Rizki
Rizki
Rizki
35
Risk Management
Program Evaluation
Christopher Cassirer
S
ince the medical professional liability insurance crises of the 1970s and 1980s, risk
management programs have been regarded by many as one of the most promising
responses to the problem of medical malpractice. In general, risk management pro-
grams are defined as the systems designed to prevent and control patient injury, enhance
quality, promote safety, and minimize the losses associated with medical malpractice
claims.
837
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In response to the crises of the 1970s and 1980s, many state legislatures passed
mandates requiring hospitals to implement risk management programs as a condition of
eligibility for licensure. Although mandates and regulations varied among the states, there
was a clear commitment to promote risk management as one of the more promising
responses to the medical malpractice problem.3
Health care provider associations and groups also demonstrated support for risk
management. The Department of Health and Human Services Task Force on Medical Lia-
bility and Malpractice and the American Hospital Association’s Medical Malpractice Task
Force issued statements advocating the strengthening and continued expansion of risk
management programs in hospitals. Further, the Joint Commission on the Accreditation
of Healthcare Organizations (JCAHO) introduced language requiring hospitals to imple-
ment various risk management program activities, such as linking risk management with
quality assurance activities in hospitals as a condition of continued accreditation.4
Despite the wealth of support that has been generated for risk management, there
is an absence of data or reliable information to suggest that risk management programs
are effective. In part this is due to the relative recency of risk management programs in
the health care industry. Second, there is little to no agreement among the professional
community about what is an effective risk management program. Third, there are real
difficulties associated with demonstrating the impact of risk management program activ-
ities on incidents and rates of adverse events and patient injuries and the frequency and
severity of medical malpractice claims. Fourth, measuring what is prevented continues
to be the most elusive goal in proving the value of risk management. Medical chart
reviews, occurrence screens, and incident reports made verbally or in writing can be
important sources of information about medical injury. Losses associated with malprac-
tice claims tend to be the focus of our evaluation activities. Risk managers, however, can
begin to enhance their skills and assume a leadership role by learning more about the
basic tools currently available to design, implement, and evaluate risk management pro-
gram effectiveness.
To help enable practicing risk managers with a better set of tools, this chapter will:
(1) present an empirically based conceptual framework to define risk management pro-
gram goals and objectives, (2) present information about the American Society for
Healthcare Risk Management’s (ASHRM) past efforts to develop a comprehensive risk
management program evaluation model that incorporates a systems perspective, a con-
tinuous quality improvement approach to program design, and evaluation, (3) review
recent research regarding hospitals’ efforts to implement the ASHRM model, (4) discuss
other studies and ongoing research efforts to evaluate risk management program effec-
tiveness, and (5) discuss future trends that will continue to affect efforts by professional
risk managers to develop tools and strategies, and recommend partnership strategies and
roles for the profession in building an evaluation model to demonstrate the effectiveness
of risk management programs in practice.
result of hospital-based adverse events and injuries to patients. Thus, efforts to develop
research-driven models, tools, and strategies to manage risk have been largely hospital-
based. Similarly, evaluation research and recommendations regarding the effective design
and development of risk management programs for health care organizations have been
largely hospital-focused.
The generally accepted frame guiding current efforts to conceptualize the goals and
objectives of risk management programs is based on the accumulating evidence drawn
from twenty years of research on rates of adverse events involving hospitalized patients
and the accumulating literature on medical malpractice closed claims studies. The most
important studies to date were conducted in the 1970s and 1980s. The results of these
investigations have impacted national policy formulation and state-enacted legislative
activities. Operationally, these studies have shaped the currently accepted framework for
defining the problem of medical malpractice and the goals and objectives of hospital and
health care risk management programs.
involved reviews of 20,864 medical records drawn from a sample of twenty-three acute
care hospitals in California. Medical records represented patient differences in age, gen-
der, race, and payment source. Hospitals included in the sample represented differences
in size, location, region, ownership, and teaching status. Reviewed medical records were
assumed to represent all California hospital discharges during 1974.
Examination of the medical records involved the application of twenty screening cri-
teria. Trained medical chart reviewers applied the criteria and identified hospitalized
patient charts where there was evidence of an adverse event. Screened charts were then
subjected to a second review by teams of physicians and physician-attorneys to determine
if a potentially compensable malpractice event (PCE) had occurred. PCEs were defined
for the study as adverse events in which patients suffered temporary or permanent dis-
ability due to errors in health care management. Physician-attorneys then reviewed all
charts with evidence of a PCE to determine if a jury would be likely to decide in favor of
the injured patient in a legal review of the malpractice claim.
The researchers estimated that 970 or 4.65 percent of medical charts provided evi-
dence of patient injuries likely due to errors in health care management of the patient,
either prior to or during hospitalization. From those initial 970 records it was determined
that 17 percent would have been likely to result in a legal determination of negligence.
Based on this research, it was later estimated that one out of every 126 patients hospital-
ized in California in 1974 suffered a potentially compensable injury.7
analysis indicated that rates were not normally distributed among the hospitals. Charac-
teristics of hospitals examined for their possible association with rates of adverse events
(AEs) and negligent adverse events (NAEs) included hospital ownership, location, size,
proportion of minority discharges, and the teaching status of the hospitals.
The results of a multivariate regression analysis indicated that university teaching hos-
pitals had a higher rate of adverse events than affiliated and nonteaching hospitals. Hospi-
tals in upstate, nonmetropolitan statistical areas had significantly fewer adverse events than
hospitals closer to the major cities. Large hospitals had fewer adverse events than medium-
size hospitals. The only hospital characteristic, however, significantly associated with neg-
ligent adverse events among the hospitals was the proportion of minority discharges.
In the most recent studies conducted by another Harvard Medical Practice Study
team, approximately 15,000 medical charts were examined from hospitals in Colorado
and Utah in 1995. Methods of chart review to identify AEs and NAEs were similar to those
utilized in the studies examining rates of medical injury in New York hospitals. Patient
injury rates ranged from 3 to 4 percent.10 Similar to the findings of the New York medical
practice study, the rate of NAEs was determined to be less than 1 percent.
Based on this data, the Institute of Medicine (IOM) estimates that as many as 44,000
to 98,000 patients experience a preventable medical injury in the process of receiving
medical care in hospitals in the United States per year.11
the past, the data suggest that the problem of medical malpractice may have been much
worse than indicated during the crises of the 1970s and 1980s.
C B
D E
Adapted from: National Association of Insurance Commissioners. NAIC Malpractice Claims: Medical Malpractice Closed
Claims, 1975–1978. Milwaukee, WIS. National Association of Insurance Commissioners, 1980; Orlikoff, J. E., Vanagunas, A. M.
Malpractice Prevention and Liability Control for Hospitals (2nd ed.). Chicago, Ill.: American Hospital Association, 1988; Morlock,
L. L., Cassirer, C., Malitz, F. E. “Hospital Risk Management and Professional Liability Claims Experience in Maryland.” Final
Report: Agency for Health Care Policy & Research, Grant Number 1 RO1 HS06735, 1997; Cassirer, C. Hospital Risk Manage-
ment Programs in Maryland (1995). Baltimore: Johns Hopkins University, 1997.
carr_ch35.qxd 11/21/00 9:41 AM Page 843
due to legal misconduct by health care providers when no evidence of medical care
related injury appeared in the medical record.
Finally, Area E represents the number of claims that result in compensation to
claimants who are injured due to negligence in the process of receiving medical treatment.
Consistent with the findings from the major studies of medical injury and malpractice, it
suggests that fewer patients are compensated than expected. As noted, in the Harvard stud-
ies, only one out of every sixteen patients who suffered an injury due to negligence
received compensation under the current liability system.
This adapted framework (Figure 35.1) initially proposed by the National Association
of Insurance Commissioners (NAIC) in the late 1970s continues to provide the most com-
prehensive paradigm for characterizing the multidimensional nature of the medical mal-
practice problem in hospitals and highlights the major goals and objectives that hospital
risk management programs attempt to address. Referring to Figure 35.1, in theory, hos-
pital risk management programs have the potential to: (1) reduce the frequency of pre-
ventable adverse events (Area A), (2) reduce the number of patient injuries due to
provider errors (Area B), (3) decrease the number of malpractice claims (Area C),
(4) manage the number of claims that do emerge to control losses (Area D), and
(5) finance risk through the most economical methods to ensure an adequate source of
funds is available to pay for malpractice claims and expenses (Areas D and E).
Organizational Structure
ASHRM recommends that a hospital risk management program should have an organiza-
tional structure to support the risk management function. Dimensions of the orga-
nizational structure that should be in place include activities to promote governing board
commitment, establishing the role and responsibilities for a designated hospital risk
manager, and activities to promote medical staff involvement in the hospital risk man-
agement program.
Governing Board Support Activities of the governing board assessed with the
ASHRM Assessment Abstract focused on whether the governing board supports the risk
management program, whether a written policy statement or plan describing the
risk management program has been developed, and if formal approval of the plan has
been secured from the governing board. Another activity assessed is whether the govern-
ing board receives reports from risk management at least twice per year.
Process measures for assessing governing board support focus on the content of the
written risk management plan. For example, whether goals and objectives have been
defined for risk management, whether the position of the risk manager in the organiza-
tional structure is identified in the plan, as well as other plan characteristics.
Other measures of process assessed whether there are established communication
channels between risk management and other organizational components and if there is
a description of the institutional policy of risk financing. Process measures also focused
on the written risk management reports to the governing body. The processes assessed
were whether the report to the governing body included information on insurance
issues, risk financing issues, and adverse events, as well as the hospital’s claims experi-
ence, among other measures.
Outcome measures focused on whether there is documentation of the governing
board approval of the risk management program and whether the governing board
updates the risk management plan at least annually. Another outcome measure assessed
is whether the governing body takes appropriate action on data from risk management
and if those actions are documented in the governing body meeting minutes.
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Designated Risk Manager One activity was assessed on this dimension of hos-
pital risk management programs. It focused on whether there is a designated person(s)
responsible for the hospital risk management program.
Process measures focused on the contents of the written job description for the risk
manager. Assessments pertained to the role of the risk manager in loss identification,
quality assurance, safety management, claims handling, risk financing, security, and
patient relations, among other roles. No outcome measures were assessed on this dimen-
sion of hospital risk management programs.
Medical Staff Involvement The ASHRM Assessment Abstract assessed whether
medical staff involvement in the hospital risk management program was structured.
Process measures further delineated the attributes of this structured involvement and
included items such as whether the medical staff had developed criteria in at least three
clinical areas to identify adverse patient events.
Other process measures assessed were whether there was a process for the medical
staff to review variations from these established criteria, whether the medical staff identi-
fied risk management problems in the delivery of patient care, whether the medical staff
recommended corrective action to resolve problems, whether the medical staff ensured
that problems were resolved, whether the medical staff participated in risk management
policy development, and whether the medical staff participated in the design of educa-
tional programs directed toward loss prevention.
Three outcome measures assessed on this dimension focused on whether the med-
ical staff had identified at least three risk management problems annually, whether the
medical staff had resolved at least three problems, and whether the number of claims
involving the medical staff had decreased over time.
Risk Analysis One activity was assessed on this dimension of hospital risk man-
agement programs. The item focused on whether a process had been developed to ana-
lyze and trend risk identification data. Assessments of process measures related to this
activity focused on whether the analysis of identified risk was stratified by location, type
of occurrence, patient characteristics, and other characteristics. The outcome measure-
ment focused on whether loss prevention activities had been initiated as a result of the
identified problems.
Loss Prevention
The third basic element recommended by ASHRM is loss prevention, which comprises
several dimensions of activity: education programs to prevent incidents from occurring,
updating informed consent policies, monitoring hospital compliance with regulatory and
accreditation requirements, analyzing claims data, and engaging in activities around
patient and family relations.
Informed Consent One activity and one process measure were assessed pertain-
ing to informed consent. There were no outcome measures assessed. The activity
assessed focused on whether the hospital provided a current, updated policy and proce-
dure for obtaining and documenting informed consent. The process measure assessed
was defined as whether the informed consent policy and procedure had been updated
within the last two years.
Patient and Family Relations Activities pertaining to patient and family rela-
tions focused on whether institutional mechanisms had been developed to assist and
respond to patients and families following an adverse event, the filing of a complaint, or
notification of lost or stolen property. The process measure assessed focused on whether
the hospital risk management program tracked the number and type of patient and fam-
ily interactions. The outcome measure assessed was whether claims had been averted due
to positive patient and family interventions.
tool was administered to risk managers in seventy-seven acute care hospitals along with
a second survey designed to collect information about perceived “better practices,”
including barriers and facilitators to enhancing program performance. In total, thirteen
hospitals in Utah, fifteen hospitals in Colorado, and forty-nine hospitals in Maryland com-
pleted a slightly modified version of the ASHRM Assessment Abstract and the second sur-
vey. The hospital risk management programs studied in Colorado and Utah are the same
hospitals studied in the recent findings on patient injury rates presented in the Institute of
Medicine report on medical error.32
Participation in the 1995 study of hospital risk management programs was motivated
by involving state chapters of ASHRM: the Utah Healthcare Associated Risk Managers
(USHRM), the Colorado Healthcare Associated Risk Managers (CHARM), and the
Maryland Society for Healthcare Risk Management (MSHRM). Each state chapter of
ASHRM supported the project by presenting their members with information about the
study including its design, specific aims, and benefits to the members. Each chapter pub-
lished an announcement of the study in their respective newsletters and/or sent a letter of
endorsement signed by the president of the local state chapter.
Informed consent to participate was a two-stage process. First, a letter describing the
study was sent to the hospital CEOs in each state. Follow-up phone calls were made to
each hospital to verify that the letter had been received and to determine if there were any
questions or concerns about participating in the study. Then, each hospital risk manager
received a telephone call to describe the project and request that the ASHRM Assessment
abstract be completed. Hospital risk managers had the opportunity to review the abstract
and to discuss the project internally with other hospital administrators prior to giving
their consent to participate.
Responding to the abstract required risk managers to indicate whether specific pro-
gram activities were “in-place” or “needed development.” To estimate the level of hospi-
tal risk management program activity, total raw scores were computed for each hospital
by counting the number of program activities “in place” and dividing that number by 134
(the total number of activities, processes, and outcome measures included in the
abstract). Sub-scores were also computed to estimate the level of activity on individual
program elements and dimensions of activity within each program element. Variation in
mean abstract activity scores are reported in the tables.
TABLE 35.2. Mean and Range of Hospital Risk Management Program Activity
Scores (%)
Based on Risk Managers’ Responses to the ASHRM Assessment Abstract (1995):
Structure, Process, Outcome, and Total Scores*
Utah Colorado Maryland TOTAL
Mean Range Mean Range Mean Range Mean Range
Structure/ 69 (21–97) 62 (44–82) 74 (37–96) 71 (22–96)
Activities
Processes 61 (14–91) 54 (15–83) 66 (29–94) 64 (14–94)
Outcomes 70 (9–100) 68 (39–91) 56 (9–100) 60 (9–100)
TOTAL 64 (15–90) 58 (26–93) 66 (28–94) 65 (15–94)
*Activity scores (%) are defined as the total number of items “in-place” divided by the total number possible per dimension,
multiplied by 100.
*Activity scores (percent) are defined as the total number of items “in-place” divided by the total number possible per dimension, multiplied by 100.
management activities were implemented. For example, among those hospitals partici-
pating in integrated delivery systems, many reported that the corporate entity had cen-
tralized the risk management function. Specific activities may have been available through
the corporate office, but implemented specifically within their institutions. Other pro-
grams reported they did not have formal and separate risk management programs.
Instead, risk management activities were part of a patient advocate or patient ombudsman
function. Still another program reported that increased competition, consolidation, and
integration in the local market had led to a corporate decision to fold the risk manage-
ment function into the human resources department. Issues of physician credentialing,
review, and response to incidents of patient injury that are tied to risk management pro-
gram activities were considered by this institution to be “employee” performance issues
and best housed within the human resources function.
In general, there did not appear to be any consensus among the risk managers in the
three states regarding “one best way” to design or implement a risk management pro-
gram within their institutions. Instead, there were perceptions about “better practices”
and a suggestion that there may be a range of alternative models that have the potential
to improve quality, safety, and reduce risk. Other models include insurer-based initiatives
and medical specialty-focused risk management interventions, among others.
Risk managers did, however, identify opportunities to enhance the ASHRM model.
One suggestions was to review the relevance of the criteria defined by ASHRM. It has been
ten years since the abstract was published. Another recommendation was that while the
ASHRM model is conceptually sound, the model reflects errors of commission rather than
errors of omission. Much of the marketplace is highly penetrated by managed care orga-
nizations and payment arrangements, which create incentives to omit certain approaches
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to diagnosis and related treatments. The consequences of these actions may not be appar-
ent for many years to come, creating concerns about how to best manage this emerging
exposure. The model designed by AHSRM is based on the assumption that injuries are the
result of committed acts. Thus, in the ASHRM model, an important focus of an effective
risk management program, is to design systems that utilize incident reporting to identify
and manage potentially compensable events.
Regardless of the approach or area of activity in medicine that is the focus of a hos-
pital- or organization-based risk management intervention, there remains an ongoing
substantive and empirical challenge to defining appropriate measures of risk manage-
ment program outcomes. The successful evaluation of risk management program effec-
tiveness to promote evidence-based management is dependent upon defining and
measuring outcomes. There are few if any who have been successful in reaching consen-
sus on what is an acceptable set of measures for assessing organizational risk and defin-
ing measures that can be utilized to inform decision making, prevent injury, and improve
the management of claims. Identification of incidents of patient injury continues to be a
challenge. Providers remain reluctant to report adverse events. Data and systems to
review and share information are under development. However, developing acceptable
measures of adverse event rates, relevant measurements of claims frequency, and sever-
ity that can be compared within and across organizations remains an important chal-
lenge. Fundamentally, risk management programs are designed to prevent patient injury
from occurring in the first place. Measuring the impact of injuries prevented remains a
largely undeveloped area of research and program evaluation.
Adverse Events
A primary objective of hospital risk management programs is to prevent and control
patient injuries. Historically, the methods utilized to detect incidents of injury include
incident reports and occurrence screens. Incident reports are limited in that providers
are traditionally unwilling to report information. Occurrence screens have been broad
and poorly specified, often providing more data than information. The studies conducted
in California and by the Harvard researchers in which criteria were utilized to screen
medical charts formed the basis of much of the early work on occurrence screens. Med-
ical chart review to collect data on injuries continues to warrant substantial criticism.
Currently, the shift to managed care and related strategies to shape and direct
provider decision making is creating a climate in which more treatments and services are
omitted. Increasingly, incident identification requires an understanding of the clinical
decision making process and tracking and analysis of services omitted, as well as acts
committed to detect adverse events. Standardized measures of clinical decision making
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Claims Management
Another important objective of hospital risk management programs is to prevent and con-
trol losses associated with medical malpractice claims. Malpractice claims management
is itself a complex phenomenon with an intricate array of processes and players. Deci-
sions about how to address a claim once it is filed are critical for ensuring that funds are
managed efficiently and effectively. Traditional measures have focused on the frequency
and severity of malpractice claims—that is, the number of claims and the amount spent
on claims. Opportunities exist in defining more specific and standardized measures of
claims management practices particularly ones that incorporate a time dimension. For
example, early intervention to address an adverse event before it becomes a claim is crit-
ical. Once a claim is made, managing financial losses and reducing time to resolution of
a claim can lower expenses.
activities since the early 1970s.38 As part of its effort to define the next direction for risk
management program development and measures of effectiveness, attention needs to be
directed toward developing operational definitions of differences and core sets of activ-
ities that are independent of safety and quality and unique to managing risk. Then, risk
managers can begin to lead the design and development of an evaluation strategy that
can integrate and manage across these core functions in the related areas of quality,
safety, and risk.
As noted, the history of risk management is currently tied in large part to success
stories based on faith and anecdote rather than quantitative assessments of program
performance. The future of risk management program success, however, will require that
the profession develop a strategy that begins with evidenced-based management prac-
tices. Again, risk managers themselves must respond to the call for action to share the
learning about defining the models, tools, and approaches to measuring the impact of
their activities.
To continue the dialogue and enhance professional practice in evaluating risk man-
agement program effectiveness, risk management professionals must also continue to uti-
lize and work in partnership with ASHRM and other professional risk organizations to
create and experiment with new models and tools to help demonstrate value-added risk
management. As the nation continues to struggle with issues surrounding patient injury,
patient safety, and improving quality, the call goes out to the profession to reactivate its
historical role as a leader role in patient injury prevention.
CONCLUSION
The purpose of this chapter has been to highlight some of the key issues that pertain to
the evaluation of health care risk management programs. Hospitals played a major role
in this discussion. Despite many efforts to create change in factors that contribute to inci-
dents of patient injury in hospitals, these institutions continue to be a place where many
of the most severe and disabling medical injuries occur.
To help risk managers begin to reframe and rethink approaches to developing hos-
pital risk management program assessment tools in the future, this chapter also pre-
sented some of the history of medical injury in hospitals and a conceptual framework for
defining the objectives of hospital risk management program interventions. To date, this
framework remains one of the most comprehensive approaches to describing the
multidimensional character of the problem of medical injury. Although the focus here has
been to identify the role and objectives of hospital risk management programs, it also
provides a powerful framework for areas of opportunity to think through strategies for
relating to quality improvement and emerging patient safety initiatives.
In addition, this chapter presented information and reviewed recent research on
current efforts to adopt a hospital risk management program assessment model based
on the recommendations of ASHRM. A key finding from the research, noted previously, is
that there is wide variation in institutional commitment to development hospital risk
assessment programs. Further research is needed to identify and understand the factors
that may help explain this observed variation.
Finally, this chapter discussed the future of health care risk management and issued
a call to the profession to continue to pursue a partnership strategy and to reactivate its
role as a leader in the patient injury prevention and patient safety movement.
carr_ch35.qxd 11/21/00 9:41 AM Page 857
Endnotes
1. Morlock, L. L., and others. “Medical Liability and Clinical Risk Management.” Managing
Quality of Care in a Cost Focused Environment. Tampa, Fla.: American College of
Physician Executives, 1999.
2. HCFA Manual, 1978.
3. U.S. General Accounting Office. Health Care Initiatives in Hospital Risk Management.
Washington, D.C.: GAO/HRD-89-79, 1989.
4. Morlock, L. L., and others. “Medical Liability and Clinical Risk Management.” Managing
Quality of Care in a Cost Focused Environment. Tampa, Fla.: American College of
Physician Executives, 1999.
5. Nat’l Assoc. of Ins. Comm., 1980.
6. Morlock, L. L., and others. “Medical Liability and Clinical Risk Management.” Managing
Quality of Care in a Cost Focused Environment. Tampa, Fla.: American College of
Physician Executives, 1999.
7. Danzon, P. M. Medical Malpractice: Theory, Evidence, and Public Policy. Cambridge,
Mass.: Harvard University Press, 1985.
8. Brennan, T. A., and others. “Incidence of Adverse Events and Negligence in Hospitalized
Patients. Results of the Harvard Medical Practice Study-I.” New England Journal of Medi-
cine, 324(6), Feb. 7, 1991, pp. 370–376.
9. Weiler, P. C. “Toward No-Fault Compensation/Organizational Liability.” Medical Malprac-
tice On Trial. Cambridge, Mass.: Harvard University Press, 1990.
10. Thomas, E. J., Studdert, D. M., Newhouse, J. P., and others. “Costs of Medical Injuries in
Utah and Colorado.” Inquiry, 36, 1999, pp. 255–264.
11. Kohn, L. T., Corrigan, J. M., Donaldson, M. S. “To Err is Human: Building a Safer Health
System.” Institute of Medicine, Washington, D.C.: National Academy Press, 1999.
12. Danzon, P. M. Medical Malpractice: Theory, Evidence, and Public Policy. Cambridge,
Mass.: Harvard University Press, 1985.
13. Ibid.
14. Morlock, L. L., and others. “Medical Liability and Clinical Risk Management.” Managing
Quality of Care in a Cost Focused Environment. Tampa, Fla.: American College of
Physician Executives, 1999.
15. Mills, D. H (ed.). California Medical Association and California Hospital Association’s
Report on Medical Insurance Feasibility Study. Sacramento, Calif.: Sutter Publications,
1980.
16. Orlikoff, J. E., and Vanagunas, A. M. Malpractice Prevention and Liability Control for
Hospitals (2nd ed.). Chicago: American Hospital Association, 1988.
17. Morlock, L. L., and others. “Medical Liability and Clinical Risk Management.” Managing
Quality of Care in a Cost Focused Environment. Tampa, Fla.: American College of
Physician Executives, 1999.
18. Wade, R. D. Risk Management HPL: Hospital Professional Liability Primer (1st ed.).
Columbus: Ohio Hospital Insurance Company, 1983.
19. Monagle, J. F. Risk Management: A Guide for Health Care Professionals. Rockville, Md.:
Aspen Publications, 1985.
20. Troyer, G. T., Salman, S. L. (eds.). Handbook of Healthcare Risk Management.
Rockville, Md.: Aspen Systems Corp., 1986.
21. Orlikoff and Vanagunas, 1977.
carr_ch35.qxd 11/21/00 9:41 AM Page 858
22. Orlikoff, J. E., and Vanagunas, A. M. Malpractice Prevention and Liability Control for
Hospitals (2nd ed.). Chicago: American Hospital Association, 1988.
23. Harpster, L. M., and Veach, M. S. (eds.). Risk Management Handbook for Health Care
Facilities. American Society for Health Care Risk Management: American Hospital Associ-
ation, 1989.
24. Morlock and Malitz, 1991.
25. Morlock, L. L., and others. “Medical Liability and Clinical Risk Management.” Managing
Quality of Care in a Cost Focused Environment. Tampa, Fla.: American College of
Physician Executives, 1999.
26. American Society for Healthcare Risk Management (ASHRM). Hospital Risk
Management Self-Assessment Manual. Chicago: American Hospital Association, 1991.
27. Monagle, J. F. Risk Management: A Guide for Health Care Professionals. Rockville, Md.:
Aspen Publications, 1985.
28. Orlikoff, J. E., and Vanagunas, A. M. Malpractice Prevention and Liability Control for
Hospitals (2nd ed.). Chicago: American Hospital Association, 1988.
29. Wade, R. D. Risk Management HPL: Hospital Professional Liability Primer (1st ed.).
Columbus: Ohio Hospital Insurance Company, 1983.
30. Ziegenfuss, J. T., and Perlman, H. “Decreasing Medical Malpractice.” Health Care
Management Review, 14(4), 1989, pp. 67–75.
31. Morlock, L. L., Cassirer, C., and Malitz, F. E., “Hospital Risk Management and Professional
Liability Claims Experience in Maryland.” Final Report: Agency for Health Care Policy &
Research, Grant Number 1 RO1 HS06735, 1997.
32. Kohn, L. T., Corrigan, J. M., Donaldson, M. S. “To Err is Human: Building a Safer Health
System.” Institute of Medicine, Washington, D.C.: National Academy Press, 1999.
34. Ibid.
35. Cook, R. I. A Brief Look at the New Look in Error, Safety and Failure of Complex
Systems. Cognitive Technologies Laboratory. Chicago: University of Chicago, 1999.
36. Morlock and Malitz, 1991.
37. U.S. General Accounting Office. Health Care Initiatives in Hospital Risk Management.
Washington, D.C.: GAO/HRD-89-79, 1989.
38. U.S. General Accounting Office. Testimony-Medical Malpractice: Experience With
Efforts To Address Problems. Washington, D.C.: GAO/T-HRD-93-24, 1993.
39. Wade, R. D. Risk Management HPL: Hospital Professional Liability Primer (1st ed.).
Columbus: Ohio Hospital Insurance Company, 1983.
Suggested Readings
American Hospital Association. Medical Malpractice Task Force Report on Tort Reform and
Compendium of Professional Liability Early Warning Systems for Health Care Providers.
Chicago: American Hospital Association, 1986.
American Society for Healthcare Risk Management (ASHRM). Hospital Risk Management Self-
Assessment Manual. Chicago: American Hospital Association, 1991.
Brennan, T. A., and others. “Incidence of Adverse Events and Negligence in Hospitalized Patients.
Results of the Harvard Medical Practice Study-I.” New England Journal of Medicine, 324(6),
Feb. 7, 1991, pp. 370–376.
Cassirer, C. Hospital Risk Management Programs in Maryland (1995). Baltimore: Johns
Hopkins University, 1997.
carr_ch35.qxd 11/21/00 9:41 AM Page 859
Cook, R. I. A Brief Look at the New Look in Error, Safety and Failure of Complex Systems.
Cognitive Technologies Laboratory. Chicago: University of Chicago, 1999.
Danzon, P. M. Medical Malpractice: Theory, Evidence, and Public Policy. Cambridge, Mass.:
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