Policy AD-460 Health Care Risk Management Training Plan 2023-06-22

Imprimir
Compartir
Oscuro
Claro
DF

The content is currently unavailable in Spanish (Mexico). You are viewing the default English version.

Resumen del artículo

¿Te ha resultado útil este resumen?

Gracias por tus comentarios


Policy Title: Health Care Risk Management Training Plan
Policy Number: AD-460	Policy Owner: Director of Quality Improvement		Effective Date: 7/1/23
Attachment(s): Attachment A: 2023-2024 Health Care Risk Management Training Plan Activities		Original/ Reviewed Date(s): 5/29/18, 5/31/18, 5/31/19, 6/21/21, 7/7/22, 6/22/23
Policy Executive: Chief Medical Officer (CMO)	Policy Executive Signature:		Approval Date: 6/22/23
Board Representative: N/A	Board Representative Signature:		Approval Date:

Purpose

The purpose of the Health Care Risk Management Training Plan is to ensure that the areas and activities of highest clinical risk for Westside Family Healthcare are addressed with appropriate training for staff members and contractors, as appropriate.

Policy

As part of its overall Risk Management Plan, Westside Family Healthcare (Westside) performs risk assessments to identify the areas of highest clinical risk and establishes appropriate training for staff members and contractors.

At a minimum, this training includes:

Obstetrical training for all providers who treat patients of reproductive age;
Obstetrical training for all providers involved in prenatal and postpartum care (whether or not they provide labor and delivery services);
Obstetrical procedures training (including continuing education for electronic fetal monitoring and shoulder dystocia drills) for all providers involved in labor and delivery for Westside patients;
Infection control trainings:
- All staff members and contractors: infection prevention and control, bloodborne pathogens, and hand hygiene training and monitoring
- Medical assistants and dental assistants: sterilization of medical and dental equipment, in addition to the above;
HIPAA privacy training for all staff members and contractors; and
Dental procedure-related training for all dental providers (surgical site infection or other).

Training is provided and tracked as outlined on Attachment A: 2023-2024 Health Care Risk Management Training Plan Activities.

Scope

All Westside locations and all Westside staff members and contractors.

Definitions

None

Procedures

Proactive risk assessments and reviews are performed by the Director of Quality Improvement, Chief Operating Officer/Risk Manager, and Compliance Manager/Corporate Compliance Officer in collaboration with the Culture of Safety Committee and the Compliance and Risk Management Committee in order to identify areas of highest clinical risk.

Assessments take into account the minimum standards for training set in the policy above, as well as incidents, near miss events, and other methods detailed in the Risk Management Plan, including closed claims data, adverse event reports, past accreditation or licensing surveys, medical records, clinical and risk management research, walk-through inspections, safety and quality improvement committee reports, insurance company claim reports, risk analysis methods such as Failure Mode and Effects Analysis (FMEA), Root Cause Analysis (RCA), Systems Failure Analysis, and informal communication with providers.

Based on these risk assessments, Westside develops priority areas along with corresponding training and tracking methods.

This training and tracking is reported to the Quality Improvement Committee (QIC) of Westside’s Board on an ongoing basis, and, at a minimum, annually.

1. This policy and documentation of required training completion are also included as part of Westside’s annual HRSA FTCA Deeming Application.

References

Health Services Resource Administration (HRSA)
1. Chapter 21: Federal Tort Claims Act (FTCA) Deeming Requirements, HRSA Health Center Program Compliance Manual, August 2018. (https://bphc.hrsa.gov/compliance/compliance-manual/chapter21)
2. Federal Tort Claims Act (FTCA) Deeming Requirements, HRSA Health Center Program Site Visit Protocol (SVP), April 13, 2023. (https://bphc.hrsa.gov/compliance/site-visits/site-visit-protocol/federal-tort-claims-act-ftca-deeming-requirements)
3. HRSA Program Assistance Letter (PAL) 2023-01, Calendar Year 2024 Requirements for Federal Tort Claims Act (FTCA) Coverage for Health Centers and Their Covered Individuals, February 2, 2023. (https://bphc.hrsa.gov/sites/default/files/bphc/compliance/pal-2023-01.pdf)

ECRI Institute

1. ECRI Clinical Risk Management Resources (https://www.ecri.org/components/HRSA/Pages/default.aspx)
2. ECRI Obstetrics Training Suite (https://www.ecri.org/components/hrsa/Pages/efm.aspx)

ATTACHMENT A:

2023-2024 Health Care Risk Management Training Plan Activities

Priority Area	Training Type	Training Methods	Tracking Methods
Obstetrical –Reproductive-Age Patient Care	Obstetrical training relevant to care of all reproductive age patients	1. All providers who treat patients of reproductive age (and who are not women’s health providers required to take any obstetrical trainings listed under 2 and 3 below): Annually via online ECRI course or equivalent¹	1. Confirmation of training by Westside Director of Women’s Health through certificate or equivalent and maintenance of documentation.
Obstetrical – Pregnant Patient Care	Prenatal and Postpartum Care (course determined annually)	2. All providers involved in prenatal and postpartum care (whether or not they provide labor and delivery services): Annually via online ECRI course or equivalent¹	2. Confirmation of training by Westside Director of Women’s Health through certificate or equivalent and maintenance of documentation.
Obstetrical – Labor and Delivery Procedures	Electronic Fetal Monitoring (EFM)	3.A. All providers involved in labor and delivery for Westside patients: Maintain current certification via hospital partner training or online ECRI course or equivalent²	3.A. Annual confirmation of current training through certificate or equivalent by Westside Director of Women’s Health and maintenance of documentation.
	Shoulder Dystocia	3.B. All providers involved in labor and delivery for Westside patients: Maintain current certification via hospital partner or online ECRI course or equivalent².	3.B. Annual confirmation of current training through certificate or equivalent by Westside Director of Women’s Health and maintenance of documentation.
	L&D procedure-related training (course determined annually, as needed)	3.C. All providers involved in labor and delivery for Westside patients: Annual labor and delivery procedure training via online ECRI course (from Obstetrical Training Suite) or equivalent¹ Important Note: If EFM or shoulder dystocia is taken that year, this additional training is not required.	3.C. Confirmation of annual training through certificate or equivalent by Westside Director of Women’s Health and maintenance of documentation. Important Note: If fulfilled by 3A or 3B that year, 3C is not required.
Infection Control	Blood-Borne Pathogens	3.A.1. New staff: Initially via new staff orientation	3.A.1. New staff orientation tracking
	Blood-Borne Pathogens	3.A.2. All Staff: Annually via HealthStream online training or Westside-developed in-person training	3.A.2. HealthStream or Westside training tracking.
	Infection Prevention and Control	3.B.1. New staff: Initially via new staff orientation	3.B.1. New staff orientation tracking
	Infection Prevention and Control	3.B.2. All staff: Annually via HealthStream online training or Westside-developed in-person training	3.B.2. HealthStream or Westside training tracking.
	Hand Hygiene	3.C.1. New staff: Initially via new staff orientation	3.C.1. New staff orientation tracking
	Hand Hygiene	3.C.2. All staff: Annually via HealthStream online training or Westside-developed in-person training	3.C.2 HealthStream or Westside training tracking
	Sterilization of Equipment	3.D.1 New Medical and Dental Assistants: Initially via Westside-developed in-person training³	3.D.1 Confirmation by Director/Associate Director of Clinical Operations and Director/Manager of Dental Operations, including maintenance of documentation.
	Sterilization of Equipment	3.D.2 Medical and Dental Assistants: Annually via Westside-developed in-person training³	3.D.2 Confirmation by Director/Associate Director of Clinical Operations and Director/Manager of Dental Operations, including maintenance of documentation.
HIPAA Privacy	HIPAA Training	4.A.1 New staff: Initially via new staff orientation	4.A.1 New staff orientation tracking
HIPAA Privacy		4.A.2 All staff: Annually via HealthStream online training or Westside-developed in-person training	4.A.2 HealthStream or Westside training tracking and annual evaluation
Dental – Procedure-Related	Surgical Site Infection or other procedure-related training (course determined annually)	5. All dental providers: Annually via online ECRI course or equivalent⁴	5. Confirmation of training by Westside Director of Dental Operations and documentation in HR record

¹Annual training to be determined each year by Director of Women’s Health (or Chief Medical Officer)

²Must be approved by Director of Women’s Health (or Chief Medical Officer)

³Annual training to be developed by Director/Associate Director of Clinical Operations and Director/Manager of Dental Operations, with the assistance of the Director of Quality Improvement (DQI) and/or Infection Prevention and Control (IPC) Nurse.

⁴Annual training to be determined by Director of Dental Operations (or Chief Medical Officer)

¿Fue útil este artículo?

What's Next

AD-470 FTCA-Related Claims Management 2023-06-21