious organizational risk. Particularly, healthcare is complex, and many organizations manage their risks independently. Some of the risks may be unique to a particular institution based on location, types of services offered, and the people involved. Equally, some risks may be given weight regarding attention and resources over minor ones. Ineffective management of risks could lead to organizational underperformance The organization will be managed in line with its mission, vision, values that are as follows: 1. Mission: Quality and affordable healthcare services to our community is our number one priority. 2. Vision: To be the leading healthcare facility in our community. Values: Our values are: a) Protection for all b) Patient is king c) Respect for patients d) Service to the community e) Excellence f) Integrity Payne Center will be able to live the values by: 1. Being communicated to ensuring a safe day every day. The facility will ensure the safety of its patients, and its partners are its greatest preference. The patient will be the center of everything it does as it has always been. 2. The facility will give care that is respectful and helpful to individual patient likings, needs, and values. The patient’s choices will guide all clinical decisions. 3. Payne Centre will be responsible and accountable for its behavior and how others perceive it. It will abide by all its commitments and do what it promises to do always. 4. The center will strive for excellence through continuous pursuit of the highest standards in healthcare quality and individual and organizational performance 5. Healthcare and wellbeing will be the core function of the facility. Services offered at the hospital will be for the holistic development of the community. 6. The hospital will value its service over self-interest. It will be accountable to those it serves for the resources in its trust: human, material, financial and knowledge. Board of Directors Payne Centre will have a board of directors whose responsibilities will be to ensure that: 1. Corporate values and standards exist to guarantee the integrity of the senior board management and other staff; 2. Enough systems and regulations are installed identifying and solving complaints resulting from unethical activities; 3. Relevant policies touching on governance, risk management, human resource management, and procurement of goods and services are formulated and adopted; 4. The established and maintenance of a sound internal control system at all levels of the facility; 5. Continuous refinement in quality of care and services of the organization; 6. Promotion of positive relationships between the hospital and the medical staff. It all take all actions regarding hospital privileges for physicians and allied health professionals; 7. Conducts its activities with good faith to enhance hospital-based healthcare that solves the community needs; 8. Reflects community wishes. 9. Promotion and maintaining of positive ties with the community, local business, financiers, authorities, and other hospitals. Human Resource Management The facility is aware that employees play a major role in determining its success. Therefore, it will ensure proper management of its human resources to guarantee a high-quality healthcare. Kabene, Orchard, Howard, Soriano, and Leduc (2006) note that effective human resources management strategies are required to achieve better results. To ensure effective human resource management, the hospital will make sure that: 1. Proper selection, hiring, and retention mechanisms are put in place. All vacancies at the organization will be announced through selected media channels. Subsequently, the most qualified candidates will be selected, interviewed and the ones that emerge top retained; 2. Enough personnel are recruited for various functions. Mainly, this will ensure that work is fairly distributed and employees are not overworked. Enough doctors and nurses will be hired to attend to the patients; 3. The hospital will source for regular training of its staff to equip them with the latest best practices in the industry. It will be the function of the management to organize for its employees to attend workshops related to improvement of healthcare facilities in the country; 4. A performance appraisal system will be in place to ensure that all staff carry out their day to day functions as required. Besides, appraisals systems help prevent cases of absconding of duty and reluctance to carry out duties as stipulated in their performance contracts (Klussmann, 2009). 5. There will be a guideline on how to promote employees based on merit; 6. All cases related to employee disputes will be heard and solved by the human resource department. Accountability of Employees For accountability purposes, the facility will: 1. Develop predictive care paths; 2. Use evidence-based medicine. Notably, this will be achieved through incorporation of evidence-based practices that complements the aim of getting better outcomes at an affordable cost (Fetters, & Tilson, 2012). Also, additional external knowledge such as research studies will serve as an example for the center's improvement effort. 3. Facilitate proper coordination: the center will encourage collaboration among all its employees. Good coordination will be realized by setting up effective communication channels. 4. Use of incentives that support accountability: Payne expects their employees to put the best effort when carrying out day-to-day functions. An incentive structure will be created to encourage greater ownership among its staff. Argue that accountable care can be achieved through giving incentives to providers to improve the quality and efficiency of care 5. Establish process metric: some of the process parameters that can be adopted include patient cycle time, cost by the procedure. The data can be used in real time to manage cost and outcome variability. It can also be used to identify opportunities and improve efficiency. In addition to this, the hospital will establish quality and outcome metrics to improve quality. Risk Assessment The main goal of the hospital is to provide a combination of professional and caring practices. Here are some of the uncertainties that the organization may encounter and ways to manage them: 1. Privacy and confidentiality risks: issues of privacy and confidentiality of patient is common in most health care facilities. Numerous cases where patient’s identity and details are revealed without their consent are prevalent. To avoid this, the facility will invest in a secure patient management system that will be cyber risk-free and protected from any unauthorized access. A strict work policy will also be effected to make sure that employees who have contact with patients information do not use it for any other purpose other done intended or share the same with third parties. A robust data management system will also go a long way in safeguarding the facilities financial stability, security, and reputation. 2. Healthcare infections: healthcare-acquired infections have led to the death of tens of thousands of lives around the world. At any given time, at least 1 in 25 hospital patients has one such infection (Ace Group 2015). To prevent the same in Payne Centre, the management will ensure that its sanitations systems are up-to-date and operational. All employees will be taught to correctly use the systems to keep patients safe. 3. Alarm fatigue: some doctors and nurses fail to respond to alarms that monitor patients due to fatigue. Alarm fatigue is a growing concern for hospitals, and the outcomes can be fatal (Ace Group 2015). To eradicate alarm fatigue among its doctors and nurses, the hospital will provide a list of precautions that will ensure safe alarm management and fast response in high-risk sections. 4. Violent cases in medical facilities: whereas hospitals are places of healing, they can also become exposed to cases of violent incidents that could put the lives of patients and medical professionals at risk. Nowadays, hospitals have become targets of attacks, intimidation, harassment, and other disruptive actions. Violent cases continue to be reported across hospitals around the world (Ace Group 2017). The aggressors can include family members, healthcare employees, vendors, and visitors. To deal with this issue, Payne Centre will strictly observe its zero-tolerance policy that states no type of violence be it psychological, verbal, or physical will never be allowed. Perpetrators will also be warned in advance of the disciplinary action that will be taken including termination. 5. Fraud: lately, many hospitals are becoming victims of fraud where the people in charge of finances acquire money through illegal means. Equally, most of the fraud cases involve former entangled employees or providers. For organizations to prevent or minimize fraud, they are expected to have compliance programs and protocol that identify irregularities and illegal activity. Also, they ought to be proactive and responsive to patients, the family of patients, employees among others who allege fraud or wrongdoing (Advisory Board, 2017). All staff for Payne who decides to end their contract with the facility will undergo interviews regarding any substantial or perceived compliance or fraud concerns. Control Activities The following steps will be taken to prevent the risks identified 1. Infection control: patients suffering from infectious diseases such as diarrhea, skin rashes, known epidemic ailments and known carriers of a communicable strain of virus will be excluded from others. Equally, those who are at risk of acquiring infections from other patients will be put in separate rooms. Moreover, isolation will ensure that infected patients do not transmit viruses to other patients or staff (Dellinger, 2016). 2. A proper security system will be mounted on strategic parts of the organizations with the aim monitoring for any criminal activity. Most importantly, this will complement the strict non-tolerance policy to violence inwards and other working areas. Employees will also be warned in advance of the consequences of engaging in activities that demean the organization such as fighting with their counterparts. 3. Policies will play a major role in reducing some of the risks. As earlier stated, there will be a policy regarding the sharing of patients details to third parties and breach their confidentiality. Due to the prevalence of social media use and the risks to poses to patients privacy and confidentiality, the hospital's doctors and nurses will be required not to divulge any work related experiences on online platforms. Furthermore, the organization's employees will be warned from posting images or patients details on Facebook, Twitter, and other social media platforms. All this will be contained in Payne’s social media policy. 4. Concerning fraud and based on earlier recommendations, the hospital will develop compliance programs and protocol to identify any suspicious activities. Also, the company will establish a culture where employees will be encouraged to report any fraudulent activities without fear of intimidation. The management will avail to staff and patients a hotline number and email address where they can report any fraudulent activities anonymously. Information and Communication Effective internal communications are crucial for the optimal functioning of any organization. Effective communication supports the development of positive bonds with the shareholder community. Additionally, it can be used to shape attitude and behaviors in workplaces. For this reason, Payne Centre will place great emphasis to ensure a smooth communication system. To achieve this, the organization will: 1. Encourage a culture of openness where management and employees interact freely. The reason for this is that it will be easy for two-way flow of information, as managers will be more accessible. Deland, Gordon, and Kelly (2017) explain that most healthcare facilities suffer from communication breakdown since healthcare members to don't communicate with each other about patient’s needs. They add for success to be achieved in hospitals; there should be collaboration among all types of providers across the facility. To achieve the three objectives of enhancing quality, lowering costs, and improving the patient experience, Payne will maintain open communication channels. 2. Regular communication: the organization will ensure a consistent flow of information where all the stakeholders are furnished with the necessary details regarding activities taking place at the facility. For maximum benefit, different communication channels will be used to post the messages for maximum clarity. All oral communication on necessary functions will always be backed with hard copies and be displayed on notice boards and employees emails for maximum clarity. 3. Communicating with stakeholders: Stakeholders are an important group in a company and need to be regularly informed of its activities. Some of the organization's shareholders include the national government, regulators, general public, patients, and the pharmaceutical industry among others. They need to access to timely and reliable information in formats that are readily digestible (Gopal, 2009). Payne will ensure that information is presented in a simplistic manner that is easy to be understood by all its shareholders. Since they are comfortable with concepts of materiality and risk/opportunity assessments, what the organization will do is frame its stories within familiar concepts that will help them understand the message faster. The center quality information is dispensed by addressing specific expectations that different shareholders may have. For example, all communications channeled to employees will address issues such as how the company is investing in their growth. Monitoring Activities The organization will perform several evaluations occasionally to make sure that internal control processes are functioning. Some of the surveillance activities will include: 1. Employee survey: with the need to ensure that its employees stay motivated, the hospital will occasionally subject them to reviews with the aim of improving their workplace. The survey will seek to unravel any challenges present that may hinder them from performing their objectives as required and find solutions to them. Equally, through surveys, the employer will gauge their satisfaction and motivation levels. The most significant bit of surveys is that they make employees also feel that their opinion matter in the organization, which will help, boost their productivity. Using this method, the management will ensure that the feedback is kept confidential, and the outcome made known to employees within a reasonable time-frame. 2. Security checks: Random checks will be carried out to ensure that the hospital security system is fully functional. The checks will ensure that all the CCTV cameras, duress alarms, electronic access for doorways are in working condition. Moreover, the checks will help reveal whether there should be an upgrade on any weaknesses detected. 3. Computer and Financial System Checks: due to intensified threats to computer and financial systems of most organizations, Payne hospital will be carrying out regular checks to ensure that their securities are intact. The checks would help highlight any suspicious activities that can be prevented before full damage. Additionally, the findings of the exercise would enable the hospital to carry out necessary upgrades. Computer systems in organizations need to be safeguarded from malicious software and virus that may cause a lot of damage to its files. Part of the evaluation will include updating on antivirus software and upgrading other security measures put in place to protect the institution's information. Foster (2013) writes that some the computer checks may help minimize administrative time and inefficiencies in organizations. The other advantage is that it could decrease the potential for financial and loss of critical files. 4. Payne Hospital will ensure that any recommendations from are fully implemented within the shortest time. Mainly, this will make it possible for it to continue to operate at the highest level of efficiency possible. Besides checks, the management will take seriously communication from its employees, public, and regulators among others on issues that will help it improve its performance. Accountable care can be achieved through giving incentives to providers to improve the quality and efficiency of care. Reference Ace Group (2017). 11 Critical Risks Facing the Healthcare Industry - Sponsored Content by ACE Group. Risk & Insurance. Retrieved 17 April 2017, from http://riskandinsurance.com/11-critical-risks-facing-the-healthcare-industry/ Advisory Board (2017). How hospitals can prevent fraud (and address fraud allegations). Advisory.com. Retrieved 17 April 2017, from https://www.advisory.com/daily-briefing/2014/11/21/how-hospitals-can-prevent-fraud Deland, E., Gordon, J., & Kelly, R. (2017). Let’s talk about improving communication in healthcare. Columbia Medical Review, 1(1). Dellinger, E. (2016). Prevention of Hospital-Acquired Infections. Surgical Infections, 17(4), 422-426. http://dx.doi.org/10.1089/sur.2016.048 Fetters, L., & Tilson, J. (2012). Evidence-based physical therapy. Philadelphia: F.A. Davis Company. Foster, M. (2013). Computer systems analysts play important roles in most companies. ajc. Retrieved 18 April 2017, from http://www.ajc.com/business/computer-systems-analysts-play-important-roles-most-companies/MLV8p63yEDereHkFDGbHCN/ Gopal, N. (2009). Business communication. New Delhi: New Age International. Hage, D., & Abrams, E. (2011). 7 Ways to Improve Accountability for Care. Beckershospitalreview.com. Retrieved 17 April 2017, from http://www.beckershospitalreview.com/hospital-physician-relationships/7-ways-to-improve-accountability-for-care.html Kabene, S., Orchard, C., Howard, J., Soriano, M., & Leduc, R. (2006). The importance of human resources management in health care: a global context. Human Resources For Health, 4(1). http://dx.doi.org/10.1186/1478-4491-4-20 Klussmann, W. (2009). Philosophy of Leadership - Driving Employee Engagement in integrated management systems. Diplomica Verlag. Read More