Risk management and loss control for outpatient clinics

Health care delivery has increasingly shifted to outpatient settings and telemedicine. Clinics are a type of health care facility that is primarily focused on the diagnosis and/or treatment of outpatients and offer convenience and ease of access for patients, including walk-in and prescription services. Many types of primary and specialized care are delivered in clinic settings.

Primary care clinics, typically focused on general health and wellness and treating common illnesses, are usually staffed by primary care physicians, physician assistants and nurse practitioners specializing in internal medicine, family practice and pediatrics. There are many types of specialty clinics, including orthopedics, dialysis, alternative therapies, sleep disorders, speech therapy, pain management, physical therapy, weight loss, behavioral health and many others.

Clinics may operate independently or as an extension of a health care system and more recently as a business unit of large retail stores and national pharmacy chains. There is also an increasing use of mobile clinics (40% growth since 2019)¹ providing greater access to health care that can offer health screenings, vaccinations, mammograms, dental services, pediatric services, workplace wellness, mental health counseling, and even urgent care.²

Some clinics can access a patient’s electronic medical records from other facilities and providers. This helps promote proper continuity of care and the reduction of medication and treatment errors, all of which enhances patient safety.

Two leading causes of loss for medical professional liability claims in clinic settings are improper performance of treatment/procedure and failure to diagnose. Studies of these causes of loss have been often addressed in medical and risk management literature.

These include such factors as missed and/or delayed diagnoses, failure to obtain an adequate patient history, failure to create an appropriate follow-up plan, failure to perform an adequate patient physical examination, incorrect interpretation of test result, problems in patient handoffs and patient-related factors (such as noncompliance, medication errors, communication errors between staff and providers, noncompliant patients, inadequate tracking, and communication of lab test results).³

A landmark study in 2019, Medical Malpractice in America, by CRICO/Candello found that, although true across all health care settings, the most common factors in outpatient medical professional liability cases are clinical judgement: representing 52% of all ambulatory care cases; technical skills were a factor in 40% of those cases; communication was a factor in 30% of ambulatory care cases.⁴

It should be noted that there has been an increase in overcrowding and wait times for treatment in emergency departments resulting in patients with high acuity conditions seeking care at alternative locations including clinics.⁵

Risk management

The following are risk management and loss control focus areas for outpatient clinic settings:

• Ensure there is an identified staff person with designated risk management responsibilities.
• Informed consent ideally should be documented by a printed form and/or a written note in the medical record and include risks and benefits of a treatment or procedure, especially those that may be deemed experimental or alternative treatments.
  Information flow disruptions can cause patient injuries. All pertinent information must be seen by the treating/attending provider. This information includes but is not limited to consultation reports, radiology and laboratory results, and results of any studies that are adverse and therefore require immediate attention, e.g., panic values – defined as being outside the normal range for the patient’s age and sex for which lack of intervention and control may result in harm to the patient.
• There needs to be established protocols for communicating information to patients, especially adverse results, and/ or significant or questionable incidental findings, or conditions needing urgent attention.
• When referring patients, there should be communication as to which provider has the ongoing responsibility for patient care and communicate this to patients as well.
• Procedures and treatments performed in an outpatient setting should comply with federal and state laws and regulations and specialty-specific guidelines.
• Equipment (e.g., defibrillators, ET tubes, etc.) and drugs that may be appropriate to stabilize patients in the event of an emergency should be considered to be close at hand if there is a likelihood of such an event in a clinic.
• For patient telephone calls, develop a triage process, especially for calls that must be routed to the most appropriate provider and ensure proper documentation.
• Document noncompliant patient behaviors identified including descriptions of potential harmful consequences.
• Medication errors can be a source of clinic malpractice claims. Identify drug allergies through thorough patient histories and display allergies prominently in the patient’s medical record.
• Encourage staff to question medication orders that are unclear or confusing or inconsistent with diagnosis or history.
• Ensure there is a qualified staff member responsible for creating an infection control plan and update any that predate COVID-19.
• Staff should be trained and proficient in Advance Cardiac Life Support in clinics where the need for resuscitation is a possibility due to the patient conditions and/or treatment.

References:
¹ National Association of Community Health Centers. The MOBILE Health Care Act: Everything You Need to Know.
² Bizway. 7 On-Demand Mobile Health Clinics Business Ideas for 2024.
³ Webster, John S. et.al. Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement With Promising Teamwork Tools and Strategies.
⁴ CRICO/Candello.2018 CBS Comparative Benchmarking Report. Medical Malpractice in America: A 10-Year Assessment with Insights (candello.com). 2018. p.19.
⁵ Sartini M, Carbone A, Demartini A, Giribone L, Oliva M, Spagnolo AM, Cremonesi P, Canale F, Cristina ML. Overcrowding in Emergency Department: Causes, Consequences, and Solutions-A Narrative Review. Healthcare (Basel). 2022 Aug 25;10(9):1625. doi: