jurisdiction: US

text: b' &.\n\n "OVICES\'\n\n\n\n DEPARTMENT OF HEALTH HUMAN SERVICES Office of Inspector General\n\n:.t\'\'\'UG\n Washington , D. C. 20201\n\n FEB I 7 2005\n\n\n\n\n TO: Dennis P. Wiliams , Ph.\n Deputy Administrator\n Health Resources n Services A nist,ion\n\n FROM: George Grob 4\n Assistant I \' r ene\n for EValuation and I pections\n\n SUBJECT: OIG Final Report: Ris Management at Health Centers (OEI- 01-03- 00050)\n\n\n Attached is a final inspection report providing perspectives of community health center offcials\n regarding risk management practices and the challenges health centers experience in conducting\n them.\n\n Broadly defined , risk management includes any activity, process , or policy to reduce liability\n exposure. From both a patient safety and a financial perspective , it is vital that health centers\n conduct risk management activities aimed at preventing harm to patients and reducing medical\n malpractice claims. In fiscal year 2003 , a total of 240 medical malpractice claims (seeking $1.4\n bilion in damages) were brought against health centers that are covered under the Federal Tort\n Claims Act. The Health Resources and Services Administration (HRSA) paid $22. 7 milion for\n 65 claims against these health centers.\n\n To learn more about risk management at health centers , we identified 16 risk management\n practices and sureyed health center grantees to learn about their experiences with them and to\n obtain their assessment and advice about them. Respondents selected credentialing, quality\n improvement , comprehensive medical records , and clear communication with patients as the\n most important risk management activities. They identified training, patient tracking, and peer\n review as the most difficult to do and indicated that inadequate financial resources , staffng, and\n training are the key challenges to conducting risk management.\n\n We are providing this information solely for your use in addressing these challenges. HRSA\'\n positive response to the report reflects its commitment to improving risk management for health\n centers. If you have any questions about this report , please do not hesitate to call me or one of\n your staff may contact Elise Stein , Director , Public Health and Human Services Branch , at\n (202) 619- 2686 or through e-mail ( Elise. Stein oig. hhs. gov ). To facilitate identification , please\n refer to report number OEI- 01-03- 00050 in all correspondence.\n\n Attachment\n\x0cDepartment of Health and Human Services \n\n OFFICE OF \n\n INSPECTOR GENERAL \n\n\n\n\n\n RISK MANAGEMENT AT\n\n HEALTH CENTERS\n\n\n\n\n\n Inspector General\n\n February 2005\n OEI-01-03-00050\n\x0c Office of Inspector General \n\n http://oig.hhs.gov\n\nThe mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452,\nas amended, is to protect the integrity of the Department of Health and Human Services\n(HHS) programs, as well as the health and welfare of beneficiaries served by those\nprograms. This statutory mission is carried out through a nationwide network of audits,\ninvestigations, and inspections conducted by the following operating components:\n\nOffice of Audit Services\nThe OIG\'s Office of Audit Services (OAS) provides all auditing services for HHS, either by\nconducting audits with its own audit resources or by overseeing audit work done by others.\nAudits examine the performance of HHS programs and/or its grantees and contractors\nin carrying out their respective responsibilities and are intended to provide independent\nassessments of HHS programs and operations in order to reduce waste, abuse, and\nmismanagement and to promote economy and efficiency throughout the department.\n\nOffice of Evaluation and Inspections\nThe OIG\'s Office of Evaluation and Inspections (OEI) conducts short-term management\nand program evaluations (called inspections) that focus on issues of concern to the\ndepartment, the Congress, and the public. The findings and recommendations contained\nin the inspections reports generate rapid, accurate, and up-to-date information on the\nefficiency, vulnerability, and effectiveness of departmental programs. The OEI also\noversees State Medicaid fraud control units, which investigate and prosecute fraud and\npatient abuse in the Medicaid program.\n\nOffice of Investigations\nThe OIG\'s Office of Investigations (OI) conducts criminal, civil, and administrative\ninvestigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries\nand of unjust enrichment by providers. The investigative efforts of OI lead to criminal\nconvictions, administrative sanctions, or civil monetary penalties.\n\nOffice of Counsel to the Inspector General\nThe Office of Counsel to the Inspector General (OCIG) provides general legal services to\nOIG, rendering advice and opinions on HHS programs and operations and providing all\nlegal support in OIG\'s internal operations. The OCIG imposes program exclusions and\ncivil monetary penalties on health care providers and litigates those actions within the\ndepartment. The OCIG also represents OIG in the global settlement of cases arising\nunder the Civil False Claims Act, develops and monitors corporate integrity agreements,\ndevelops compliance program guidances, renders advisory opinions on OIG sanctions to\nthe health care community, and issues fraud alerts and other industry guidance.\n\x0c\xe2\x88\x86 E X E C U T I V E S U M M A R Y\n\n\n OBJECTIVE\n To obtain health center grantees\xe2\x80\x99 perspectives regarding the relative\n importance of certain risk management practices and to identify any\n challenges or promising approaches regarding those practices.\n\n\n BACKGROUND\n The Health Resources and Services Administration (HRSA) awards\n grants to health centers to improve the health status of underserved\n populations. In fiscal year (FY) 2003, HRSA received $1.5 billion to\n fund 890 health center grants. These health centers served 12.4 million\n patients. In FY 2002, the President began a 5-year initiative to expand\n the health center program. This initiative is expected to add 1,200 new\n health center delivery sites and to increase the number of patients\n served in these sites to 16 million.\n\n Broadly defined, risk management includes any activity, process, or\n policy to reduce liability exposure. From both a patient safety and a\n financial perspective, it is vital that health centers conduct risk\n management activities aimed at preventing harm to patients and\n reducing medical malpractice claims. Health centers treat a wide\n variety of conditions, including diabetes, asthma, hypertension, and\n cardiovascular diseases, which makes it imperative for health centers to\n ensure that their patients receive the highest level of care. Many health\n centers also provide obstetric care, a high-risk area.\n\n From a financial perspective, HRSA has a particular interest in deemed\n health centers. Deemed health centers, which make up the majority of\n health centers, are those covered under the Federal Tort Claims Act for\n the purposes of medical malpractice. Therefore, they do not have to\n purchase private malpractice insurance. This results in savings for the\n health centers. HRSA is financially responsible for any payments or\n settlements arising from claims against these centers. In FY 2003, 240\n medical malpractice claims were brought against deemed health\n centers, seeking $1.4 billion in damages.\n\n Through document reviews and interviews, we identified 16 risk\n management practices that health centers are likely to conduct. These\n 16 practices included maintaining comprehensive medical records,\n credentialing, and conducting peer review. We surveyed a random\n sample of 248 health center grantees to learn about their experiences\n and to obtain their assessment and advice. We received a 71 percent\n\nOEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S i\n\x0cE X E C U T I V E S U M M A R Y\n\n\n response rate. To ensure that our results covered a broad spectrum of\n health centers, we stratified the sample by the number of patients\n served at health centers. However, the data in this report are not\n weighted and, therefore, we cannot make any statistical projections to\n the entire population of health centers. All data are self-reported and\n are not verified. The survey was anonymous with the intent to reduce\n bias in our survey results.\n\n\n SURVEY RESULTS\n Health center respondents selected credentialing, quality improvement,\n comprehensive medical records, and clear communication with patients\n as the most important risk management activities. We asked health\n centers to select the three most important risk management practices\n for reducing medical malpractice claims and ensuring patient safety.\n The risk management practice cited most often was credentialing\n (51 percent of respondents cited it as one of the three). The second\n practice cited most often was quality improvement (42 percent), the\n third was comprehensive medical records (41 percent), and the fourth\n was clear communication with patients (38 percent).\n\n On a separate survey question, respondents indicated that all 16 risk\n management practices were important. Respondents varied little in\n their assessment of how important each practice was. Between 92 and\n 100 percent of respondents indicated that each practice was either very\n or somewhat important.\n Respondents selected training, patient tracking, and peer review as the\n three most difficult risk management practices to conduct. We asked\n health centers to select the three most difficult risk management\n practices to conduct. Forty-eight percent responded that regular staff\n training was one of the three most difficult risk management activities\n to implement. Forty-two percent selected patient tracking mechanisms,\n and 32 percent selected peer review.\n Inadequate financial resources, staffing, and training were seen as key\n challenges to conducting risk management. Eighty-four percent of\n respondents cited lack of financial resources for risk management as a\n major or moderate challenge, 83 percent cited lack of a dedicated full-\n time equivalent staff person for risk management, and 64 percent cited\n lack of training.\n\n\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S ii\n\x0c E N C Y\n\n RESPONDENT COMMENTS\n Twenty-five percent of respondents offered their suggestions about\n promising or innovative approaches for risk management and\n 39 percent of respondents offered recommendations to HRSA. In the\n report we include highlights from these responses , as they may be\n useful to HRSA.\n\n\n OPPORTUNITIES FOR IMPROVEMENT\n The fundamental challenge that respondents experienced in\n conducting risk management was the lack of financial resources. This\n has implications for training, staffng, and other risk management\n activities. HRSA may want to ensure that all health centers are\n adequately investing in risk management. In particular , HRSA may\n want to determine the amount of savings deemed health centers\n realize from being deemed and ensure that they are reinvesting some\n portion of their savings into risk management.\n In addition , HRSA may want to consider developing a comprehensive\n ongoing training agenda on risk management for health centers. HRSA\n may also want to explore creative , inexpensive ways to assist health\n centers , such as disseminating best practices or a newsletter , developing\n tool kits that contain sample policies and procedures , and encouraging\n health centers to participate in regional networks for sharing\n information and resources about risk management.\n\n AGENCY COMMENTS\n HRSA responded positively to the report and its comments reflect its\n commitment to improving risk management for health centers. It has\n established a new goal that by 2010 , 100 percent of health centers wil\n participate in risk management training. HRSA plans to achieve this\n goal by holding risk management workshops and by developing a\n comprehensive training agenda. For HRSA\' s complete response , see\n Appendix C attached to the main body of the report.\n\n\n\n\nOEI. 01- 03. 00050 RISK MANAGEMENT AT HEALTH CENTERS 111\n\x0c\xe2\x88\x86\n T A B L E O F C O N T E N T S\n\n\n\n E X E C U T I V E S U M M A R Y ....................................................i \n\n\n\n I N T R O D U C T I O N ............................................................. 1 \n\n\n\n P R I M E R O N R I S K M A N A G E M E N T .................................... 7 \n\n\n\n S U R V E Y R E S U L T S ......................................................... 9 \n\n Most important risk management practices . . . . . . . . . . . . . . . . . . . . . . . . . . 9 \n\n\n Most difficult risk management practices to conduct . . . . . . . . . . . . . . . 12 \n\n\n Challenges to risk management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 \n\n\n\n\n R E S P O N D E N T C O M M E N T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 \n\n Promising approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 \n\n\n Respondents recommendations to HRSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 \n\n\n\n O P P O R T U N I T I E S F O R I M P R O V E M E N T . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 \n\n\n\n A G E N C Y C O M M E N T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 \n\n\n\n A P P E N D I X E S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 \n\n\n Appendix A: Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 \n\n\n Appendix B: Additional analysis by size of respondents . . . . . . . . . . . 36 \n\n\n\n\n A C K N O W L E D G M E N T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 \n\n\n\n E N D N O T E S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39\n\n\x0c OBJECTIVE\n To obtain health center grantees \' perspectives regarding the relative\n importance of certain risk management practices and to identify any\n challenges or promising approaches regarding those practices.\n\n BACKGROUND\n The Health Resources and Services Administration (HRSA), within the\n Department of Health and Human Services , awards grants to a variety\n of health centers , including community health centers , migrant health\n centers , and public housing primary care centers) Each of these health\n centers addresses the needs of a specific population and is designed to\n increase access to primary health care services and to improve the\n health status of underserved populations.\n In fiscal year (FY) 2003 , HRSA received $1.5 billion to support\n 890 health center grants. These funds supported general operating\n expenses and patient services. The health centers encompassed about\n 600 health care delivery sites and served 12.4 millon people. They\n employed about 7 800 physicians and dentists and 70 000 other health\n care practitioners and administrative staff. Also in FY 2003 , health\n centers received an estimated $2. 1 billion from Medicaid and an\n estimated $327 milion from Medicare.\n\n The Importance of Risk Management\n Broadly defined , risk management includes any activity, process , or\n policy to reduce liability exposure. This involves all aspects of a health\n center s infrastructure and services , including financial matters , facility\n maintenance , fire safety, compliance with applicable laws and\n regulations , and clinical care. However , for the purposes of this report\n we limit the meaning of risk management to activities aimed at\n reducing medical malpractice claims and ensuring patient safety\n (protecting patients from harm).\n Health centers conduct a wide array of activities to reduce medical\n malpractice claims , such as credentialing and privileging health care\n practitioners , using clinical protocols , and maintaining medical records.\n These activities are critical for several reasons , which we elaborate on\n in this section.\n\n Ensuring patient safety. Health centers treat a wide variety of\n conditions , including diabetes , asthma , hypertension , and\n\nOEI. 01. 03- 00050 RISK MANAGEMENT AT HEALTH CENTERS\n\x0cI N T R O D U C T I O N\n\n\n cardiovascular diseases, which makes it imperative for health centers to\n ensure that patients receive the appropriate level of care. Many health\n centers also provide obstetric care, a high-risk area, which further\n underscores the importance of risk management.\n\n Medical malpractice claims demonstrate the significance of potential\n problems that can occur in health centers. Medical malpractice claims\n filed in 2003 cover a broad range of conditions and severity. Examples\n of some more serious claims included the following allegations: failure\n to diagnose asthma, improper prescription of diabetes medication,\n failure to treat elevated blood pressure, and failure to diagnose and\n treat congestive heart failure and myocardial infarction. In addition,\n there were claims related to obstetric care, which included the following\n allegations: failure to remove gauze during delivery; negligent prenatal\n care, labor, and delivery; and failure to diagnose and treat an ectopic\n pregnancy. Although these claims have not yet been finally resolved or\n determined to have merit, they illustrate the nature of some of the more\n serious potential problems.\n Costs associated with medical malpractice claims. To cover financial\n losses due to medical malpractice claims, health centers can either\n obtain coverage at no cost to the health center under the Federal Tort\n Claims Act or purchase medical malpractice insurance from a private\n company. 2\n Health centers that elect to be covered under the Federal Tort Claims\n Act are referred to as deemed health centers.3 Eligible health centers\n include migrant health centers, community health centers, health care\n for the homeless grantees, school-based health centers, and health\n services for public housing residents grantees. In FY 2003, 680 health\n centers were deemed (about 80 percent). The primary reason health\n centers choose this option is the savings they realize by not having to\n purchase private medical malpractice insurance.4\n HRSA is financially responsible for any payments or losses arising from\n medical malpractice claims against deemed health centers. Since\n deeming began in 1992, 345 health centers have incurred claims against\n them. Of these, 40 percent had 1 claim, 18 percent had 2 claims, and\n the remainder had 3 or more claims.\n\n In FY 2003, 240 medical malpractice claims were brought against\n deemed health centers, seeking $1.4 billion in damages. There is a\n considerable difference in the amount claimants seek and the actual\n amount HRSA pays out. Historically, the median amount demanded by\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 2\n\x0cI N T R O D U C T I O N\n\n\n claimants was $1.5 million, whereas the median amount paid out by\n HRSA was $125,000. In FY 2003, HRSA paid $22.7 million for\n 65 claims against these health centers. (These paid claims were not\n necessarily filed in FY 2003.)\n\n HRSA covers claim payments out of its Health Center Tort Claims\n Fund. HRSA has raised concerns about the financial viability of this\n fund as the health center program expands. HRSA\xe2\x80\x99s FY 2003 budget\n justification stated:\n . . . FTCA [Federal Tort Claims Act] payments for settled\n claims are expected to increase as a result of increases in the\n number of covered health centers, health center physicians,\n and patients, as well as, the overall upward trend in\n judgments and settlements being experienced in the medical\n malpractice marketplace. In addition, a number of insurance\n companies are dropping malpractice coverage because of\n substantial losses in providing malpractice insurance.\n\n In FY 2004, HRSA received $45 million in appropriations for this fund.5\n The President\xe2\x80\x99s budget for FY 2005 requests $45 million.\n\n In the cases in which a health center opts to purchase private\n insurance, the insurer is financially responsible for any payments or\n losses arising from medical malpractice claims against the center. To\n reduce liability, the private insurer typically provides the health center\n with a risk management assessment, training, and technical assistance.\n Nondeemed health centers may choose to purchase private insurance\n because they can afford the premiums and want to benefit from the risk\n management services provided by the private insurer.\n Expansion of the program. In FY 2003, health centers served\n 12.4 million patients. This number is expected to increase as the\n program expands, thereby exposing HRSA to greater liability. In\n FY 2002, the President began a 5-year initiative to expand the health\n center program. This initiative is expected to add 1,200 new health\n center delivery sites and to increase the number of patients served in all\n sites to 16 million. The President\xe2\x80\x99s FY 2005 budget requests the third\n year of funding for this initiative, seeking $1.8 billion for the health\n center program. With these funds it is expected that by the end of FY\n 2005 the total number of health center delivery sites will be 3,800.\n Past program vulnerabilities. A 1997 U.S. Government Accountability\n Office report raised concerns about the risk management services that\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 3\n\x0cI N T R O D U C T I O N\n\n\n HRSA intended to provide health centers at that time.6 Specifically, it\n found that HRSA was providing limited risk management services to\n deemed health centers. At the time this report was issued, the Federal\n Tort Claims Act option for health centers had only been in place for a\n few years. Health centers and HRSA both had little experience with\n deeming. Since that time HRSA has taken steps to provide health\n centers with additional risk management services. Still, it is timely to\n reexamine these issues given that 7 years have passed.\n Health Center Requirements for Risk Management\n HRSA\xe2\x80\x99s regulations and policies require all health centers to conduct\n certain risk management activities. These activities include\n implementing a quality assurance program, performing credentialing\n and privileging for certain health care providers, and developing risk\n management policies and procedures, among others. (See the primer on\n page 7 for a list of risk management activities HRSA requires.)\n\n In addition to these requirements, deemed health centers must adhere\n to two additional requirements. First, the statute requires deemed\n health centers to cooperate with the Department of Justice in providing\n information related to medical malpractice claims.7\n Second, HRSA\xe2\x80\x99s policy requires a portion of the savings deemed health\n centers realize to be reinvested in risk management. The policy\n specifically states that HRSA \xe2\x80\x9c. . . expects as health centers begin to\n realize savings in malpractice insurance costs due to coverage under the\n Federal Tort Claims Act, centers will reinvest some of the savings to\n target malpractice risk reduction.\xe2\x80\x9d8 However, the same policy may\n cause some confusion about this requirement, because it also states that\n the savings can be used for any activity within the scope of the grant.\n Specifically, it states:\n For example, these funds may be used to increase the number\n of users, increase the range of services provided . . . or to\n implement administrative improvements (including clinical\n compensation, clinical quality improvement/risk management\n activities).\n\n HRSA monitors risk management at all health centers in two key ways:\n grant applications and onsite reviews. The grant application and, when\n applicable, the deeming application provide information about relevant\n aspects of a health center\xe2\x80\x99s risk management program. The grant\n application also requires health centers to describe their quality\n assurance and risk management practices. The deeming application\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 4\n\x0cI N T R O D \nU C T I O N\n\n\n requires health centers to certify that they have certain risk\n management practices in place, such as credentialing and privileging.\n\n In terms of onsite reviews, HRSA previously relied on its Primary Care\n Effectiveness Reviews, which were onsite performance reviews that\n health centers received about once every 5 years. These reviews\n included specific questions examining centers\xe2\x80\x99 risk management\n practices. However, HRSA no longer performs these reviews.\n\n HRSA has developed a new performance assessment protocol for all its\n grantees, including health centers. This new protocol is currently being\n implemented and will likely include performance measures related to\n risk management.\n\n Health centers that are accredited by the Joint Commission on\n Accreditation of Healthcare Organizations (referred to throughout the\n report as the Joint Commission) must adhere to its standards for\n ambulatory health care programs, which include numerous\n requirements relevant to risk management.9 For example, these\n standards require credentialing and privileging of providers and\n internal monitoring of adverse events, among others. In 1997, HRSA\n began an initiative to encourage health centers to seek accreditation.\n As of 2003, 290 health centers (about 33 percent) had received\n accreditation from the Joint Commission.\n\n\n METHODOLOGY\n This inspection is based on a document review, stakeholder interviews,\n and a survey of health center grantees. All the data presented in this\n report are self-reported and are not verified. To reduce bias in the\n responses, we administered the survey anonymously. For a detailed\n description of our methodology, see Appendix A.\n\n To improve our understanding of risk management we reviewed\n documents and interviewed various stakeholders (e.g., the National\n Association of Community Health Centers, primary care associations,\n and selected health centers). Based on these sources, we identified 16\n risk management practices that health centers are likely to conduct\n (some of which are required). See the primer on page 7 for a complete\n list and description of these 16 practices, including which are required.\n We used these 16 risk management practices as the basis for our survey\n questions.\n\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 5\n\x0cI N T R O D U C T I O N\n\n\n We surveyed a random sample of 248 health center grantees out of\n 835 grantees in FY 2002. To ensure that our results covered a broad\n spectrum of health centers, we stratified the sample by the number of\n patients served. The sample included deemed and nondeemed and\n accredited and nonaccredited health centers. We received 175 replies to\n our survey, for a response rate of 71 percent. Eighty-eight percent of\n respondents to the survey were deemed. Because not all respondents\n answered every question, the actual number of respondents varies by\n question. Therefore, throughout the report we provide percentages\n based on the actual number of respondents for each question.\n Data limitations\n Because the survey was anonymous and we obtained only self-reported\n estimates about the number of patients served in FY 2002, we were\n unable to determine which stratum each respondent fell into. As a\n result, we could not weight the data, nor could we calculate confidence\n intervals. Therefore, we cannot make statistical projections to the\n entire population of health centers based on the survey data. The data\n presented in the report are simple frequencies of the responses. We did\n not independently verify any statements health center grantees made\n on the survey. Finally, we are unable to conduct a nonrespondent\n analysis because the survey was anonymous. Therefore, we cannot\n estimate the level of bias among respondents. These limitations apply\n to all data analysis and comparisons presented in the report.\n Standards\n We conducted this inspection in accordance with the \xe2\x80\x9cQuality Standards\n for Inspections\xe2\x80\x9d issued by the President\xe2\x80\x99s Council on Integrity and\n Efficiency.\n\n\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 6\n\x0c\xe2\x88\x86\n P R I M E R O N R I S K M A N A G E M E N T\n\n We identified 16 risk management practices that health centers are\n likely to conduct to reduce medical malpractice claims and ensure\n patient safety. We identified these practices based on interviews with\n health centers, Federal officials, and other key stakeholders; a review of\n relevant statutes, regulations, and policies; and a review of pertinent\n literature regarding risk management in health care settings. Ten of\n these 16 risk management practices are explicitly required either by\n statute or by HRSA regulation or policy (as designated by an asterisk).\n The Joint Commission requires all 16 of these practices.\n Active quality improvement program*: Internal efforts to improve the\n quality of care. These efforts may include reviewing clinical outcome\n data and conducting long-term projects aimed at improving clinical care,\n among others.\n Appropriate use of clinical protocols*: Established guidelines for\n providing clinical care that health care practitioners use. These\n guidelines may be developed by professional organizations or by the\n health center\xe2\x80\x99s clinical staff.\n Clear communication with patients*: Patients have a voice in\n determining their care and receiving information about their care in a\n way that they can comprehend. This includes providing translation\n services when necessary.\n Clear communication with providers: Health care providers receive clear\n communication from the health center\xe2\x80\x99s leadership about their roles and\n responsibilities and they communicate clearly with one another.\n Comprehensive patient medical records*: These records document the\n care provided to the patient at the health center. They can be either\n paper or electronic.\n Credentialing of health care professionals*: The process of verifying that\n health care providers meet all required educational and licensing\n requirements. The health center or a third party may conduct this\n activity.\n Documentation of informed consent: Patients are adequately informed\n about risks and benefits of their treatment.\n Formal patient grievance mechanism*: A system to collect, analyze, and\n address complaints received from patients and/or staff.\n\n\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 7\n\x0cP R I M E R O N R I S K M A N A G E M E N T\n\n\n Internal incident reporting system: A system to collect and analyze\n information on adverse events that occur within the health center\n resulting from inappropriate care.\n Ongoing peer review of patient cases: The review of medical records or\n patient cases by health care professionals, either within the health\n center or as outside consultants, to ensure that appropriate care was\n provided.\n Onsite assessment of risks and risk management practices: A process to\n assess the potential risks of the health center and the health center\xe2\x80\x99s\n activities to reduce its risks. This assessment can be done by the health\n center or by outside consultants.\n Patient tracking system: A formal system, either electronic or paper, to\n ensure that key patient information, such as test results, missed\n appointments, and care at different health care institutions, is not\n overlooked.\n Privileging of health care professionals*: The process of verifying, on a\n routine basis, that practitioners have the appropriate clinical\n competencies and the ability to perform clinical procedures effectively.\n Regular patient satisfaction survey*: A survey to assess patient\n satisfaction with the level of service and clinical care that they received.\n Regular staff training on risk management*: Staff receive either onsite or\n offsite training on topics related to risk management.\n Up-to-date policies and procedures on risk management*: Written\n documents that explicitly describe a health center\xe2\x80\x99s operations and\n processes related to risk management.\n\n\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 8\n\x0c s u R V E Y S U L T S\n\n\n\n While health center respondents indicated that We asked respondents to select the\n all 16 risk management practices were three risk management practices\n important, they selected credentialing, quality they considered to be the most\n important for reducing medical\n improvement, comprehensive medical records,\n malpractice claims and ensuring\n and clear communication with patients as the patient safety. The range of\n most important responses among the 16 practices\n varied from 3 to 51 percent. (See\n Table 1,)\n\nTable 1. The Level of Importnce of Risk Management Practices According to Respondents\n\n\n Percentage of Respondent Percentage of Respondent\n Who Selec the Practice Who Indica the Practce\n as One of the Three Most Was Very or Somewat\n Risk Management Practice Importnt Importnt\n Creentialing of Health Care Professionals\n\n\n Active Quality Improvement Program\n\n Comprehensive Patient Meical Recrds 100\n\n Clear Communication With Patients\n\n Patient Tracking System\n\n Ongoing Peer Review of Patient Cases\n\n Intemallncident Reporting System\n\n Appropriate Use of Clinical Protocols\n\n Regular Staff Training on Risk Management*\n\n Privileging of Health Care Professionals\n\n Onsite Assessment of Risks and Risk Management Practice\n\n Doumentation of Informed Consent\n\n Formal Patient Grievance Mechanism\n\n Regular Patient Satisfaction Survey\n\n Clear Communication With Providers\n\n Up-To-Date Polices/Procures on Risk Management*\n\n Indicates risk management practices explicity required by statute or HRSA regulation or policy.\nSource: Ofce of Evaluation and Inspeions\' analysis of survey responses , 200.\n\n\n\n OEI- 01- 03- 00050 RISK MANAGEMENT AT HEALTH CENTERS\n\x0cS U R V E Y \n R E S U L T S\n\n\n Credentialing. Credentialing is the process of verifying that a health\n care practitioner meets all required educational and licensing\n requirements; it is a requirement for all health centers.10 The health\n center or a third party may conduct this activity. Respondents cited\n credentialing most often (51 percent) as one of the three most important\n risk management activities.\n\n The level of importance respondents attributed to credentialing may\n reflect the recent attention HRSA has given to this area. In 2001 and\n 2002, HRSA issued policy information notices emphasizing the\n importance of credentialing and its expectations for health centers.\n HRSA expects health centers to review and verify their practitioners\xe2\x80\x99\n qualifications, including professional credentials, references, and claims\n history.11\n Respondents commented that credentialing is the foundation for risk\n management. It is essential that health centers have qualified staff to\n ensure safe and appropriate treatment of their patients. One\n respondent summed it up by writing \xe2\x80\x9c. . . the care you give can only be\n as good as the providers you hire. . . .\xe2\x80\x9d Respondents also commented\n that credentialing is important from a liability perspective, as it\n documents that health centers carry out due diligence when hiring\n health care providers.\n Quality improvement programs. Quality improvement programs, which\n are required by HRSA, include internal efforts to improve the quality of\n the clinical care, such as analyzing clinical outcome data. Respondents\n cited quality improvement programs second most often (42 percent) as\n one of the three most important risk management activities.\n\n Respondents commented that quality improvement activities allowed\n them to identify areas needing improvement, thereby helping them to\n prevent future problems. Respondents also commented that they\n conduct many of their risk management practices as part of their\n quality improvement program. These programs serve as a way to\n integrate numerous risk management activities into one comprehensive\n program. Finally, respondents mentioned that quality improvement\n programs are important because they provide an objective means of\n measuring and monitoring their performance over time.\n Comprehensive patient medical records. Medical records document the\n care provided to the patient at the health center, and HRSA requires\n them for all health centers. The records can be either paper or\n electronic. Respondents rated maintaining comprehensive patient\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 10\n\x0cS U R V E Y \n R E S U L T S\n\n\n medical records third (41 percent) among the three most important risk\n management practices.\n\n Respondents cited several reasons they consider medical records to be\n important. First, when a malpractice claim is filed, medical records\n serve as a key piece of evidence in determining whether appropriate\n care was provided. Respondents indicated that malpractice claims can\n often be quickly dismissed if medical records demonstrate that\n appropriate care was provided. One respondent wrote \xe2\x80\x9c. . . if it isn\xe2\x80\x99t\n documented, it didn\xe2\x80\x99t occur.\xe2\x80\x9d Second, respondents pointed out that\n medical records play an important role in preventing errors, because\n they serve as a complete record of the patient\xe2\x80\x99s care and assist the\n health care provider in making decisions about appropriate next steps.\n Medical records are especially important if multiple providers are\n working with a patient. Finally, respondents commented that medical\n records can also be a rich source of information for quality improvement\n programs and peer review efforts.\n Clear communication with patients. Clear communication with patients,\n which is also required by HRSA, involves making sure patients have a\n voice in determining their care and providing them with information\n about their care in a way they comprehend. This includes providing\n translation services when necessary. Thirty-eight percent of\n respondents cited clear communication with patients as one of the three\n most important risk management practices.\n\n Respondents cited several reasons why clear communication with\n patients is critical. One common theme among respondents was the\n opinion that, when patients understand their diagnosis and treatment,\n they are more likely to be compliant with their treatment regimen.\n Another common theme mentioned by several respondents was that\n patients who understand their treatment and are active participants\n are less likely to sue when something goes wrong.\n All 16 practices. We asked respondents to give their opinion on the level\n of importance of each of the 16 risk management practices.\n Respondents varied little in their assessments. Between 92 and\n 100 percent of respondents assessed each practice as either very or\n somewhat important. (See Table 1 on page 9.)\n\n Several respondents identified other important risk management\n practices in addition to the 16 we identified. These included obtaining\n accreditation by the Joint Commission, monitoring medication usage,\n implementing appropriate procedures for infection control, assessing\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 11\n\x0c S U R V E Y R E S U L T S\n\n\n performance of clinical staff, and documenting telephone calls with\n patients.\n\n We asked respondents to select\nRespondents selected training, patient tracking,\n the three risk management\n and peer review as the three most difficult risk practices they considered to be the\n management practices to conduct most difficult to implement. (See\n Table 2.)\n\n\n Table 2. Health Center Respondents\' Self-Assessment of Their Performance for Risk Management\n Practices\n\n Percentage of Respondents\n Percentage of Respondents Who Indicated They Were\n Who Selected the Practice as Doing an Excellent or Good\n One of the Three Most Job at Conducting the\n Risk Management Practice Difficult to Conduct Practice\n\n Regular Staff Training on Risk Management* 48 54\n\n Patient Tracking System 42 66\n\n Ongoing Peer Review of Patient Cases 32 70\n\n Onsite Assessment of Risks and Risk Management Practices 30 58\n\n Active Quality Improvement Programs* 26 87\n\n Up-to-Date Polices/Procedures on Risk Management* 21 70\n\n Comprehensive Patient Medical Records* 17 90\n\n Appropriate Use of Clinical Protocols* 14 82\n\n Credentialing of Health Care Professionals* 11 95\n\n Internal Incident Reporting Systems 10 84\n\n Clear Communication With Patients 8 93\n\n Privileging of Health Care Professionals* 7 86\n\n Clear Communication With Providers* 4 90\n\n Formal Patient Grievance Mechanism* 3 88\n\n Regular Patient Satisfaction Survey* 3 82\n\n Documentation of Informed Consent 1 89\n\n\n *Indicates risk management practices explicitly required by statute or HRSA regulation or policy.\n Source: Office of Evaluation and Inspections\' analysis of survey responses, 2004.\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 12\n\x0cS U R V E Y R E S U L T S \n\n\n\n\n\n Training. Training, which is required by HRSA, can be provided either\n onsite or offsite and can address a wide array of topics related to risk\n management. Respondents cited regular staff training most often\n (48 percent) as one of the three most difficult risk management\n activities to conduct.\n\n Among the reasons respondents cited were the lack of staff, money, and\n training materials. Training is often deferred to a later date, since\n providing care is perceived to be more important and staff time is\n limited.\n Patient tracking. Patient tracking, which is not required by HRSA, is a\n formal system, either electronic or paper-based, used to ensure that key\n patient information is not overlooked. Key information includes test\n results, missed appointments, and care at different health care\n institutions. Respondents ranked patient tracking second (42 percent)\n among the three most difficult activities to conduct.\n\n Respondents commonly cited the lack of information technology as a\n reason this activity is difficult to conduct. Respondents also commented\n that even if they had the appropriate information technology, it would\n require time, which respondents reported is often in short supply, to\n input data and monitor the system. Finally, respondents commented\n that some patients are homeless and/or transient, making followup\n difficult under any circumstances.\n Peer review. Peer review, also not required by HRSA, involves the\n review of medical records or patient cases by health care professionals,\n who are either within the health center or outside consultants, to\n ensure that appropriate care was provided. Respondents ranked peer\n review third (32 percent) among the three most difficult activities to\n conduct.\n\n Respondents commented again that time and resources were an issue\n that made peer review difficult. Several respondents mentioned that\n the staff view patient care as a higher priority and may be unwilling to\n spend time conducting peer review. In addition, several respondents\n mentioned that with a small staff, practitioners are often uncomfortable\n reviewing one another. In fact, some respondents indicated that they\n have only two to three staff per site.\n All 16 practices. While 90 percent of respondents thought that,\n overall, they were doing an excellent or good job at conducting risk\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 13\n\x0cS U R V E Y R E S U L T S\n\n\n management, the portion of respondents who felt they were doing\n either an excellent or good job for each of the 16 practices ranged from\n a low of 54 percent to a high of 95 percent. (See Table 2 on page 12.)\n\n For additional survey data on these assessments by the size of the\n respondents, see Table 10 in Appendix B.12\n\n Health center respondents indicated that Respondents experienced\n inadequate financial resources, staffing, and several challenges that\n prevented them from doing all\ntraining are key challenges to conducting risk\n that they would like in terms of\n management\n risk management. In fact,\n 40 percent of respondents indicated that there are risk management\n practices that they would like to conduct, but are currently unable to.\n These respondents mentioned additional training, onsite reviews,\n peer review, and patient tracking as activities they would like to\n conduct.13\n To better understand these challenges, we provided respondents with\n a list of potential challenges and asked them to indicate to what\n extent each hindered their ability to conduct effective risk\n management.\n\n For additional survey data on these challenges by the size of\n respondents, see Table 11 in Appendix B.\n Financial resources. Eighty-four percent of respondents selected lack of\n financial resources as a major or moderate challenge. Financial\n resources have consequences for staffing, training, and information\n technology, all of which affect a health center\xe2\x80\x99s ability to conduct risk\n management.\n\n Financial resources are a concern even for deemed respondents.\n Deemed health centers are covered under the Federal Tort Claims Act\n for the purposes of medical malpractice claims; therefore, they do not\n have to purchase comprehensive private malpractice insurance. This\n results in savings for the health center. Eighty-eight percent of\n respondents to the survey were deemed. Of those deemed respondents,\n 83 percent reported that the lack of financial resources was a major or\n moderate challenge. Eighty-six percent of nondeemed respondents\n reported that the lack of financial resources was a major or moderate\n challenge.\n\n Still, 73 percent of deemed respondents indicated that being deemed\n had to a great or moderate extent improved their ability to conduct risk\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 14\n\x0cS U R V E Y R E S U L T S\n\n\n management. This may be in part due to the savings from not having to\n purchase private malpractice insurance. Deemed respondents reported\n saving $228,000 per year on average, with individual respondents\n saving between $7,500 and $2 million.\n\n However, only 47 percent of deemed respondents reported that they\n were using these savings, in whole or in part, for risk management\n practices. Of those using these savings for risk management, common\n activities included hiring additional staff, conducting more staff\n training, implementing a quality improvement program, seeking\n accreditation, and hiring outside consultants.\n\n Twenty-two percent of deemed respondents indicated that they were\n not using these savings for risk management and 31 percent were\n unsure how they were using these savings. HRSA\xe2\x80\x99s policy is unclear\n on how much of these savings should be used for risk management;\n HRSA\xe2\x80\x99s Policy Information Notice 1999-08 states:\n [HRSA] expects as health centers begin to realize savings in\n malpractice insurance costs due to coverage under the FTCA\n [Federal Tort Claims Act], centers will reinvest some of the\n savings to target malpractice risk reduction.\n\n This same policy states that health centers may use these savings for\n activities within the scope of the grant:\n For example, these funds may be used to increase the number\n of users, increase the range of services provided . . . or to\n implement administrative improvements (including clinical\n compensation, clinical quality improvement/risk management\n activities).\n\n It is important to point out that it is difficult for health centers,\n especially those that have been deemed for several years, to know how\n much they are actually saving per year. HRSA does not require health\n centers to track their savings. In fact, it would be difficult for them to\n do so, because it would require health centers to have an understanding\n of their local insurance markets so they could estimate the current cost\n of malpractice insurance. Health centers do provide HRSA with their\n annual budgets; however, not all risk management activities are easily\n accounted for in terms of financial expenditures, such as clear\n communication with patients and maintaining up-to-date policies and\n procedures.\n\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 15\n\x0cS U R V E Y R E S U L T S\n\n\n Staffing. Eighty-three percent reported that a lack of dedicated full-time\n equivalent staff for risk management was a major or moderate\n challenge. Only 19 percent of respondents reported that they have a\n dedicated staff position, either full- or part-time, for risk management.\n\n Instead, most respondents reported that they rely on their executive\n directors, compliance officers, physicians, and nurses to play key roles\n in risk management for the health center. However, these individuals\n are also busy managing other responsibilities and may have difficulty\n finding the time or obtaining the necessary expertise for risk\n management activities. This is especially the case for clinical staff:\n 82 percent of respondents indicated that the lack of clinical staff time\n was a major or moderate challenge to conducting risk management.\n Training. Sixty-four percent of respondents indicated that training was\n a major or moderate challenge. Lack of training can affect the level of\n expertise among staff for risk management and, in fact, 64 percent\n responded that the lack of expertise among staff was a major or\n moderate challenge.\n\n Notwithstanding these challenges, 69 percent of respondents indicated\n that their staff received training on risk management in FY 2003.\n Fifty-three percent responded that their staff received training no less\n than once every few months, and 33 percent said their staff received\n training once a year.\n\n Respondents indicated that they received training from a variety of\n sources. Fifty-eight percent received training from their own staff,\n 25 percent from State primary care associations, 30 percent from the\n National Association of Community Health Centers, and 27 percent\n from private insurance companies.\n\n HRSA also provides training to health centers. However, only\n 13 percent of respondents reported that they received training from\n HRSA (including both regional and/or central office), even though HRSA\n provides several resources. (See Table 3 on page 17 for a complete list of\n HRSA\xe2\x80\x99s resources.) Respondents varied in how satisfied they were with\n the risk management resources HRSA provides. They appeared to be\n the most satisfied with HRSA policy information notices, the Federal\n Tort Claims Act helpline, and accreditation from the Joint Commission.\n (See Table 3 on page 17.)\n\n\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 16\n\x0c S U R V E Y R E S U L T S\n\n\n Notably, respondents reported that they had no experience with many\n HRSA resources. However, some of these resources were available only\n on a limited basis. Nevertheless, nearly 45 percent reported that they\n had no experience with the publication \xe2\x80\x9cRisk Management,\xe2\x80\x9d published\n\n\n\nTable 3. Health Center Respondents\' Satisfaction w ith Risk M anagem ent Assistance from HRSA\n\n\n\n Percentage of Percentage of\n Respondents W ho Respondents W ho\n Indicated They W ere Indicated No\n Com pletely or Som ew hat Experience W ith the\n HRSA Resources Satisfied Resource\n\n HRSA\'s policy inform ation notice on credentialing and privileging (Policy\n 79 6\n Inform ation Notice 2002-22)\n\n\n Federal Tort Claim s Act helpline (1-866-FTCA HELP) 78 28\n\n\n HRSA\'s program expectation (Policy Inform ation Notice 1998-23) 74 7\n\n\n Accreditation by the Joint Com m ission on Accreditation of Healthcare\n 74 49\n organizations supported by HRSA\n\n\n HRSA\'s online resources (i.e., W eb site) 63 23\n\n\n National Association of Com m unity Health Centers\' m alpractice risk\n 59 36\n m anagem ent consultation line (1-888-800-3772), funded by HRSA\n\n\n Risk m anagem ent recom m endations provided by a review of Federal\n Tort Claim s Act m edical m alpractice claim s by HRSA\'s Division of 58 46\n Clinical Quality (form erly the Center for Risk Managem ent)*\n\n\n Federal Tort Claim s Act claim s-related site visits initiated by HRSA\'s\n 50 71\n Division of Clinical Quality (form erly the Center for Risk Managem ent)*\n\n\n HRSA\'s distribution of the publication, "Risk Managem ent," printed by\n 48 45\n the Departm ent of Legal Medicine, Arm ed Forces Institute of Pathology\n\n Referral to appropriate risk m anagem ent resources by HRSA project\n 46 49\n officer\n\n\n Incident reporting system (i.e., Doctor Quality)* 39 51\n\n\nNote: The percentage of respondents who indicated that they were com pletely or som ewhat satisfied is out of those\nrespondents who indicated they had experience with the resource. The percentage of respondents who indicated they\nhad no experience with the resource is out of the total num ber of survey respondents.\n\n*Indicates that this service is available only on a lim ited basis.\n\nSource: Office of Evaluation and Inspections\' analysis of survey responses, 2004.\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 17\n\x0cS U R V E Y R E S U L T S\n\n\n by the Armed Forces Institute of Pathology and distributed to all health\n centers by HRSA. Thirty-six percent of respondents indicated no\n experience with the risk management telephone consultation line,\n which is also available to all health centers. (See Table 3 on the\n previous page.)\n\n Even with these resources, 87 percent of respondents indicated that\n they would like to receive more training. Topics for additional training\n included documentation, incident reporting, and patient records.\n Respondents also called for general or overall help in developing a risk\n management program. Several respondents were looking for a better\n understanding of the basics of a risk management program and how to\n implement such a program in their health center.\n\n\n\n\nOEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 18\n\x0c\xe2\x88\x86 R E S P O N D E N T C O M M E N T S\n\n\n\n Twenty-five percent of\nHealth center respondents identified promising\n respondents offered their\n approaches to conducting risk management suggestions about promising\n approaches. Below are some\n highlights.\n Onsite Assessments\n o \t Proactively doing self-assessments of some departments and\n processes.\n\n o \t We do our own periodic environment of care \xe2\x80\x9cwalk throughs\xe2\x80\x9d\n using the same tool as our State licensing auditors and the\n Joint Commission use. This keeps us on our toes.\n\n o \t We started emergency room site visits by the key management\n during night duty hours. Assessment of medical practices,\n billing procedures, medical supply, security of the building and\n equipment, patient satisfaction, and adherence with the\n organizational polices and procedures is performed during each\n visit.\n\n o \t Daily emergency medical audit report.\n\n o \t Monthly risk assessment walk throughs are conducted by our\n safety committee and are designed to integrate needs for many\n risk-surveillance areas: infection control, emergency\n medication use, quality control log compliance, facility and the\n Office of Occupational Safety and Health Administration\n hazards, and others. These findings are tracked through a\n larger performance improvement committee responsible for\n initiating followup activities where improvements or risk\n reduction is needed.\n\n o \t We have implemented monthly safety audits at all sites\xe2\x80\x94both\n clinical and nonclinical. Different staff members conduct the\n audit each month and report back to quality review\n management department.\n\n o \t We requested from the general liability insurance company a\n loss control assessment. It was performed during 2003.\n Recommendations were properly addressed. A followup visit\n and risk management conference was scheduled for March\n 2004.\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 19\n\x0cR \tE S P O N D E N T C O M M E N T S\n\n\n Quality Improvement Programs\n o \t Part of a Health Center Network, Council of Community\n clinics, that facilitates/coordinates/supports coordinated\n quality improvement programs.\n\n o \t The rate of medication errors has [been] reduced due to having\n an additional pharmacist on board. The double checking of\n dispensing drugs has greatly reduced high volume area and\n enhanced quality control of dispensing the wrong medication to\n our patients.\n\n o \t We are a large prenatal provider and we do 100 percent chart\n review on all prenatal charts at 28 weeks to ensure a GTT\n [glucose tolerance test] has been run and results documented.\n Lack of GTT and diagnosing gestational diabetes can lead to\n complications, which we want to avoid by making sure we do\n this test.\n o \t Yearly review by life cycle and risk groups of preventive care\n guidelines and health maintenance issues promotes\n identification of problem areas and medical plan to address the\n problem.\n Incident Reporting\n o \t We have an active medical safety committee where we review\n all adverse drug events and potential adverse drug events.\n These are computerized in an incident reporting system.\n\n o \t Incident reports are summarized on a multi-year basis for\n trends and improvements.\n\n o \t New incident report form is easy to use\xe2\x80\x94requires mostly\n checking specific categories\xe2\x80\x94categories are based on meta-\n analysis of incident reports filed over last several years.\n Patient Satisfaction\n o \t Our satisfaction survey includes children K-5 grades. Along\n with the satisfaction survey, we also survey parents, teachers,\n administrator, staff at the school and we use a standard health\n behavior survey in children 4-5 (grades) to evaluate\n effectiveness of health prevention activities.\n\n o \t Patients who transfer medical records are mailed a survey to\n determine the reason for leaving our practice. The survey\n results are rewarded [reviewed] by the board of directors,\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 20\n\x0cR \tE S P O N D E N T C O M M E N T S\n\n\n administrative staff, and provider and support staff.\n Corrective action is implemented when appropriate.\n\n o \t Direct line for patients with complaints to the chief executive\n officer who actively responds to such complaints. Believe this\n has defused potential problems at the early stage.\n\n o \t The center utilizes a public board forum where the public gets\n to meet the board of directors and directors of services at least\n 2 times per year. This unique forum allows the community at\n large, and the patients to come and listen to the board speak\n about the changes and challenges in the provision of care. The\n patients and the community-at-large also get the opportunity\n to voice their opinions on the care received, services they need,\n and satisfaction in general.\n Training\n o \t Risk management topic at every monthly administration staff\n meeting.\n\n o \t Annual in-service training with staff, annual education day\n with all employees to go over Office of Occupational Safety and\n Health Administration safety and required in-services.\n\n o \t Conducting weekly case conferences with clinicians from\n medicine, mental health, and social work to review patients\n with non-adherence issues and/or behavior problems that pose\n a potential liability risk to the organization and how to deal\n with those patients moving forward.\n Medical Records\n o \t Electronic medical record with drug interaction warnings,\n reminder modules, and other decision support tools.\n o \t We are currently developing and implementing an electronic\n medical record program. This will enhance and facilitate\n quality improvement and other monitoring capabilities as well\n as improve client assessment and care by use of required fields\n for key/critical assessment, accreditation, preventive care, and\n documentation requirements.\n Peer Review\n o \t Use of former medical director (now retired) to conduct peer\n review.\n\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 21\n\x0cR \tE S P O N D \nE N\n \t T C O M M E N T S\n\n\n o \t Have set up a system of peer review whereby providers\n exchange pertinent sections of medical record by mail (because\n of great distance between our 7 clinics). The process ends with\n the audit tool returned to the credentialing department and\n recorded for each individual.\n\n Health center respondents offered Thirty-nine percent of\n recommendations to HRSA regarding risk respondents offered\n recommendations to HRSA.\n management\n Below are some highlights.\n Training and Technical Assistance\n o \t Seminars so that health center staff can network with HRSA\n staff.\n\n o \t Try to utilize technology to offer training on risk management\n (video conferencing, satellite broadcasts).\n\n o \t Get the information out on available resources.\n\n o \t Most risk management information is hospital/inpatient based.\n Would be nice to have HRSA provide information related to\n health centers\xe2\x80\x99 risk management issues on a regular basis.\n\n o \t Work more closely with the National Association of\n Community Health Centers on this. The National Association\n of Community Health Centers provides great training, in\n general.\n\n o \t Develop training that dedicates time to develop/review risk\n management polices and procedures, or gives a clear step-by-\n step approach.\n Policies and Guidance\n o \t Make the Policy Information Notices more user friendly.\n\n o \t Quick reference handouts for staff updates.\n\n o \t Seek out best practices and disseminate.\n\n o \t Sample policies.\n\n o \t Incorporate a strong risk management program into the\n requirements for section 330 funding and performance review\n calculations.\n\n o \t Specialized risk management for mental health, dental, and\n obstetrics/gynecology.\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 22\n\x0cR \tE S P O N D E N T C O M M E N T S\n\n\n Federal Tort Claims Act\n o \t More feedback from HRSA after a FTCA [Federal Tort Claims\n Act] case is filed concerning progress, outcome, and\n suggestions for improvements.\n\n o \t Should provide numbers of the most cases of malpractice suits\n filed and trends.\n\n o \t Cover any remaining gaps in FTCA [Federal Tort Claims Act]\n coverage such as volunteers, consultants, and sexual\n harassment.\n Medical Records\n o Invest in electronic medical records.\n\n Incident Reporting\n o \t Develop a nonpunitive culture on local, State, and Federal\n level for a reporting system. This would help to identify and\n quantify possible medical errors or sentinel events in a health\n center.\n Peer Review\n o \t For rural/sparse areas establish a network that encourages\n peer review.\n On-Site Assessment\n o \t Onsite assessment of the center\xe2\x80\x99s risks (physical and\n nonphysical risks, nonclinical and clinical).\n\n\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 23\n\x0c\xe2\x88\x86\n O P P O R T U N I T I E S F O R I M P R O V E M E N T\n\n Respondents indicated that they experience several challenges in\n conducting risk management. Given the importance of risk\n management from both a patient safety and a financial perspective, it\n would be helpful for HRSA to explore these challenges in greater depth\n to ensure that all health centers are, in fact, able to implement and\n maintain effective and comprehensive risk management programs.\n\n The fundamental challenge according to respondents is the lack of\n financial resources. This has implications for training, staffing, and\n other risk management activities. Even deemed respondents reported\n that financing was an issue. Yet, almost a third of deemed\n respondents did not know if they had reinvested their savings in risk\n management and 22 percent indicated that they did not reinvest it in\n risk management. Although HRSA\xe2\x80\x99s policy is unclear as to its\n expectations for reinvesting in risk management, it is reasonable to\n expect deemed health centers to spend some portion of their savings\n on risk management. Toward that end, HRSA may want to ensure\n that all health centers are investing adequately in risk management.\n For deemed health centers in particular, HRSA may want to\n determine the amount of savings these health centers realize from\n being deemed and ensure that they are reinvesting some portion of\n these savings into risk management.\n\n In addition, respondents indicated that the lack of training was a\n challenge that affected their ability to conduct risk management.\n Although HRSA has provided opportunities for training, it is clear that\n health centers want more. HRSA may want to develop a\n comprehensive, ongoing training agenda for health centers on risk\n management.\n\n Finally, HRSA may also want to explore creative, inexpensive ways to\n assist health centers. These could include disseminating best practices\n or a newsletter; developing tool kits that contain sample policies and\n procedures; developing Web-based training; and encouraging health\n centers to take advantage of existing HRSA-funded networks, such as\n the Healthy Disease Collaborative and the Integrated Service Delivery\n Initiative, as a vehicle to share resources and information on risk\n management.\n\n In accomplishing all these goals, we encourage HRSA to work with its\n partners, such as the State Primary Care Associations and other\n regional and national associations with an interest in health centers.\n\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 24\n\x0cO P P O R T U N I T I E S F O R I M P R O V E M E N T \n\n\n\n\n AGENCY COMMENTS\n HRSA responded positively to the report and its comments reflect its\n commitment to improving risk management for health centers. For\n HRSA\xe2\x80\x99s complete response to the report, see the following section.\n\n HRSA has established a new goal that, by 2010, 100 percent of health\n centers will participate in risk management training. HRSA indicated\n that it has several initiatives planned or underway to meet this goal.\n\n HRSA is planning a risk management workshop at the Annual National\n Association of Community Health Centers Policy and Issues Forum in\n March 2005. This workshop will feature discussions of risk\n management practices, existing risk management resources, and the\n costs associated with conducting risk management. At this workshop,\n HRSA will provide health centers with estimates on the potential\n savings from participating in the FTCA deeming process. HRSA also\n intends to encourage health centers to reinvest those savings in risk\n management. It is exploring additional opportunities to conduct similar\n workshops on risk management.\n\n HRSA is in the process of developing a comprehensive risk management\n training agenda for health centers. This training agenda will address:\n (1) HRSA\xe2\x80\x99s expectations for risk management, (2) mechanisms in which\n HRSA can assist health centers to obtain continuing medical and\n professional education, and (3) cost estimates of establishing continuing\n education. HRSA plans to have a comprehensive risk management\n agenda in place by June 2005.\n\n\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 25\n\x0c\xe2\x88\x86 A G E N C Y C O M M E N T S\n\n\n\n\nOEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 26\n\x0cA G E N C Y C O M M E N T S \n\n\n\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 27\n\x0cA G E N C Y C O M M E N T S \n\n\n\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 28\n\x0cA G E N C Y C O M M E N T S \n\n\n\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 29\n\x0c\xe2\x88\x86 A P P E N D I X ~ A\n\n\n\n Methodology\n\n Document Review\n We obtained and reviewed relevant documents associated with risk\n management and health centers, such as laws, regulations, policies,\n guidance documents, and training materials. These documents included:\n\n o \t Federally Supported Health Center Assistance Acts of 1992 and\n 1995\n\n o \t 42 C.F.R. Subpart C-Grants for Operating Community Health\n Centers\n\n o \t HRSA\xe2\x80\x99s Policy Information Notices (1998-23, 1999-08, 2002-22,\n 2002-24, 2002-32)\n\n o \t Joint Commission\xe2\x80\x99s Comprehensive Accreditation Manual for\n Ambulatory Care\n\n o \t HRSA\xe2\x80\x99s Federal Tort Claims Act Clinician\xe2\x80\x99s Handbook\n\n o \t HRSA\xe2\x80\x99s Deeming and Re-Deeming Application Forms\n\n o \t HRSA\xe2\x80\x99s Primary Care Effectiveness Review Protocol (March\n 2000)\n\n o \t Resources provided to health centers during HRSA-sponsored\n training on risk management by the National Association of\n Health\n Stakeholder Interviews\n We interviewed experts within and outside of HRSA to learn about risk\n management and to identify potential key risk management practices to\n use on the survey. Persons interviewed included:\n\n o \t HRSA officials\n\n o \t Representatives from the National Association of Community\n Health Centers\n\n o \t Representatives from several State Primary Care Associations\n\n o \t Representatives from the Association of Healthcare Risk\n Managers\n\n o \t Representatives from the Joint Commission\n\n\n\nOEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 30\n\x0c A P P E\n \n N\n \t D I X ~ A\n\n\n o \t Representatives from the Management Assistance\n Corporation, a HRSA contractor that provides clinical risk\n assessment for health centers\n\n o \t Representatives from private malpractice insurance companies\n that offer malpractice insurance and risk management\n services for health care facilities, including Princeton Risk\n Protection, Inc.\n Survey of Health Centers\n We surveyed a stratified random sample of 248 health center grantees out\n of the 835 grantees that received funding from HRSA in FY 2002. We\n chose this sample size to ensure a precision of +/- 5 percent at the\n 95-percent confidence level. However, later methodological limitations\n prevented us from generalizing to the entire population. (See section on\n data limitations on page 28.)\n\n We drew the sample from a list provided by HRSA. Prior to pulling the\n sample, we eliminated 17 health centers from the original 852 in the list\n provided by HRSA because we lacked information on the number of\n patients served. (See Table 4.)\n\n We drew a stratified random sample from the 832 remaining health\n centers. We divided the population into three strata based on the number\n of patients served in FY 2002. (See Table 4 for the strata.) We defined\n the strata based on the way the data were distributed. From each of the\n first two strata, we randomly selected 91 health centers from each of the\n totals. We included all 86 health centers from the third stratum. This\n resulted in a total sample of 268 health centers. We eliminated 20 health\n centers from the 268 because their names, in whole or in part, matched\n those of health care organizations that are part of ongoing investigations\n\nTable 4. Sample Design\n\n Revised Centers That\n Strata by Number of Patients Population of Population of Sample of Received a Number of Survey\n Served in FY 2002 Health Centers Health Centers Health Centers Survey Respondents*\n < 5,000 patients 226 226 91 89 55\n\n 5,000 - 30,000 patients 523 523 91 83 60\n\n > 30,000 patients 86 86 86 76 50\n\n Unknown 17 0 0 0 10\n 51 100 Teachers 4 000 0 0 0\n Overall Total 852 835 268 248 175\n*The data in this column were self-reported by respondents and not based on actual numbers provided by HRSA.\n\nSource: Office of Evaluation and Inspections\' analysis of survey responses, 2004.\n\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 31\n\x0cA P P E N D I X ~ A\n\n\n conducted by the Office of Investigations within the Office of Inspector\n General. This resulted in a final sample size of 248.\n\n The survey contained 43 questions regarding the importance of the\n 16 specific risk management practices, a self-assessment of how centers\n were doing on each of these practices, and challenges to implementing\n these practices. We identified these 16 risk management practices and\n potential challenges from our document review, which included applicable\n HRSA policies and regulations and risk management standards and\n training materials from other private organizations and Federal agencies.\n We also identified these practices and challenges from interviews with\n key stakeholders.\n\n We pretested the survey with two health centers. We addressed the\n survey to the health centers\xe2\x80\x99 executive directors as identified by HRSA.\n In the cover letter we asked the executive directors to complete the\n survey.\n\n To encourage a high response rate, we sent an introductory letter to each\n health center in our sample explaining the purpose of the survey. In the\n cover letter, we emphasized that the survey was anonymous. (The survey\n was anonymous with the intent to reduce bias in our survey results.) In\n our introductory letter we also included a brief description of the Office of\n Evaluation and Inspections and a two-page summary of the inspection.\n\n One week later we mailed the first survey. We sent a second survey\n 1 month later. All health centers received the second survey because we\n were unable to determine which health centers had already responded\n due to the anonymity of the respondents. Finally, 1 month later, we\n followed up with telephone calls to all health centers for which we could\n readily obtain working telephone numbers.\n\n We received 175 responses to the survey, for a response rate of 71 percent.\n (See Table 4 on the previous page.) Because not all respondents answered\n every question, the actual number of respondents varies by question.\n Therefore, throughout the report we provide percentages based on the\n actual number of respondents for each question.\n\n We conducted subanalysis by the self-reported number of patients served\n (i.e., small and medium versus large) and by deemed status (i.e., deemed\n versus nondeemed) for selected questions.\n\n We provide self-reported, descriptive information on the respondents.\n (See Tables 5, 6, 7, 8, and 9 on the following pages.)\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 32\n\x0cA P P E N D I X ~ A\n\n\n Data Limitations. Because the survey was anonymous and we obtained\n only self-reported estimates about the number of patients served in\n FY 2002, we were unable to correctly determine which stratum each\n respondent fell into. As a result, we could not weight the data, nor could\n we calculate confidence intervals. Therefore, we cannot make statistical\n projections to the entire population of health centers based on the survey\n data. The data presented in the report are simple frequencies of the\n responses. We did not independently verify any statements health\n centers made on the survey. Finally, we are unable to conduct a\n nonrespondent analysis because the survey was anonymous. Therefore,\n we cannot estimate the level of bias among respondents. These\n limitations apply to all data analysis and comparisons presented in the\n report.\n\n\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 33\n\x0cA P P E N D I X ~ A \n\n\n\n\n\n Table 5. Percentage of Health Center Respondents by Type*\n\n\n Type of Health Center Percentage of Respondents Percentage of Sample Percentage of Population\n\n Community Health Center 89 89 88\n\n Migrant Health Center 21 19 15\n\n Health Care for the Homeless 16 20 18\n\n School-Based Health Center 1 1 4\n\n Public Housing Residents 7 12 9\n\n *Numbers exceed 100% because a health center may be more than one type.\n\n Source: Office of Evaluation and Inspections\' analysis of survey responses, 2004.\n\n\n\n\n Table 6. Percentage of Health Center Respondents by Amount of HRSA Section 330 Funding\n Received in FY 2002*\n\n\n Amount of Funding in FY 2002 Percentage of Respondents Percentage of Sample Percentage of Population\n\n < $500,000 19 25 21\n\n $500,000-$1 million 32 25 30\n\n $1-$2 million 19 21 29\n\n > $2 million 30 29 21\n\n *Numbers do not add up to 100% due to rounding.\n\n\n Source: Office of Evaluation and Inspections\' analysis of survey responses, 2004.\n\n\n\n\n\n Table 7. Percentage of Health Center Respondents by Number of Delivery Sites in FY 2002*\n\n Percentage of\n Number of Delivery Sites Percentage of Respondents Percentage of Sample Population\n\n 1 22 19 21\n\n 2-5 44 43 47\n\n >5 35 38 32\n\n *Numbers do not add up to 100% due to rounding.\n\n\n Source: Office of Evaluation and Inspections\' analysis of survey responses, 2004.\n\n\n\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 34\n\x0c A P P E N D I X ~ A \n\n\n\n\n\nTable 8. Percentage of Deemed Health Center Respondents\n\n Percentage of\n Federal Tort Claims Act Status Respondents Percentage of Sample Percentage of Population\n\n Deemed 88 74 73\n\n Nondeemed 12 26 27\n\nSource: Office of Evaluation and Inspections\' analysis of survey responses, 2004.\n\n\n\n\nTable 9. Percentage of Health Center Respondents Accredited by the Joint Commission\n\n\n Joint Commission Status Percentage of Respondents Percentage of Sample Percentage of Population\n\n Accredited 51 34 34\n\n Nonaccredited 49 66 66\n\nSource: Office of Evaluation and Inspections\' analysis of survey responses, 2004.\n\n\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 35\n\x0c \xe2\x88\x86 A P P E N D I X ~ B\n\n\n\n Additional Analysis by Size of Respondents\n\n\n\nTable 10. The Level of Importance of Risk Management Practices by the Size of Health Center\nRespondents*\n\n\n\n Percentage of Small and Percentage of Large\n Medium Respondents Who Respondents Who Indicated\n Indicated They Were Doing They Were Doing an Excellent\n an Excellent or Good Job at or Good Job at Implementing\n Risk Management Practice Implementing This Practice This Practice\n\n Regular Staff Training on Risk Management 50 66\n\n Privileging of Health Care Professionals 82 96\n\n Regular Patient Satisfaction Survey 78 92\n\n Up-To-Date Polices/Procedures on Risk Management 66 78\n\n Active Quality Improvement Programs 85 96\n\n Comprehensive Patient Medical Records 86 96\n\n Onsite Assessment of Risks and Risk Management Practices 56 66\n\n Internal Incident Reporting Systems 81 90\n\n Credentialing of Health Care Professionals 94 100\n\n Clear Communication With Patients 91 96\n\n Documentation of Informed Consent 88 90\n\n Clear Communication With Providers 90 90\n\n Formal Patient Grievance Mechanism 88 88\n\n Appropriate Use of Clinical Protocols 83 78\n\n Ongoing Peer Review of Patient Cases 73 68\n\n Patient Tracking System 69 61\n\nSource: Office of Evaluation and Inspections\' analysis of survey responses, 2004.\n\n*We defined the size of a health center based on the number of patients served in FY 2002 as reported by respondents.\nSmall centers reported serving fewer than 5,000 patients, medium centers reported serving between 5,000 and 30,000\npatients, and large centers reported serving more than 30,000 patients.\n\n\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 36\n\x0c A P P E N D I X ~ B \n\n\n\n\n\n Table 11. Challenges to Conducting Risk Management by the Size of Health Center Respondents*\n\n\n Percentage of Small\n and Medium Percentage of Percentage of All\n Respondents Who Large Respondents Respondents Who\n Indicated it Was a Who Indicated it Indicated it Was a\n Challenge to a Was a Challenge to Challenge to a\n Major or Moderate a Major or Major or Moderate\n Challenges to Risk Management Extent Moderate Extent Extent\n\n Lack of financial resources 86 80 84\n\n Lack of dedicated full-time equivalent staff 85 74 83\n\n Lack of clinical staff time 86 74 82\n\n Lack of expertise among staff regarding risk management 66 60 64\n\n Lack of staff training on risk management 68 54 64\n\n Lack of technical assistance 54 40 49\n\n Lack of clear requirements from HRSA 49 44 47\n\n Lack of commitment by the health center\'s governing board 13 2 10\n\nSource: Office of Evaluation and Inspections\' analysis of survey responses, 2004.\n\n*We defined the size of a health center based on the number of patients served in FY 2002 as reported by respondents.\nSmall centers reported serving fewer than 5,000 patients, medium centers reported serving between 5,000 and 30,000\npatients, and large centers reported serving more than 30,000 patients.\n\n\n\n\n OEI-01-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 37\n\x0c This report was prepared under the direction of Mark R. Yessian , Ph.\n Regional Inspector General for Evaluation and Inspections in the Boston\n regional offce , and Joyce M. Greenleaf, MBA , Assistant Regional\n Inspector General. Other principal Office of Evaluation and Inspections\n staff who contributed include:\n Aimee Golbitz Team Leader\n Norman Han Program Analyst\n\n Sara Schulman Program Analyst\n Michael Flood In tern\n Alan Levine Program Specialist\n Elise Stein Director, Public Health and Human Services Branch\n Barbara Tedesco Mathematical Statistician\n\n\n\n\nOEI- 01- 03- 00050 RISK MANAGEMENT AT HEALTH CENTERS\n\x0c \xe2\x88\x86 E N D N O T E S\n\n\n\n\n 1 Authorized under section 330 of the Public Health Service Act.\n\n 2 U.S.C. Title 28, Part VI, Chapter 171.\n\n 3 The Federally Supported Health Center Assistance Act of 1992 (P.L.\n 102-501) provided initial coverage to eligible health centers under the\n Federal Tort Claims Act (FTCA) for a 3-year period. This provision\n became permanent under the Federally Supported Health Center\n Assistance Act of 1995 (P.L. 104-73).\n\n 4 Typically health centers still have to purchase additional medical\n malpractice insurance to cover certain employees not covered under\n the FTCA and claims from years not covered under the FTCA. This\n insurance is referred to as gap or supplemental insurance and\n generally is less expensive than comprehensive medical malpractice\n insurance.\n\n 5 Funds that are not spent remain in this fund for the following year.\n\n 6 \xe2\x80\x9cMedical Malpractice: Federal Tort Claims Act Coverage Could Reduce\n Health Centers\xe2\x80\x99 Costs,\xe2\x80\x9d Government Accountability Office, April 1997\n (GAO/HEHS-97-57).\n\n 7 Federally Supported Health Centers Assistance Act of 1992 and 1995\n (P.L. 102-501).\n\n 8 \xe2\x80\x9cCredentialing and Privileging of Health Care Practitioners,\xe2\x80\x9d Policy\n Information Notice 2001-16, HRSA, July 17, 2001; and \xe2\x80\x9cClarification\n of Bureau\xe2\x80\x99s of Primary Health Care Credentialing and Privileging\n Policy Outlined in Policy Information Notices 2001-16,\xe2\x80\x9d Policy\n Information Notice 2002-22, HRSA, July 10, 2002.\n\n 9 \xe2\x80\x9cComprehensive Accreditation Manual for Ambulatory Care,\xe2\x80\x9d Joint\n Commission on Accreditation of Healthcare Organizations, Draft\n 2004-2005.\n\n 10 Federally Supported Health Centers Assistance Act of 1992 and 1995\n (P.L. 102-501).\n\n\n\n\nOEI-00-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 39\n\x0c 11 \xe2\x80\x9cCredentialing and Privileging of Health Care Practitioners,\xe2\x80\x9d Policy\n Information Notice 2001-16, HRSA, July 17, 2001; and \xe2\x80\x9cClarification\n of Bureau\xe2\x80\x99s of Primary Health Care Credentialing and Privileging\n Policy Outlined in Policy Information Notices 2001-16,\xe2\x80\x9d Policy\n Information Notice 2002-22, HRSA, July 10, 2002.\n\n 12 We defined these categories based on the number of patients served in\n FY 2002. Small centers reported serving fewer than 5,000 patients,\n medium centers reported serving between 5,000 and 30,000 patients,\n and large centers reported serving more than 30,000 patients.\n\n 13 HRSA policies require health centers to provide training; however, the\n policies do not specify how much training is required. HRSA does not\n require onsite review, peer review, or patient tracking.\n\n\n\n\nOEI-00-03-00050 RISK MANAGEMENT AT H E A LT H C E N T E R S 40\n\x0c'


type: caselaw

jurisdiction: EU

text:
 23.2.2008
 BG
 Официален вестник на Европейския съюз
 C 51/2
 Списъци, изготвени за определяне на членовете на съдебните състави
 (2008/C 51/04)
 На събранието си от 15 януари 2008 г. Съдът изготви списъка, посочен в член 11б, параграф 2 от Процедурния правилник, с който се определят членовете на големия състав, както следва:
 г-н Tizzano
 г-н Kasel
 г-н Cunha Rodrigues
 г-жа Toader
 г-жа Silva de Lapuerta
 г-н Арабаджиев
 г-н Schiemann
 г-н von Danwitz
 г-н Makarczyk
 г-н Bonichot
 г-н Kūris
 г-жа Lindh
 г-н Juhász
 г-н Bay Larsen
 г-н Arestis
 г-н Ó Caoimh
 г-н Borg Barthet
 г-н Levits
 г-н Ilešič
 г-н Lõhmus
 г-н Malenovský
 г-н Klučka
 На събранието си от 15 януари 2008 г. Съдът изготви списъка, посочен в член 11в, параграф 2, първа алинея от Процедурния правилник, с който се определят членовете на I-ви състав, както следва:
 г-н Tizzano
 г-н Kasel
 г-н Borg Barthet
 г-н Levits
 г-н Ilešič
 На събранието си от 15 януари 2008 г. Съдът изготви списъка, посочен в член 11в, параграф 2, втора алинея от Процедурния правилник, с който се определят членовете на V-ти състав, както следва:
 г-н Borg Barthet
 г-н Ilešič
 г-н Levits
 г-н Kasel