Vendor Selection for Work-Related Illnesses/Injuries

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Clinic Selection

• Is the clinic in the Preferred Provider Network (PPO) used by Liberty Mutual?

  Yes

  No

  N/A

• If no, are there PPO clinic's available?

  Yes

  No

  N/A

Clinic Interview

• What are the clinic's hours of operation?

• Does the clinic provide any type of after-hour, on-call coverage?

  Yes

  No

  N/A

• Is the clinic available to see injured Team Members at the time of injury?

  Yes

  No

  N/A

• What notification process is required?

• What is the average / expected waiting time?

• (Observation) How busy was the waiting room at the time of the interview?

• Does the clinic specialize in occupational related care?

  Yes

  No

  N/A

• Does the physician believe that returning an injured Team Member to work in some capacity as soon as medically possible is in the Team Member's best interest?

  Yes

  No

  N/A

• Will the physician work with the company and it's return-to-work policy?

  Yes

  No

  N/A

• Does the physician communicate an estimated return date for return to full duty?

  Yes

  No

  N/A

• Does the physician complete an initial medical diagnosis and an evaluation as to the relationship of the illness/injury to work?

  Yes

  No

  N/A

• Is this based on the injury as well as information submitted by the company?

  Yes

  No

  N/A

• Does the physician request clarification from the company on questionable information in order to determine relatedness of the injury to work?

  Yes

  No

  N/A

• Does the clinic provide immediate feedback to the company (phone, e-mail, fax, etc.) and ongoing communication as needed?

  Yes

  No

  N/A

• Does the physician question immediately when there is contradictory or questionable information provided by the patient?

  Yes

  No

  N/A

• Is confirmation or denial of the employee's problem based on the physician's medical findings/facts?

  Yes

  No

  N/A

• Does the physician understand criteria of OSHA recordability?

  Yes

  No

  N/A

• Is the physician willing to come to the work site in order to better understand the nature of the work being performed?

  Yes

  No

  N/A

• Does the physician provide work limitations (not a job description or title) at the time of each clinic visit? (This should be in the form of a Transitional Work Abilities Report and include current physical limitations and date of next appointment.)

  Yes

  No

  N/A

• When does the physician involve a specialist?

• Does the physician identify the Team Member as a patient and customer?

  Yes

  No

  N/A

• Does the physician recognize that the company is also the customer

  Yes

  No

  N/A

Facility Tour

• Is the facility neat, clean and orderly in appearance?

  Yes

  No

  N/A

• Does the facility engender a feeling of confidence by its physical appearance?

  Yes

  No

  N/A

Selection and Follow-Up

• Does the physician meet the needs and expectations of the company and can they provide quality and immediate care to an injured Team Member?

  Yes

  No

  N/A

• Provide company name, location, contact person and telephone number(s).

  Complete

  Incomplete

• Has written return-to-work policies and procedures of the company been provided to the clinic?

  Yes

  No

  N/A

• Has the companies philosophy that it is the best interest of of all injured Team Member's to return to work as soon as medically appropriate been shared with the physician?

  Yes

  No

  N/A

• Has the physician been informed that the company will work with medical restrictions in an effort to transition the Team Member back to their regular job function?

  Yes

  No

  N/A

• Has the physician been requested to address return-to-work status from the onset of an injury? (Return to work should be an ongoing part of treatment recommendations and medical restrictions should be provided at each clinic visit.)

  Yes

  No

  N/A

• Add media

  Media