Academic Catalog

The Campus Health Services Risk Management Program is overseen by the Director of Administration with overall responsibility borne by the Executive Director. The Internal Review Committee is charged with event reporting through the continual monitoring of unusual occurrences, adverse incidents, near misses, deaths, and identification of trends. The program is evaluated annually by the Governing Body.

This program includes the policies and processes that have been implemented by Campus Health Services and Northern Arizona University in a comprehensive approach to risk management. Northern Arizona University has a Risk Management Office and Office of Regulatory Compliance, which includes Environmental Health and Safety, that assist all departments in protecting the health and safety of employees and the clients they serve. The Campus Health Services staff also have available to them, for assistance, the Arizona State Risk Management Office and the University Attorney’s Office.

Purpose:
To minimize the risk of:

• harm to Northern Arizona University Campus Health Services patients, clients, staff, colleagues, and visitors
• liability exposure of our health care providers, Campus Health Services, and Northern Arizona University
• financial loss to Northern Arizona University

To meet this goal, Campus Health Services has implemented a risk management program to reduce the possibility of a specific loss. The systematic gathering and utilization of data are essential to the risk management program. The risk management program consists of both proactive and reactive components. Proactive components include activities to prevent adverse occurrences (i.e., “losses”), and reactive components include actions in response to adverse occurrences. In both cases, the risk management process comprises:

• Diagnosis - Identification of risk or potential risk.
• Assessment - Calculation of the probability of adverse effect from the risk situation.
• Prognosis - Estimation of the impact of the adverse effect.
• Management - Control of the risk.

Staff Education:
Staff receive training in risk management activities at the time of hire and annually at an all staff meeting.
Risk Management training will include:

• Medical Record Law Compliance and Coding
• Fire Drills
• HIPAA
• Blood Borne Pathogens
• Child Abuse Reporting Law
• FERPA
• Preventing Workplace Harassment
• Information Security Essentials
• CERT Conduct, Ethics, Reporting and Transparency Disclosure

Plan Components:

• Internal Review Committee
  • Event Reporting
• Confidentiality
• Regulatory Compliance
  • Complying with Government Regulations
  • Complying with Contractual Agreements
  • Relationships with Competing Health Care Organizations to Avoid Antitrust and Restraint of Trade Concerns
• Professional Liability
  • Insurance Carrier Communications
  • Litigation involving Campus Health Services, its staff and health care professionals
  • Inquiries from Governmental Agencies, Attorneys, Consumer Advocate Groups, Reporters and the Media

Cross-References

Internal Review Committee and Event Reporting (ADM26b)
Purpose: Review of all adverse incidents, including deaths, trauma, and adverse drug reactions. The Internal Review Committee reviews unusual occurrences and adverse incidents on a bi-monthly basis. The purpose of this committee is to identify trends early and to quickly remedy unsafe practices. The purpose of the review of an adverse incident is to identify deficiencies in policies, processes and procedures; staff training, education, and experience; equipment and supplies and patient/client compliance with care provided.

Confidentiality (ADM27)
Purpose: To protect health information of patients and clients Campus Health Services complies with all privacy regulations. The HIPAA Privacy Rule “protects the privacy of individually identifiable health information”, The HIPAA Security Rule “sets national standards for the security of electronic health information”, and the Patient Safety Rule, which protects “identifiable information being used to analyze patient safety events and improve safety.”

Regulatory Compliance (ADM 28)
Purpose: Government Regulations - Campus Health Services complies with all federal and state (governmental) regulations in daily operations to ensure a safe environment.
Contractual Agreements – Campus Health Services adheres to the Northern Arizona University Purchasing department’s policy and procedure on contracts.
“To define the authority and process for signing contracts and other agreements. A contract is created when there is a mutual exchange of promises upon reasonably understandable terms and conditions. A contract does not have to be reduced to writing in order to be enforceable; however, as used in this Contracting website, the term contract is intended to mean a written form of communication. Many types of documents can constitute a contract, including invoices, memoranda and letters.”
Relationships with Competing Health Care Organizations to Avoid Antitrust and Restraint of Trade Concerns
The risk of antitrust or restraint of trade violations at Campus Health Services is minimal. The mission of the Campus Health Services is to provide high quality health and mental care to the students and employees (medical only) of Northern Arizona University. The clinic is not-for-profit and is subsidized by student tuition dollars and fees. Campus Health Services must be careful however to not inappropriately compete with the private sector. To ensure that this does not occur, Campus Health Services provides only services related to serving individuals associated through the university either through their student status, employee status, or through participation in an academic research or training program.

Professional Liability (ADM29)
Purpose: To ensure that all incidents that might result in a liability for the state (Campus Health Services is owned and operated by the State of Arizona) are immediately reported to the State Risk Management Office. The following components reduce risk and are detailed in the Professional Liability Policy and procedure.

• Insurance Carrier Communications
• Litigation involving Campus Health Services, its staff and health care professionals
• Inquiries from Governmental Agencies, Attorneys, Consumer Advocate Groups, Reporters and the Media

The Risk Management Program component policies and procedures referenced above are located in the Administrative Policy and Procedures section of the Campus Health Services policy and procedure manual.
Additional policies and procedures incorporated in the Risk Management Program (impaired provider, HIPAA, observers in patient areas, etc.) are located in the appropriate policy and procedure manual.

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