INTRODUCTION

While risk management is only one part of an overall medical quality program, historically it has been treated as a separate process. For this reason, it is useful to review risk management as it has evolved in the medical environment. It is necessary to understand the traditional approaches to risk management before an integrated quality control management/quality assurance program can be developed. (Although risk manager is the common term for the administrator with these duties, it is more accurate to call this person a quality control manager.)

A risk is an exposure to the chance of injury or financial loss. In medical quality control, the major emphasis has been on the management of patient injuries. These injuries result in financial losses when the patient brings a claim for compensation against the hospital. The claims may be based on physical or psychological injuries, but the usual concern has been with physical injuries because of the reluctance of the courts to award substantial compensation for nonphysical injuries. A comprehensive quality control program should also include the management of risks to the hospital's employees and other members of the health care provider team.

The ideal solution to legal quality control would be to prevent all risks. Unfortunately, this is impossible. The rendering of needed medical care is unavoidably accompanied by the occurrence of iatrogenic injuries. Other risks, while not inevitable, are too expensive to prevent completely.

The issue of cost effectiveness is critical to the development of quality control programs because of many risks may be prevented only at a cost greatly in excess of the cost of their occurrence. A provider that tried to prevent these risks would go bankrupt, even if its interventions were successful.

The complex interactions between risk factors that arise from the presence of feedback and pipelining are also crucial. Feedback and pipelining are central problems in medical quality control because of the long interval between the occurrence of a risk and the eventual resolution of the resulting judicial proceedings. This delay may allow many more persons to be injured (filling the pipeline) before the provider becomes aware of the risk. Pipelining can be avoided only by the development of more effective monitoring parameters than those currently used in the medical environment.