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SAN DIEGO -- The risk management issues facing inpatient and outpatient facilities can be very different, presenting considerable challenges for hospitals that buy clinics or ambulatory care facilities.

"We've got hospitals acquiring clinics without any clue of what they're picking up," said Debra L. McBride, assistant vp-risk management at Midwest Medical Insurance Co. in Minneapolis.

"We also have large clinics acquiring small clinics without understanding what they're getting into," Ms. McBride said. She made her remarks earlier this month in a presentation at the annual conference of the American Society for Healthcare Risk Management in San Diego.

The first questions facing a hospital acquiring a clinic facility are: how many clinics are you getting, are they large or small, and how are they staffed, Ms. McBride said.

It's not unusual in small clinics and ambulatory care facilities to have non-medical people providing medical care, such as assisting in surgeries or giving injections, she noted.

Another key concern is whether the acquired clinics will have a shared identity with the hospital. If so, the hospital may find itself in a position of "ostensible agency." Under ostensible agency, if it is perceived that the clinic's physicians work for the hospital, the hospital could be liable for any problems associated with the clinic's actual physicians.

The hospital also needs to examine the treatments administered by the clinics it is acquiring, Ms. McBride said.

"Many clinics give (drug) samples to patients, and then they don't put it in the chart," she said. In such cases, a patient subsequently may have a recurrence of an earlier problem, but new physicians might have no idea how it was previously treated.

Patient transfers between the clinic and other sites can be another concern. "Are they taking the patient in the receptionist's car?" asked Ms. McBride, suggesting that the way those transfers are done can raise a host of possible exposures.

Extended clinic hours or urgent care facilities also can raise some staff and patient safety issues, particularly if the clinics keep narcotics on site, providing a possible target for thieves.

The area of medical records and record retention is another possible exposure for a hospital acquiring a clinic to consider. The clinics must have record-keeping policies and follow-up systems in place, Ms. McBride cautioned.

"In clinics or an ambulatory care facility, everything practically goes out," she said. Policies need to be established for how laboratory results and reports are handled when they come back into a clinic.

Records release and patient authorization issues also are key concerns for a hospital acquiring outpatient facilities. The release mechanism and the issue of who is determining whether it is appropriate to release records are important considerations.

In the best case, a physician will be charged with determining whether it is appropriate to release specific records, Ms. McBride said. "But somebody needs to be looking at them to make sure that only what has been authorized goes out. And it can't be the copy service."

Other important considerations include differences in record-keeping laws that apply to hospitals and to clinics, how and where records are stored, the way records are transferred between sites, and how long records are actually retained.

"Typically, I recommend you take your longest statute of limitations and then add a year," Ms. McBride said.

How to handle patient complaints "is another important policy that needs to be in place in an ambulatory care facility," she said. She noted that some clinics designate one person to handle patient complaints. That person can then relay the complaint information to the appropriate person, such as the risk manager, at the parent hospital.

"Looking at who responds to patient complaints, we found that there's not a lot of staff training (at clinics)," she said.

Clinics also typically rely heavily on allied health professionals, and they must be properly supervised. "A supervising physician retains liability for the acts of that person, so they do need to be supervising, particularly in the beginning," Ms. McBride said.

"Credentialing is another tricky area in ambulatory care," she said. "Oftentimes, the smaller clinics don't even credential."

Training and orientation of new staff often is lacking in clinics. It's essential, Ms. McBride said, that a hospital acquiring outpatient facilities sees to it that those efforts are brought up to speed, then documents the details of the training activities so they can be tracked.

The hospital also must make sure the clinic has follow-up systems in place, particularly with regard to some sort of triggering mechanism to guarantee that patients who miss clinically critical appointments -- such as follow-ups after tests for serious illness -- are notified of the importance of coming into the clinic.

Ms. McBride conceded that the task of establishing appropriate policies for newly acquired outpatient facilities can be difficult.

"If the clinic doesn't have any policies or procedures, it seems like a fairly daunting task. . .to come in and write them from scratch," the consultant said. "That's one of the reasons you might look to take some of the hospital's policies and see if you can make them fit."

One thing that can make it easier, though, is if the clinic being acquired has its own risk manager.

"Celebrate if you've got a risk manager," Ms. McBride said.