17. The Medical Assistant as Office Manager

INTRODUCTION TO MEDICAL OFFICE MANAGEMENT

The medical assistant performs many tasks that promote the smooth running of the medical office. These tasks include maintaining the physical space, taking inventory, ordering supplies, monitoring programs such as risk man­agement and employee safety programs, orienting new employees, and processing employee payroll. The responsi­bility for these management functions may be primarily that of the medical assistant in a small office, or primarily that of an office manager in a larger setting. Office manage­ment always provides the basis for effective patient care, and its importance cannot be overestimated.

MAINTAINING THE OFFICE

In many medical practices, a medical assistant assumes responsibility for maintaining the physical space of the medical office and performing general maintenance. Heavy cleaning and equipment repair are usually not performed by office staff, but rather by contractors. Thus the medical assistant may also be responsible for managing the relation­ship between the office and contractors or vendors of ser­vices, as well as medical, pharmaceutical, and office supply companies.

Administrative Area

When sitting at the front desk, the medical assistant must be able to effectively and efficiently answer two or three incoming calls, greet patients, and handle paperwork.

Depending on the size of the administrative area, sup­plies and equipment for correspondence and billing may be stored in this area, including stationery, envelopes, billing forms, and coding reference books. In addition to the tele­phone (discussed in detail in pr. lectures), the reception area usually contains a personal computer, which is usually linked to the office’s computer network. Materials for creat­ing new patient folders should also be at hand if a paper medical record system is used.

The administrative area needs to have enough room to perform the required activities without the patient files and other papers becoming mixed up, and it must also allow the medical assistant to maintain patient confidentiality.

Again, depending on the size of the office, business oper­ations will either take place in the front office close to the reception area or in a separate area in the office. In the busi­ness office are the rest of the pieces of equipment necessary for administering the office, including the photocopy machine, fax machine, and postage meter or electronic mailing system. In small offices, an all-in-one printer- copier-fax may be used.

Patient billing records are available either in hard-copy files in the business office or on the computer. Charge slips, patient statements, and other documents are usually printed using a laser printer or ink jet printer.

The medical assistant should be familiar not only with the office equipment’s operation, but also with the mainte­nance responsibilities, such as reloading paper and adding toner or printer cartridges. In addition, the medical assistant may need to follow the terms of any maintenance agree­ments when scheduling maintenance or repairs.

Figure 48-1 Well organized front office.

Offices should also have a paper shredder for disposing of confidential documents. Although medical records must be maintained indefinitely, old telephone logs, old payroll records, canceled checks more than 7 years old, and minutes of practice management meetings should all be shredded rather than simply thrown away in the wastebasket or in a wastepaper-recycling bin. Any documents with patient information that have been scanned into the electronic medical record should be shredded if they are not retained. Shredded paper can still be recycled, and there is no danger that sensitive personal or business information will be seen by anyone who should not have access to it.

Examination and Treatment Rooms

Each examination or treatment room also needs approxi­mately 100 square feet of floor space to hold an examination or treatment table, cabinets and countertop, patient chair and physician stool, and a small surface for the physician to write on. The room should be laid out so that a physician and medical assistant can move freely about the room. Equipment and supplies should be within easy reach or stored in drawers or cabinets easy to reach.

Each examination or treatment room needs to have a sink, as well as soap and paper towel dispensers. Hand sani­tizer may be in a wall-mounted or freestanding dispenser. The examination room must also contain a wall-mounted rigid container for the disposal of sharps, such as needles, scalpel blades, or other objects that might puncture a plastic bag. Biohazard wastebaskets with a biohazard plastic liner for materials that contain body fluids, such as blood, mucus, or pus, are located either in each examination room or in the hall. Containers for hazardous waste must be covered, except when adding waste. A foot pedal to open the cover facilitates use. The examination room usually contains an ordinary wastebasket for used paper towels and table paper.

For safety reasons, examination rooms should not contain syringes, needles, or medication samples. Cleaning materi­als and chemical solutions should never be stored under the counter in an examination room, especially if it is used for children.

Waiting Room

The waiting room makes a first impression on a new patient. It must be neat and welcoming. The waiting room needs two to four chairs for each physician in the office at one time, current magazines, and a table or magazine stand to hold them. If the practice sees children, some toys should be available in a separate play area. One person should be assigned to tidy up the waiting room a couple of times during the day.

A waiting room should have signs that inform patients about office policies. The signs depend on the policies of the individual office. Common signs include the following:

    No smoking

    Copayments are expected at the time of service (or some other language regarding the expectation of payment)

    The following credit cards are accepted (followed by names of credit cards)

    No eating or drinking

    A charge will be added for returned checks to cover any bank fees

    Patients will be charged for cancelled appointments unless at least 24-hour notice is given

Some offices have a display rack with health information brochures. Brochures are available from government agen­cies, public agencies, and many companies. With the approval of the physician(s), these brochures are often pro­vided to help educate patients about health promotion and disease prevention.

Sometimes there is a television or DVD player in the waiting room. In some practices, health information videos are playing. Other practices have a radio tuned to an easy- listening station or a CD player with quiet pop or light classical music. The medical assistant may need to turn on this equipment at the beginning of the day.

Security Systems

A medical office maintains a number of different security systems.

First, if the office is entered from a corridor in an office building, the building owner or office condominium asso­ciation most likely has an electronic security system for the building itself.

Second, regardless of whether the office is entered from a corridor or directly from the outside, the practice should maintain an electronic security system against break-ins to the office itself.

The office’s security and safety alarm system is monitored by an alarm company and may or may not also be tied to the local police and fire departments. Whether or not the system is tied into the police and fire departments, the alarm company will call the practice’s liaison to the company whenever the alarm goes off.

This designated person is often the practice administra­tor or “managing partner.” However, two or three people are always listed as backups in case the liaison is not available.

Third, various places within the office require another layer of security. Medication cabinets—with all medications and prescription pads inside—should be locked, and a limited number of people should have keys to the medica­tion cabinet lock. The laboratory, physicians’ private offices, medical records cabinet or room, and business office are other areas that often have a lock and limited access.

If controlled substances are stored in the office, they should be “double-locked” (in a locked drawer within a locked cabinet). Two separate keys should open the two different locks.

ROUTINE MAINTENANCE________________________

It is important to maintain the physical space of the medical office. Depending on the size of the office, many if not most routine maintenance activities are undertaken by staff. These include controlling the temperature, cleaning cabi­nets and drawers, changing lightbulbs and replacing batter­ies in battery-powered equipment, turning the security system on and off, making sure fire protection equipment is in working order, and performing some daily cleaning. In all activities, medical assistants and other staff must be sure to protect themselves and patients from hazards and injury. Good body mechanics should be used to move sup­plies and equipment and when cleaning, as well as when working with patients. The workplace should be arranged to minimize strain during all routine and maintenance activities.

Temperature and Ventilation

The reception area and examination rooms should be kept at a comfortable temperature. People who are ill are sensi­tive to cold and drafts. The reception and patient waiting areas and examination rooms should be about 70° to 72° F. The temperature in treatment rooms, the laboratory, and physicians’ offices should be about 68° to 70° F. A room used for procedures or minor surgery can be kept a little cooler because the physician and medical assistant may be wearing gowns, masks, and hair covers.

Ventilation is also important. Keeping air circulating is important both to dissipate odors and to allow germs to escape from the office atmosphere.

General Cleaning

Larger offices may contract for cleaning services, or office cleaning may be included in the monthly rent, especially in buildings that are dedicated to medical offices. Contracted cleaning is usually done one or two times a week, so even if the major cleaning is contracted out, daily cleaning tasks still must be performed.

Daily cleaning includes tidying up all areas of the office— reception and waiting rooms, administrative space, physi­cians’ offices, examination and treatment rooms, and the laboratory.

Sinks should all be toweled dry, and rest rooms should be checked to make sure ample toilet and facial tissue, soap etc.

Putting It All Into Practice

My name is Kelsey Whitman, and I am a registered medical assistant. I usually work in one of the satellite offices of a large medical group that includes primary care providers and medical specialists. The office where I usually work was formerly a house. They are planning to close it next spring, tear it down, and build a modern office building. Even though there are some disadvantages to the current setting, it has a lot of charm. The waiting room and three small examination rooms are on the first floor with the physicians’ office, and we use the rooms upstairs for storage, a break room, and meeting rooms. I have a small office upstairs, but I never have time to sit in it. Usually we have only one physician in the office. I work with one other medical assistant, but since I have been in the practice longer, I am responsible for making sure that everything runs smoothly. I have to go to the main office once a month for a staff meeting. The meetings are held once a month late on Wednesday afternoon. We discuss issues affecting all work areas. We have also been reviewing some of the proce­dures done by medical assistants to be sure that every medical assistant in every office does things the same way. The other medical assistant will be going out for maternity leave in a few weeks, and we have been interviewing for a replacement. After an initial screening interview, I have been asked to talk to three applicants, to give them a tour of our office, and to give my feedback about how they might fit into this setting. One of the applicants seemed like a real team player, and I hope they hire her. It is so important for everyone to be able to work well together. ■

Waste containers and recycling containers should be checked daily and emptied as needed. Biohazard sharps containers should be checked daily and replaced when they are three-quarters full. The plastic liners of biohazard waste containers should be changed as needed. Contracted clean­ing services will usually not empty biohazard waste con­tainers because they contain regulated medical waste. The medical assistant must handle biohazard waste containers carefully to prevent an exposure incident. The OSHA Bloodborne Pathogen Standard outlines specific actions to take when handling regulated medical waste.

If the office staff must do more intense cleaning, this should be done at least weekly. These tasks include mopping linoleum floors and vacuuming carpets, cleaning the glass at the reception area, polishing furniture and accessories, dusting, and thoroughly cleaning the rest rooms.

It is important to try to avoid a “medical smell” in the office. This is done by maintaining proper ventilation, as well as by cleaning up spills and accidents immediately, using light or unscented air fresheners in rest rooms and examination rooms, and keeping disinfectants and cleaning materials closed tightly when not in use and out of patients’ reach.

Cleaning Cabinets and Drawers

Storage cabinets, drawers, and bookcases are cleaned less frequently, often on a day when the physician or some of the physicians in the practice are absent so that the room is not in use. After cleaning, the medical assistant should check labels on all items before putting them back on shelves. This is a good time to check for the expiration date on supplies and make a list of any items that need to be ordered or restocked from the general supply area to the cabinet.

What Would You Do?

What Would You Not Do?

Case Study 1

Jean Highsmith has brought her 1-year-old twins, Scott and Lucy, to the medical office because they have been fussy and tugging at their ears. In the waiting room, she puts the twins on the floor to play with the toys while they are waiting. When Kelsey is able to take them to an examination room, she notices that the twins, who also have runny noses, have been chewing on some of the plastic toys in the waiting room. She notices that Mrs. Highsmith has left used tissues on one of the waiting room tables. After a few minutes in the examination room, Mrs. High­smith comes to the door holding a child under each arm and tells Kelsey that Scott has thrown up a little on the examination room table. ■

Figure 48-2 Well organized supply cabinet.

Miscellaneous Tasks

Among the miscellaneous tasks that have to be performed daily are rearranging the waiting room chairs and replacing magazines in their racks (as well as toys if toys are avail­able); cleaning mirrors in the rest rooms and examination rooms; and cleaning the tops, fronts, and undersides of cabinets and paper towel dispensers. Toys must be cleaned and disinfected on a regular basis, because they can harbor microorganisms.

The medical assistant may be responsible for replacing lightbulbs in gooseneck lamps and other special lighting. Ceiling lighting is usually a responsibility of the mainte­nance staff employed by the building owner. If the space is owned by the practice, this may be a staff responsibility or may be covered by the cleaning or maintenance contract with an outside service.

PATIENT AND EMPLOYEE SAFETY

In addition to maintaining the physical environment of the medical office, it is also vital for all medical facilities to maintain a safe environment both for patients and for employees. This involves several measures.

   Manage the environment to reduce hazards.

          Train employees in general safety and to use correct methods and processes to prevent accident or injury.

          Maintain equipment and perform regular safety inspections.

          Create open lines of communication so that mistakes and accidents can be reported without fear of severe consequences.

          Analyze all incidents including “near misses” to be sure that effective systems are in place. Constant awareness of potential hazards and a culture that expects each employee to respond to potentially unsafe conditions is one of the most effective tools for preventing accident or injury.

The following are general guidelines for workplace safety as recommended by the Occupational Safety and Health Administration (OSHA):

       Keep work areas, corridors, and hallways clear of obstacles.

    Exits should be accessible, clearly marked, and well lit. Be aware of state and/or local requirements for emer­gency lighting for exit signs.

       Keep floors dry, and clean up spills as soon as possible.

    Store waste in appropriate receptacles. Remove waste promptly and dispose of medical waste appropriately .

    Do not create high piles of materials that are likely to fall. Do not climb up on chairs or other unstable objects to retrieve objects stored on high shelves.

    Do not allow electrical cords to be present in areas where people walk.

    Do not leave drawers open.

LASER RADIATION

Safe Work Practices

The office should have a safety plan, and all employees in the medical office should receive training so that they can carry out their duties correctly. The prevention of the spread of infection is always important. This is discussed in detail in Lecture 17. Equipment should always be checked for frayed electrical cords and used correctly to prevent injury. Hazardous chemicals should be handled and discarded safely as discussed in Lecture 18. Laboratory safety should be maintained according to guidelines in Lecture 29. There should be a plan to respond to spills of blood, body fluids, or chemicals. Areas that are restricted for safety reasons (such as the medical laboratory) should be clearly marked. Employees should report any unsafe condition to their supervisors. Protective equipment is provided by the employer and should always be used by each employee. Lecture 49 will discuss emergency and disaster response in detail.

Signs and Instructions

The office should post signs to instruct patients and employ­ees as needed. As defined by OSHA, danger signs indicate that there is immediate danger and special precautions should be taken. These signs must be red on the upper panel with black lettering and a white background. They are more common in construction areas than the medical office. Caution signs warn against potential hazards. They should be predominantly yellow with either yellow lettering on a black background or black lettering on a yellow background. Caution signs should be used if potentially

Figure 48-3 Examples of caution signs for radiation and laser radiation.

hazardous procedures are performed in the medical office such as x-ray examinations or laser treatments (Figure 48-3). Signs should designate areas where access is restricted. Safety instruction signs (if necessary for employees; e.g., at an eyewash station) should have an upper panel that is green with white lettering. Labels or color-coding should also be used for all biohazard boxes, biohazard waste, and flam­mable gases. Smoking should not be permitted in a physi­cian’s office, and signs advising patients and visitors that the office is a smoke-free environment should be clearly posted in the waiting area. Exits should be clearly marked, and an emergency evacuation map should be posted near the door to the waiting room. Exit signs should be white with red lettering not less than 6 inches high and % inch wide. Lighted exit signs should be tested by shutting off the lights in the room; bulbs should be replaced if necessary.

Highlight on Ergonomics and Worker Safety

A typical working day in a medical office puts a lot of physical stress on personnel. Bending, lifting, reaching, squatting, having a telephone stuck in the crook of the neck, and repeatedly using a typing keyboard put stress on the body. The human body was not designed by nature to perform such activities so frequently.

Common causes for disabling workplace injury include the following:

                 Overexertion injuries caused by excessive lifting, carrying, or pulling an object

                 Falls either on the same level or from a higher to lower level

                 Injuries caused by bending, tripping, slipping without falling, or attempting to avoid falling

                 Repetitive strain injuries caused by performing a repetitive task in the same way over and over

                 Being struck by or struck against an object

Ergonomics and Good Body Mechanics

The word ergonomics comes from the Greek root ergon, which means “work.” Ergonomics is the study of maximizing work effi­ciency by adapting the work environment for optimal physical and mental function. For example, office seating should be designed to provide maximum support for the back, and computer keyboards should be positioned to reduce repetitive motion injuries to the hands, wrists, and arms. But ergonomics does not have to be high tech; it can be as simple as placing a small footstool at the side of an examining table, not only so the patient can step up before sitting on the table, but also so the doctor, who stands and per­forms examinations for hours a day, can rest a foot there and take pressure off his or her lower back. Ergonomics can also affect selection of shelving and storage units to minimize strain when storing items or removing them from storage. In addition to adapt­ing the environment, good body mechanics promote work effi­ciency and prevent injury. See the discussion in Chapter 22 of ways to use good body mechanics.

Preventing Falls

Most workplace injuries from falls occur in the service industry. Several measures can be implemented in the medical office to prevent personnel (as well as patients) from tripping and falling. Good lighting, preventing clutter in walkways, closing drawers, cleaning spills promptly, and emphasizing safety can reduce the likelihood of falls. Medical assistants should wear sturdy shoes and avoid walking too fast, carrying items that block vision, and failing to pay attention to their surroundings.

Monitoring Environmental Safety

Because constant attention is required to maintain a safe environment, it is important to create a procedure to check regularly for potential hazards. A safety checklist is a useful tool for regular safety inspections. It should include the categories to be assessed and have a space to write down any action that needs to be taken. Each part of the office should be checked for adequate lighting, clear walkways, proper storage of supplies, and removal of rubbish and biohazard waste. It is especially important to be sure that heavy boxes have not been stored in a high area where they could fall, that electrical cords are in good repair and do not cause a tripping hazard, and that spills have been attended to promptly. Storage of compressed gases, medications, and chemicals should be assessed according to office policies (Procedure 48-1).

PROCEDURE 48-1

Creating an Environmental Checklist and Performing a Safety Inspection

PROCEDURE 48-1

Outcome Perform and document a safety inspection after creating an environmental checklist.

Equipment/Supplies

• Area to be inspected

Pen and paper (or computer and word processing file) to create an environmental checklist

        Procedural Step. Create a checklist of types of hazards to be inspected for, including obstructed walkways and tripping hazards; electrical hazards; improperly stored boxes; inadequate lighting; wet floors; and improperly labeled and stored biohazards, medications, and chemicals.

        Procedural Step. Moving from room to room in the designated area, first make a general inspection to be sure that floors are dry and all furniture and fixtures are in good repair. Then make a detailed inspection as required for each section on the checklist. If a problem is found, fix it if possible, but always note the problem on the checklist.

        Procedural Step. Check for walkways that are wide enough for usual traffic without clutter. Be sure that there are no frayed carpets and no items that obstruct the walkway such as boxes, electrical cords, or debris. Be sure that there are no open drawers or cabinet doors.

Procedural Step. Check all electrical cords and plugs to ensure there is no fraying or malfunction. Principle. Frayed electrical cords are a potential fire hazard and can cause electrical shocks.

Procedural Step. Check all storage areas to be sure that the tops of cabinets are clear and that supplies have been stored without potential to fall and cause injury. Procedural Step. Assess each light to be sure that all lightbulbs are in working order. Note any exceptions. Make a note if it seems that any area does not have adequate lighting.

Procedural Step. Depending on the type of area, be sure that all biohazards, chemicals, or other potentially hazardous materials are labeled correctly. Be sure that medication cabinets are locked. Be sure that chemicals are stored in secure areas away from patients. Procedural Step. After completing the checklist, create a written plan to respond to any problems that you could not fix during the inspection.

MAINTAINING EQUIPMENT

Within the physical environment of the office there are many pieces of equipment, both for medical purposes and for business purposes. The medical assistant who manages the office is responsible for relationship management with the individuals or companies that sell and maintain the equipment, as well as with those who provide supplies for the equipment.

Inventory

An inventory is a detailed list of items in stock or in the possession of an individual or business. An equipment inventory lists each piece of equipment, the serial number, the date it was purchased, the length of the warranty, the name of the provider who services it, the manufacturer’s suggested service schedule, and the last date of service. The office may also maintain a log validating maintenance and repair for larger pieces of equipment, such as computers and copiers.

An inventory is important for two reasons.

                  Tax consequence: Larger pieces of medical and office equipment are depreciated over 5 years, whereas smaller pieces of equipment and supplies can be fully deducted as an expense in the year in which they are purchased. (Depreciation is a name for the account­ing methods used to account for the anticipated useful life of a piece of equipment and its loss of value over time.)

          Theft or damage: In case of theft or damage, an inventory is necessary to make a complete report to the police and/or claim to the office’s insurance company.

Operation manuals for the equipment can be stored centrally with the inventory list, or each manual can be stored with the piece of equipment for which it is used. Many pieces of equipment come with a plastic pouch on the side of the item or storage unit in which manuals and maintenance schedules can be kept.

Monitoring Equipment Function and Readiness for Use

The medical assistant should always be on the lookout for equipment problems, especially problems that could lead to a dangerous situation. All instruments should be checked when preparing them for sterilization. Before machines are used, the medical assistant should look for frayed wires, bent or damaged instruments, and machines that are not functioning properly.

Office machines should be dusted or wiped with a damp cloth regularly, following manufacturers’ guidelines. Batteries, fluids, paper, toner, and other supplies should be replaced as needed. If there is a maintenance log for the piece of equipment (e.g., the autoclave log, copier log), the medical assistant should document any maintenance (Procedure 48-2).

The decision whether to repair or replace a piece of equipment will usually be made taking several factors into account:

    The age of the piece of equipment

    How expensive a new piece of equipment is

    The level of use the equipment gets

    Whether the manufacturer still produces parts for repair

    Whether any important features have been added to newer models of the equipment

If there is no service contract for the piece of equipment and the decision is made to repair it, a repair service must be located and a repair arranged. The manufacturer usually has a list of authorized repair services by region. In larger organizations, a purchase order is usually necessary for an equipment repair.

Emergency equipment must always be ready for use. This equipment must be checked at least monthly, and more often in many larger facilities. The contents of the emergency box or crash cart (discussed in detail in Lecture 35) should be checked for completeness by a designated person, who will initial a form to verify the presence of each item on the checklist.

Oxygen tanks are checked at the same time as emergency equipment. They should be sent to be refilled when the level falls to a predetermined level. Expiration dates of emergency medications are checked at the same time.

Service Contracts

Many pieces of medical office equipment are purchased with a service contract. A service contract is an agreement that provides for repair calls over a specific time period after the manufacturer’s warranty has expired. A warranty is a promise by the manufacturer to repair or replace defective parts in an item during a specific time period. The service calls in a service contract may be free or have a specified charge, depending on the contract. Contracts usually call for larger pieces of equipment to be serviced at the physi­cian’s office. Smaller pieces of equipment often have a two- price contract: one price if the item is brought to a service center for repair and another price if repair is carried out on site.

Service Calls

Before calling in a service technician, the medical assistant should check the equipment thoroughly. A plug acciden­tally removed from a socket or a disconnected wire is often the cause of what seems like a machine breakdown.

If there is a service contract, all necessary routine maintenance should be performed in the office, or an appointment should be scheduled for a technician to perform it.

The medical assistant should keep a record of all service calls, the reason the call was made, the response, whether there was a service charge, and the suggested follow-up.

New Equipment Purchases

Although the physicians in the practice or the clinic administrator may be responsible for purchasing equip­ment, the medical assistant may be asked to help research options.

Manufacturers are glad to send information about the piece of equipment in question. Many companies now have websites that can be browsed to see product features and costs. Some sites even have video demonstrations. A dem­onstration can often be arranged.

Some practices look for used equipment or furniture. Companies that sell equipment from a number of manu­facturers often have used equipment in inventory. Used equipment can also be found from physicians who are buying new equipment or retiring. Before purchasing a piece of used equipment, it is recommended to be sure that the manufacturer still supports the product (i.e., manufac­tures replacement parts so that it can be repaired).

The medical assistant may be asked to research the “lease versus buy” decision, whether to purchase the equipment or lease it over a period of time. Most medical and office equipment can be leased. Leasing and buying each have advantages and disadvantages, mostly in terms of tax treat­ment. The practice lawyer should be consulted on this deci­sion. Laboratory equipment may be provided at a reduced cost or for a low monthly lease depending on the number of tests performed, so it is important to compare options among different companies.

When new equipment is received in the office, it is a good idea to note numbers of replacement parts, such as bulbs, batteries, and cartridges, and add them to the supply-ordering system.

PROCEDURE 48-2 Performing Routine Maintenance of Equipment

Outcome Perform equipment maintenance and document on equipment maintenance log.

Equipment/Supplies

                                    Piece of equipment to be maintained                                                    • Supplies necessary for the piece of equipment (e.g.,

                                    Cloth for dusting                                                                                         paper, batteries, toner, fluids)

                                    Maintenance log sheet

PROCEDURE 48-2

         Procedural Step. Locate the piece of equipment to be checked.

         Procedural Step. Check all electrical cords and plug to ensure there is no fraying or malfunction.

Principle. Frayed electrical cords are a potential fire hazard and can cause electrical shocks.

         Procedural Step. Check the piece of equipment for cracks, dents, or other damage; obvious impairment; or malfunction.

         Procedural Step. Check any keyboard or keypad for cracks, faded numbers, or letters or other impairment.

         Procedural Step. Dust or clean the outside or case of the piece of equipment according to manufacturer’s directions.

Principle. Dust can interfere with correct function of the machine.

         Procedural Step. Check leads and other wires or other tubing.

Procedural Step. Check or change batteries, fluid, toner, or other essential components.

Add paper to the photocopier as needed.

           Procedural Step. Schedule any required maintenance if appropriate.

           Procedural Step. Fill out the equipment maintenance log.

Example:

Equipment description:BESTCOPY OFFICE PHOTOCOPIER 
Serial Number:266XXX49500Model Number:6500AA 
Date:Action Taken/Comments:Initials
5/26/XXMachine checked, glass cleaned, toner added.SH, CMA (AAMA)
5/30/XXStreaks on copies, service call arranged. Technician cleaned drum.SH, CMA (AAMA)
6/2/XXMachine checked, glass cleaned.SH, CMA (AAMA)

SUPPLIES

A busy medical office goes through an enormous amount of supplies—both clinical and administrative—in a month. Managing the purchase and stocking of supplies is another management task that often falls to a medical assistant.

The quantity of supplies that can be ordered at one time depends on the amount of storage space in the office. A practice can usually get a better price by ordering large amounts, but many offices are limited in the amount they can store. Sometimes it is possible to get extra storage space in the basement of the building where space is being rented.

Also, many physicians receive discounts on supplies by virtue of membership in some sort of a buying group or independent practice organization. Other practices are beginning to move toward website-based purchasing of medical supplies, which may result in significant cost savings.

It is important to develop a good system of tracking supplies, usage, and storage capacity. In this way, reordering is not done too early when there is no room or too late when the practice may actually run out of important supplies.

When planning a new office or office move, it is impor­tant to plan for adequate supply-storage space.

Supply Inventory

A supply inventory is a listing of all the supplies regularly used in the office. This inventory can be kept in a notebook with a separate page for each supply, or it can be a set of cards—one for each supply item. Notebook pages or cards can be grouped either by the type of supply (e.g., surgical disposable, photocopier) or by the supplier. The inventory can also be kept on the computer. A list is printed when supplies are counted.

The information on the supply list should contain the following:

         The item’s name.

          Any specific size used.

          The usual supplier.

          The cost per a standard quantity (e.g., $3.50 per 100) if known.

          The reorder point, which is a number that identifies when the remaining quantity of the item is low enough that the item must be reordered. The reorder point is calculated by determining the number of items used per day or week and the number of days or weeks it takes for an order to be received. For instance, if the office uses 100 pairs of gloves per day, there are 50 pairs in each box, and it takes 5 working days to receive a new order of gloves, the reorder point would be when fewer than 15 boxes (750 gloves) are in the supply room (7^2 days’ worth).

    The quantity ordered each time.

Figure 48-4 shows a sample supply inventory. Informa­tion related to specific items is often maintained on cards or a sheet with the items ordered (Figure 48-5).

The card usually contains additional information about order dates and dates of receipt, initialed by the person who placed and/or received the order.

Most offices routinely order supplies on a monthly basis. Some supplies are routinely reordered each ordering

ITEM NAME SUPPLIER ITEM # COST REORDER AT # TO ORDER
      
      
      
Bandages & Dressings     
nonsterile sponges 2″ x 2″H MedicalXY 2544$3.50/pkg/2005 pkg10 pkg
nonsterile sponges 4″ x 4″H MedicalXY 7812$8.25/pkg/2005 pkg10 pkg
sterile sponges 4″ x 4″H MedicalXY 5540$22.00/box/002 box5 box
non-sterile conforming bandage 2″Winscott49J265$5.25/pkg/1210 pkg10 pkg
non-sterile conforming bandage 4″Winscott49J266$8.62/pkg/1210 pkg10 pkg

Figure 48-4 Sample supply inventory.

Figure 48-5 Form for inventory control.

period, but others are ordered only on an “as needed” basis. For these items, the medical assistant may check the supply closet and generate a list of needed supplies. Computerized inventory record keeping can be maintained on a spread­sheet (Procedure 48-3).

Even if the office has been using the same supplier for a long time, it is a good practice to check other suppliers at least annually to see if a better relationship can be estab­lished. This might involve discounts for the volumes pur­chased, faster delivery, better prices overall, or availability of more products from another supplier than from the current supplier. If a new supplier has offered a better price, the medical assistant should always give the current supplier the opportunity to “meet or beat” the current offer. An established relationship is a known quantity in terms of delivery reliability and overall quality of the relationship. When items are ordered repeatedly from the same supplier, the medical office is usually billed instead of having to pay in advance for the supplies.

When supplies are being stored in the main supply area, supplies with the expiration date closest to the current date should be placed at the front of the area so that they are used first. New supplies are stored behind the older supplies.

PROCEDURE 48-3

PROCEDURE 48-3 Taking a Supply or Equipment Inventory

Outcome Take a supply or equipment inventory.

Equipment/Supplies

                                                                                                                                                                                  Inventory list   • Items to inventory

                                                                                                                                                                                  Notebook or cards          • Pen

1. Procedural Step. Obtain a list of items in inventory— either on a written or computer-generated inventory list, inventory notebook, or box of inventory cards. Principle. The process of taking an inventory includes validating the presence or absence of a given set of items.

2. Procedural Step. Check each item in the inventory record against the items present in all areas of the medical office. For equipment, validate serial numbers. For supplies, consider the supplies on hand in examina­tion rooms and storage areas, checking expiration dates and disposing of those that are expired.

Principle. Expired items should be thrown away and not counted as part of the inventory. The point of taking inventory is to keep track of the number of items on hand that can be used.

        3. Procedural Step. For an equipment inventory, make every effort to locate each piece of equipment on the list and validate that it is in working condition. Docu­ment if the item is missing or needs repair. For a supply inventory, check the quantity of supplies on hand against the quantity listed as the reorder point. If the quantity of items on hand is close to the reorder point, flag the item as one that needs to be reordered per the custom of your office.

     4.    Procedural Step. Check that the information on the inventory card or list is correct and complete. There should be a serial number for equipment and a descrip­tion of the size, color, and price, as well as the usual supplier for supplies.

Principle. You will need this information when replac­ing equipment or reordering supplies.

        5. Procedural Step. Be sure that your storage space is tidy, that items can be found when needed, and that supplies are arranged so that those with the oldest expiration date are at the front of the storage shelf.

Principle. Supplies are useless unless they can be found. Supplies with the oldest expiration date should be used first.

       6.  Procedural Step. Place inventory cards, computer printout sheet, or inventory book in the proper location for follow-up, including placing orders or updating computer information and storage until needed again.

Check the quantity of supplies on hand.

Restocking

Moving supplies from the central supply area to the place where they will be used is called restocking. Examination rooms should be restocked once or twice daily. General supplies in administrative areas are usually restocked weekly. The photocopy and fax machines may need paper daily, depending on the volume of work done.

Ordering Supplies

A supply order is created by combining the list of supplies that are routinely ordered with the items that have been “flagged” using the inventory control system. When this list is complete, the supplier for each item must be identified and orders for that supplier created. Most offices will try to have one or two suppliers for clinical supplies and one or two for administrative supplies. Medications may be pur­chased from the same company as the one used for clinical supplies or from a pharmaceutical supplier.

Supplies are usually ordered in one of four ways: by telephone, by fax, by mail, or online (Figure 48-6). Even when using the telephone or computer, it is important to print or maintain a paper record of the transaction to rec­oncile against receipt of the supplies and for proper account­ing. If ordering by fax, it is a good idea to make a follow-up phone call to make sure the fax has come through clearly and that the order-entry person at the supply house has no questions.

Fax or mail order purchases are submitted on a form listing the item, item number, amount, color, and so on. This form may be unique to the office or an order form supplied by the vendor, the company that sells the supplies or equipment. Some organizations may use a tracking number to reconcile receipt of supplies and payment of the invoice.

When the vendor cannot ship the item immediately, the item is said to be on back order. The order should be flagged to be sure it arrives when promised. A back-ordered item is usually not billed until it is shipped.

In some states, ordering of medications, needles, and sterile solutions requires an authorization from a physician

Figure 48-6 Supplies may be ordered using a catalog order form.

and a copy of the physician’s state medical license for purchase. For purchase of controlled substances, such as narcotics, a physician authorization and a copy of the physician’s federal Drug Enforcement Administration cer­tificate is necessary.

What Would You Do?

What Would You Not Do?

Case Study 2

Kelsey accepts a delivery of a large box of supplies from UPS at a time when the office is especially busy. She places the box in the supply room and continues with her work. Toward the end of the day, she realizes that she has not opened the delivery. She goes to the supply room and opens the outer box. Inside, there are boxes and packages of dressings, bandages, tape, tissues, gauze squares, and other items. Kelsey has an appointment, and she is anxious to finish up so that she can leave the office. ■

Receiving Supplies

Different suppliers ship their supplies in different ways, including using the U.S. Postal Service, large national package delivery companies such as United Parcel Service (UPS) or FedEx, and local courier services.

Most delivery services will ask for a signature to confirm that the delivery has been made. When supplies are received, they should immediately be brought to the storage room. At the first convenient opportunity, the packing slip should be inspected and reconciled with the order to make sure all items have been received or that items that are to be received in a separate delivery are noted on the packing slip. If the packing slip is incorrect, the missing items should be noted and the supplier notified.

The packing slip should be clipped to the order form. When all items have been received, the order form with all the packing slips attached should be marked “all items received” and placed in the accounts payable folder. If the order was not prepaid, the invoice (itemized bill for items that have not been prepaid) should arrive within a few days of delivery of the final items on the order.

Once the contents of a shipping box have been placed in storage, the box should be discarded. It is not recom­mended to keep boxes or cartons used for shipping because they may be dirty and can harbor insects or rodents.

CREATING AN ENVIRONMENT FOR TEAMWORK

Managing the medical office goes beyond the physical space, equipment, and supplies. It is also important to manage the people who work in the office. The medical assistant should help to establish an environment that sup­ports teamwork, one in which people are willing to help one another out but are also willing to allow each individual to display her or his particular expertise. The medical assis­tant may help set the tone for teamwork by showing respect for each employee and his or her skills and pitching in to help orient new employees or anyone who needs a little assistance during an especially busy time.

Staff Meetings

In a busy office where each person is performing specialized tasks, regular staff meetings can also promote teamwork. These meetings should occur often enough—weekly or, at most, monthly—so that situations in need of correction can be dealt with quickly. The medical assistant may be respon­sible to schedule and/or lead these meetings.

The staff meeting should be used to share information or work through changes in office practice or procedures, discuss ways to improve patient satisfaction and office performance, and encourage staff to take advantage of opportunities to improve skills. Some skill improvement efforts can take place in the form of training sessions in the office on new equipment or computer systems. Others can be opportunities to attend off-site seminars and workshops.

In planning a meeting, a written agenda (list of specific items of business to be covered) assists in focusing the meeting and ensuring that all important business is consid­ered in an organized way. One person should be assigned the task of taking minutes (a record of the meeting’s proceedings).

Written minutes are valuable because they assist indi­viduals who attended a meeting to follow up on suggestions and decisions. The agenda should be prepared in advance, but except for a large, formal meeting, it need not be cir­culated until the meeting begins. Minutes, however, should be circulated. They should be distributed as soon as possible after the meeting, although they are not usually formally approved until the beginning of the next meeting.

Orienting and Training Employees

A new employee will be required to provide documentation in order to be added to the office payroll. All employees must have a Social Security number and complete an I-9 (Employment Eligibility Verification) form before they can begin working. The medical assistant may be responsible for reviewing the Social Security card and/or documents that establish identity and eligibility to work in the United States. Information about obtaining or replacing a Social Security card or changing the name on a Social Security card is available from the Social Security Administration.

Before the end of the first withholding period, a new employee must fill out a W-4 form, which identifies the number of exemptions claimed for proper income tax with­holding. This form is updated annually, and the current version can be obtained from the Internal Revenue Service (IRS) website. An employee can submit a new form any time that his or her status changes—for example, if the employee gets married or has a child. If the employee elects to claim fewer exemptions than he or she is legally entitled to, the medical office will withhold more money from the employee’s paycheck. Individuals claim fewer exemptions

Figure 48-7 Medical assistants may need to help medical assisting students during their externship.

to be sure that adequate funds are withheld to cover their income tax liability.

A photocopy of any licenses or certificates should also be obtained from a new employee. All documents should be placed in the employee’s personnel file.

Working with New Employees or Medical Assisting Students

The medical assistant may be asked to participate in the orientation and training of a new medical assistant. This usually involves explaining physician preferences and working with the new employee to be sure that he or she understands how all procedures should be performed. The office may have a checklist of skills or tasks that the new employee must demonstrate before being allowed to perform them without supervision. If a new employee is not familiar with a specific piece of equipment, such as the model of electrocardiograph or spirometer, the medical assistant may be responsible for training the new employee to use it. A similar process is used when the office accepts medical assisting students for externship. The medical assistant must allow a medical assisting student to observe each procedure and then perform it with supervision until the medical assistant can perform the procedure correctly without supervision (Figure 48-7).

PREPARING PAYROLL

Employees must always be paid, or the office cannot retain staff. Preparing a payroll is an increasingly complex task. Consequently, many offices—even those that have long done their own payroll—are switching to outside payroll services. Whether or not payroll is done in the office, files are kept on all employees.

Payroll records for individual employees include the following:

    Name, address, Social Security number, and occupation

    The employee’s withholding allowance certificate (W-4), which is used to calculate the amount withheld for federal income taxes

    Dates of employment

    Record of hours worked, wages paid, annuity, and pensions

    Record of all payroll deductions

These records must be kept for at least 4 years and be available for review by the IRS.

Employees may fill out timecards to report the hours worked, or they may punch in and out using a time clock. Most medical assistants are paid an hourly rate. In this case the gross pay, the amount of money earned before any deductions, is calculated by multiplying the number of hours worked times the hourly rate. Some office employees may receive a salary, a fixed amount paid on a regular basis that does not depend on the number of hours worked. In this case the gross pay is the predetermined amount.

Deductions

Income Taxes

Employers are required to withhold federal income taxes based on the amount paid to an employee and the number of withholding allowances the employee claims. The IRS publication Employer’s Tax Guide contains detailed infor­mation including tables to determine the amount to withhold.

Social Security and Medicare

Social Security tax (called FICA after the Federal Insurance Contributions Act) funds the national program of retire­ment benefits into which all workers pay 4.25% of the first $110,000 in income. Employers still pay 6.2%. In addition, 1.45% of all employee wages are withheld for Medicare taxes, and the employer must pay an additional 1.45%.

State Taxes

Most states require employers to withhold state income tax based on the amount earned and the number of withhold­ing allowances reported for the state (which may be differ­ent from the federal W-4 allowances).

Employer Obligations

The employer is required to deposit withheld income taxes, as well as employee and employer Social Security and Medi­care taxes, following the schedule outlined in the IRS pub­lication Employer’s Tax Guide.

The employer is required to provide each employee with two copies of form W-2, the Wage and Tax Statement, by January 31. This form is used by the employee to complete his or her personal income tax forms. State income taxes are usually included on this form.

Unemployment Tax

Federal unemployment tax (FUTA) is paid by the employer on the first $7000.00 of income at a rate of 0.8% (for 2012). The money, which must be deposited quarterly, is used to pay unemployment compensation for workers who have lost their jobs. States also require employers to pay unemployment tax for their employees, and a few states also require employers to withhold an unemployment tax from their employees.

Preparing Payroll Checks

If the payroll is being done in the office, the individual who does the payroll must gather time sheets or timecards if they are used; calculate wages, taxes, and other deductions for each employee; prepare the checks; and record five items of information in the payroll record for each employee:

   Total wages for the pay period (gross pay)

          Federal, state, and (sometimes) local income taxes, as well as Social Security and Medicare taxes

          Other deductions, such as health insurance, uncov­ered medical expenses, dependent care, and retire­ment savings

    Net pay, or take-home pay (pay after deductions)

          Gross pay, or total pay, from January 1 to the end of the pay period being recorded

Before wages are calculated, time sheets or timecards should be reviewed for accuracy. (If a time clock is used, the exact times of clocking in and clocking out are recorded.) If the payroll is being managed by a service outside the office, the supervising medical assistant is responsible only for collecting time sheets and transmitting to the payroll agency each employee’s gross pay for the pay period.

MANAGING PHYSICIAN AND EMPLOYEE SCHEDULES

Physician Schedules

In addition to the medical office appointment schedule, physicians must be scheduled for other responsibilities related to patient care. In a group practice, one physician must always be on call (i.e., available to take telephone calls from patients and make arrangements so that urgent and emergency health care needs of patients will be met). Physi­cians in solo practice often collaborate with other physicians in their community to provide this service. The medical office usually develops a standard schedule, but individual physicians must be assigned to cover each on-call time period. After the schedule has been arranged, physicians usually must work with one another if they want to switch or change days.

If the medical practice has satellite offices, physicians must be assigned times to see patients in the main office and in the other offices. If possible, coverage must be coordinated so that there is at least one physician in the satellite office every day. A master schedule is usually created, but variations occur depending on time of year and circumstances. For example, sometimes satellite offices are closed during holiday or vacation periods.

In many practices the physicians make nursing home visits. In addition to scheduled blocks of time for these visits, there must also be a plan to provide urgent care if a nursing home resident becomes ill. Some physicians always see their own patients, and in other practices there is one physician who is responsible for nursing home patients on a given day.

Employee Schedules

Other staff members must also be scheduled to provide coverage in both the primary office and any satellite offices. Usually employees must submit requests in writing for days off, changes to the regular schedule, and vacation. Depend­ing on the size of the office, the medical assistant or office manager may be responsible for creating the work schedule for staff other than the physicians. When one of the medical assistants or another staff member calls in sick, efforts must be made to find a replacement. The medical office often has contact with medical assistants or other employees who will work on a per diem basis; per diem is a Latin term meaning “per day” or “by the day.” Per diem employees do not have a fixed schedule. They may be given a weekly schedule depending on office needs, and, in addition, they may be called in on a day when extra help is required. The office may also use an employment agency to obtain temporary employees, especially if one of the regular medical assistants is unable to work for an extended period of time.

Kelsey Whitman: The office where I did my externship was in a physician office building next to the local hospital. It was a very clean, modern office, and I learned so much there. There were two physicians specializing in inter­nal medicine. At the beginning of the day, we got everything ready for the patients. We made sure the waiting room was tidy, stocked every examination room, and turned on the CD player so that patients could listen to music. The office closed for an hour at noon, and after the morning patients had left, we checked the waiting room, picked up the magazines, and made sure there was no trash on the tables. In the afternoon, it was my job to go through the examination rooms and make sure that all items were restocked. While I was on my externship, one of the physicians went on vacation for a week, and we used that time to clean all the drawers and cabinets in the examination rooms. We took everything out and cleaned each area with soap and water. We found expired supplies at the back of the cabinets, and we had to discard them. It was a lot of work, but when we were done, everything seemed much better organized. Before my externship, I didn’t realize the amount of work it is to keep everything looking neat and professional in a medical office. ■

PROVIDING RESOURCES FOR STAFF AND PATIENTS

Office Policy and Procedure Manuals

Medical Office Policies

Effective management of the medical office requires activi­ties to meet all legal requirements and to maintain a high standard of patient care. A guiding principle for manage­ment of the office is called a policy.

Often an organization formulates its own statements (written policies) to help it provide guidance to employees and adhere to laws or regulations. For example, a medical office might have written policies regarding sexual harass­ment, confidentiality, patient rights, and honest and ethical billing, to name just a few. Conditions of employment, in­cluding employee performance, attendance and punctuality, vacation time, sick time, paid time off, and employee evalu­ation are also included.

These are collected in a policy manual, which can easily be reviewed by employees and regulatory agencies. It is the responsibility of the manager to review existing policies and implement changes if necessary. A new employee might be required to review the policy manual and sign a statement to that effect.

If a policy needs to be reviewed, it is usually discussed in a staff meeting and a draft of the revision is circulated for review among office staff. Once there is consensus about the revision, the revised policy is accepted and the revised version is placed in all copies of the policy manual. The date of acceptance and/or revision should be clearly indicated on each policy. A new policy may be necessary, especially when new federal legislation is passed, such as the Health Insur­ance Portability and Accountability Act (HIPAA). A new policy is also written as a draft, circulated, discussed, and eventually accepted and added to the policy manual.

Written Procedures

In order to put policies into practice, an organization uses procedures. A procedure is a description of the steps to handle a specific situation or perform a certain task. Written procedure manuals are common in large organizations, but they can also benefit smaller medical offices, for several reasons. Procedures related to employment (such as request­ing vacation days) are often included in the general policy manual.

Procedure manuals are excellent resources for new em­ployees. They can also provide guidelines and information when a long-term employee suddenly becomes unavailable, either by changing jobs or becoming ill. They encourage office staff to reflect on the methods used to accomplish tasks and examine the reasons for specific actions. A pro­cedure manual for laboratory tests is required under CLIA.

Regular review of procedures is necessary to be sure that they are up to date and conform to changes in legal regula­tions and/or improvements in technology. There may be separate procedure manuals for clinical procedures and administrative procedures.

Procedures that facilitate proper functioning of every area of the office should be available. New procedures should be written when they are missing or when new equipment or different supplies have changed how things are done. It is helpful to add photographs, especially of tray setups or supplies and equipment needed for special proce­dures. The medical assistant may oversee the job of setting the schedule to review or create procedures, obtaining written or verbal input from those who actually carry out the tasks, and finalizing the written procedures. Like poli­cies, each procedure should be dated. Procedure manuals throughout the office should be kept up to date.

After the procedure manual has been created, all person­nel, especially new staff members or those with questions, should be encouraged to use the procedure manual as a reference. It often seems easier to ask questions of co-workers with experience, but it increases independence and indi­vidual capability if staff is encouraged to refer to the written manual.

Locating Community Resources

The medical assistant can be helpful to patients by iden­tifying community resources to meet patient health needs (Procedure 48-4). The medical office may keep a list of local organizations with telephone numbers or other contact in­formation in the following areas:

        Support for alcoholism or addiction

        Support for caregivers of individuals with decreased mental or physical function

        Adult day care

        Visiting nurse and homemaker services

        Legal aid

        Local civic organizations including services for children, families, elders, and the homeless

        Local board of health

        Hospital-sponsored rehabilitation, weight control, smok­ing cessation programs

        Immunization clinics

        Cardiopulmonary resuscitation (CPR) and first aid training

National organizations focus on many diseases. Most will provide information, and some have local chapters or can refer patients to local organizations. The medical assistant can be helpful by assisting the patient to search the Internet for these organizations. Many hospitals also have extensive pro­grams related to specific diseases or conditions, and the medical assistant should become familiar with those in his or her locality, especially those sponsored by the hospital with which the practice physicians are affiliated. The hospital newsletter is a good source of information on new programs for patients. See Appendix C on the Evolve site for the national contact information of some community resources.

PROCEDURE 48-4

PROCEDURE 48-4 Locating Community Resources
Outcome Locate appropriate community resources.
Equipment/Supplies • Local telephone bookLibrary access
• Office list of community resourcesLocal newspapers
• ComputerPen
• Local hospital newsletter(s)Notepad
1. Procedural Step. Research local sources to identify and/or age group served. Alphabetize resources within
community agencies with resources to assist patients. each group.
Potential sources of information include the library, Principle. Arranging lists in alphabetic order facilitates
local newspapers, local cable TV stations, local tele- finding specific information and avoids any impression
phone books, local hospital newsletters, and the of favoritism or recommending one agency more than
Internet. another.
Principle. Familiarity with local agencies improves the4.Procedural Step. When the list is complete, save and
medical assistant’s ability to provide useful information print copies as needed.
about community resources to patients.5.Procedural Step. Ask the office physicians to review
2. Procedural Step. As resources are identified, create and approve the list.
a list including pertinent information about the Principle. Any referral made by a medical office should
resource: name, services available, address, telephone have the approval of the practice physicians.
number, website address, contact name or informa­6.Procedural Step. Update the list when information
tion, and other useful information. The list may be changes, when a new resource is identified, and on a
created using pen and paper, but it should be periodic basis to be sure information is accurate.
transferred to a word processing file for ease of7.Procedural Step. Use the list to make appropriate rec-
duplication. ommendations to patients either in response to patient
3. Procedural Step. Once the document file has been questions or when instructed to by one of the office
substantially completed, group resources by subject physicians.

What Would You Do?

What Would You Not Do?

Case Study 3

Ellen Pritchard has brought her mother, Elizabeth Brown, a 76-year-old widow, to the office for a physical examination. Kelsey notices that Ellen looks upset at the check-out desk after Mrs. Brown has been seen by the physician. Kelsey asks Ellen if anything is the matter. Ellen says, “I’m worried about my mother. She has lost weight, and I don’t think she is eating properly. She lives alone, and I help her as much as I can, but lately I’m not sure it’s enough. I don’t know what to do.” ■

RISK MANAGEMENT

Risk management is the process of assessing risk and put­ting in place policies and procedures that minimize it. Often, the focus of risk management activities is on avoiding law­suits. Risk in a medical office comes in a number of forms.

Minimizing Risk of Injury or Illness

Physical risk involves the risk of injury or illness to employ­ees, patients, and visitors. Business risk also exists: the risk of reduced patient visits because of poor “customer rela­tions.” Any medical office seeks to minimize these risks and prevent lawsuits that may result from injuries related to patient care or an accident in the office.

The medical assistant or office manager is often respon­sible for maintaining the risk management program, in close consultation with the physician or the managing partner among the physicians. In larger clinics or hospitals there may be a full-time risk manager, or risk management may be a part of the duties of one of the clinic’s top admin­istrators. Policies and procedures are designed by the physi­cians and the office’s top administrator, who work closely with an attorney, an insurance professional, and a risk man­agement professional. When a new policy is adopted, a copy is given to each employee covered by the policy. Policy and procedure manuals, once developed, should be accessible to all employees when questions arise.

Incident Reports

Whenever something happens in the office for which the office could be considered liable, an incident report should be filled out. An incident can be as simple as a staff member or patient tripping over a chair, or it could be as serious as a staff member sticking himself or herself with a needle that has just been used to give an injection.

The incident report should be initiated by the staff member who is injured or who is closest to the patient or visitor when he or she is injured. A supervisor should review the report before giving it to the individual who manages the risk management program.

Incident report forms vary widely but usually ask for the following information:

    Date and time that the incident occurred

    Name and identifying information of the individual(s) involved

    Address, building, and room number where the incident occurred

    Description of how the incident occurred and exactly what occurred

    Complete description of any injury or potential injury

    Name(s) and identifying information for any witnesses

    Name and contact information for the person in the organization to whom the incident was reported

    Date of receipt and follow-up by supervisor Incident reports should always be filled out if a patient, employee, or visitor slips or falls, if a medication error is made, if blood is drawn from the wrong patient, if the number of surgical instruments counted after a procedure does not match the number counted before the procedure, or if an employee is stuck with a needle.

Any witnesses to the incident should be asked for their name, address, and phone number so that the office’s insur­ance provider can call and investigate the incident further if necessary. The report should be dated and signed by the person filling it out. A physician and/or supervisor’s signa­ture also goes on the form, according to the office’s policy for incident reports (Procedure 48-5).

Liability Coverage

Every office should have adequate insurance protection against liability, both professional liability (commonly called malpractice) and liability for any accident that might occur in the office.

Professional liability insurance covers a medical profes­sional for patient claims that diagnostic procedures, tests, or treatments either caused an injury or failed to detect an existing medical condition that should have been detected using good medical practice.

Some physicians purchase insurance in their own name only and have professional staff members purchase their own professional liability policies. If this is the case, the medical assistant can purchase a professional liability policy through a professional organization, such as the American Association of Medical Assistants.

In other cases a practice purchases professional liability insurance for the entire staff. If this is the case, every profes­sional staff member should be named on the policy.

The office should also have adequate insurance to cover property damage to the office because of fire, storm, or flooding (similar to homeowner’s insurance). In addition, the practice should have adequate coverage against per­sonal injury sustained on the office’s property by a patient or employee. Many patients are ill and/or fragile, and a fall can occur at any time. The policy should cover any injury sustained on the property controlled by the prac­tice. If the practice is in an office building, the public hallways are the responsibility of the landlord or medical office condominium association. If the office is in a free­standing building, the practice is responsible for any occurrences that happen on walkways, in the parking lot, or in other outdoor areas up to the public road or sidewalk.

PROCEDURE 48-5 Completing an Incident Report

Outcome Complete an incident report.

Equipment/Supplies

         Incident report form (such as OSHA Form 301)                                      • Notes from witnesses to the incident

         Pen

         Procedural Step. Interview all witnesses to the inci­dent, and make notes as needed to complete the inci­dent report.

Principle. The incident report is based on factual infor­mation, but individuals involved in the incident may not be available when the report is actually written.

         Procedural Step. Obtain an incident report form and fill in information about the person (or persons) who are the main subject of the incident including name, date of birth, and address.

         Procedural Step. Complete any information about health care provided including the names and identify­ing information for physicians or health care profes­sionals who provided treatment.

Principle. Risk management includes taking all pos­sible steps to minimize an adverse result from an incident.

         Procedural Step. Complete all information to describe the incident in detail including time, location (address, building, room number), what happened, and any injury or illness that resulted from the incident. Include the names and identifying information of any witnesses.

Principle. Documentation of this information as soon as possible after the incident makes it easier to establish the facts about the incident at a later time.

         Procedural Step. Include the name and contact infor­mation of the individual within the office to whom the incident was reported. The supervisor should add information about any follow-up that occurs at a later date. The supervisor should initiate any additional required reports to appropriate government agencies. Principle. Follow-up for an incident is a crucial step in effective risk management.

         Procedural Step. Review the report with the subject of the incident if possible before signing the report and obtaining his or her signature, also if possible. Obtain a supervisor’s signature as well.

Principle. Signatures on an incident report indicate that parties involved have been informed of the con­tents of the report.

PROCEDURE 48-5

MEDICAL PRACTICE and the LAW

If an injury occurs in the medical office, it is usually necessary for the injured person to prove negligence in order to be compensated for the injury.

                  The medical office and its employees can be sued by patients and visitors to the office for accidental injuries that occur anywhere on the premises. Injury that is not a result of professional activity is covered by the office’s general liability insurance policy. For example, if any individual other than an employee slips and falls on a wet floor in the office and is injured, the medical office would be legally liable.

                  A patient who is injured as a result of medical treatment might initiate a lawsuit for professional negligence (malprac­tice). For example, a patient might be accidentally burned from a hot pack that was too hot or left on too long. This type of lawsuit would be covered by professional liability insurance.

In a second category of injuries, liability is assumed and neg­ligence does not have to occur.

                  Injury from defective equipment falls under the category of product liability. For example, a machine might suddenly create sparks and injure anyone near it. Provided that the office staff was using the equipment correctly and had maintained the equipment according to the manufacturer’s directions, the manufacturer would be liable for any injury.

                  An injury to office employees while on the job is covered by mandatory workers’ compensation insurance paid for by the employer. ■

What Would You Do?

What Would You Not Do? responses

Case Study 1

Page 1128

What Did Kelsey Do?

           Put the twins in an examination room as soon as possible.

           Asked Mrs. Highsmith to place the used tissues in the waste­basket before taking the twins to the examination room. Then she provided hand sanitizer for Mrs. Highsmith.

         As soon as possible, put on disposable gloves and removed the plastic toys that the twins had had in their mouths so that they could be cleaned before other children played with them.

         When told that Scott Highsmith had thrown up a little, put on disposable gloves, used paper towels to absorb as much liquid as possible, and then promptly cleaned and disinfected the surrounding area.

         Reassured Mrs. Highsmith that children are ill sometimes and cleaning up is all in a day’s work.

What Would You Not Do? RESPONSES—contd

          Noted the color and amount of vomit so that she could inform the physician.

What Did Kelsey Not Do?

          Did not ask Mrs. Highsmith to prevent the twins from playing with any toys because they had colds.

          Did not tell other mothers in the waiting room that they might not want to let their children play with the toys until they could be disinfected.

          Did not wait to perform routine cleaning until the lunch break or after office hours.

          Did not tell another staff member or Mrs. Highsmith to clean up when Scott vomited.

What Would You Do/What Would You Not Do?

Review Kelsey’s response and place a checkmark next to the

information you included in your response. List the additional infor­mation you included in your response.

Case Study 2

Page 1135

What Did Kelsey Do?

          Checked the number of each type of item against the packing slip to be sure the order was complete. Made a notation if any items were missing.

          Placed all the items in their assigned storage area, either that night or the next day. Placed newer items behind older items.

          When placing items into storage, checked items on the shelves to be sure that none of them had expired.

          If any items were missing or backordered, made a notation on the packing slip. Then she placed the packing slip in the accounts payable folder to indicate that the order had been received.

          Removed the shipping box to the designated area for trash.

What Did Kelsey Not Do?

          After opening the large box, did not leave the office before checking the packing slip. Another staff member might assume that the individual who opened the box had also checked the contents.

          Did not just stack the items on shelves in the storage room randomly because she was in a hurry.

           Did not discard the packing slip after checking the order.

           Did not keep the shipping box because it might be dirty or harbor pests.

What Would You Do/What Would You Not Do?

Review Kelsey’s response and place a checkmark next to the information you included in your response. List the additional infor­mation you included in your response.

Case Study 3

What Did Kelsey Do?

           Encouraged Ellen to reach out and find out if there were ser­vices that could help her mother.

           While Mrs. Brown was present, included her in the conversation.

           If speaking to Ellen privately was an option, offered understand­ing of how difficult it is to know what to do when a parent begins to be less able to function independently.

           Offered to help Ellen find resources for delivered meals or homemaking services in the community.

           Referred Ellen to local agencies that provide elder services.

           Offered to ask the physician if a referral to a visiting nurse would be appropriate.

What Did Kelsey Not Do?

           Did not exclude Mrs. Brown from the conversation or treat her like a child.

           Did not push Mrs. Brown or Ellen to accept her suggestions, but rather just offered information.

           Did not promise that the physician would make specific referrals.

What Would You Do/What Would You Not Do?

Review Kelsey’s response and place a checkmark next to the

information you included in your response. List the additional infor­mation you included in your response.

TERMINOLOGY REVIEW

Back order

Depreciation

Gross pay Inventory Invoice Minutes Net pay

Per diem

Policy Procedure Reorder point

Risk management Salary

Service contract Social Security tax (FICA)

Vendor

Warranty

W-4

Medical Term

Word Parts Definition

A term used for items ordered that cannot be shipped immediately, usually because they are out of stock.

Accounting methods to respond to the loss of value of a property or piece of equipment over time.

The total amount earned in a time period by an employee before any deductions.

A detailed list of items in stock or in possession of an individual or business.

An itemized bill for items whose cost has not been prepaid.

A written record of the proceedings of a meeting.

The actual amount of money paid directly to an employee after taxes and other deductions have been taken out.

A term used for employees who do not have a fixed schedule but are scheduled by the day according to office needs.

A guiding principle for the management of a medical office or business.

A list of the steps to handle a certain situation or perform a certain task.

A number on a supply inventory that indicates when a specific item should be reordered to be sure that the supply will not run out before the new order is received.

The process of assessing risk and putting policies and procedures in place to minimize it.

A fixed amount of money paid on a regular basis that does not depend on the number of hours worked.

An agreement that provides for service for a piece of equipment after the warranty expires.

A tax collected from employers and employees to fund the Social Security program, which provides benefits to retired workers.

A company from whom supplies or equipment is purchased.

A promise by the manufacturer to repair or replace defective parts in an item during a specific time period.

The form used to claim allowances for federal income tax reporting.

^ ON THE WEB

For information on U.S. government forms related to payroll and employment:

I-9 form (United States Citizen and Immigration Services): www.uscis.gov/files/form/i-9.pdf Internal Revenue Service: www.irs.gov W-2 (Wage and Tax Statement)

W-4 form (for employee withholding)

Withholding tax tables

Form 941 (employer’s quarterly tax return)

Form 940 (employer’s annual federal unemployment [FUTA] tax return)

Social Security Administration: www.ssa.gov Obtain a Social Security number Apply for a replacement Social Security card For information on worker safety:

OSHA Guide to Complicance for Medical and Dental Offices: www.osha.gov/Publications/osha3187.pdf OSHA Small Business Handbook: www.osha.gov/Publications/smallbusiness/small-business.pdf