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Patient quality-management departments. Patient safety staff often generally recognize the safety activities might best be thought of as value of using data to understand the true those that specifically relate to how the envi- impact of human error on a system, in all ronment in which care is provided is opti- aspects of the hospital operation, and focus mized so that care can be delivered in a safe on solving problems centrally so that all units and effective manner.
Patient safety princi- and departments can learn and benefit. This ples also aggressively promote the concept of is better than using a more episodic systemic mindfulness, which requires open approach, which historically addressed each and honest discussion about the root causes problem as a single, isolated event. Physician Support for Risk Management Although the focus is now on aspects of the patient safety movement that offering safe and effective care through have not yet been fully developed into risk- recognition of system faults, rather than see- or quality-management programs, but in a ing each error as an individual or personal truly integrated organization, they should be fault, physicians as well as all staff must at least closely aligned.
Other organiza- early investigative stage and their honest and tion departments also play important roles in fully transparent discussions with patients staff education, but the role of the risk man- may actually prevent a suit and aid in a favor- ager in this process cannot be underesti- able resolution of a claim.
The risk manager should interface It is often easier to engage physicians who with the staff-education department to coor- are employees of the organization in the risk dinate educational programs and determine management process, especially when they the topics most relevant to individual staff are appointed to various risk management groups.
Whenever possible, the risk manager committees by the chief executive officer or should participate in new-employee orienta- by the chief of staff; however, physicians who tion and be a part of all staff continuing have staff privileges at the organization but education. Risk management who offer premium credits to physicians who also has been viewed negatively by some are actively engaged in risk management pro- physicians who associate it only with litiga- grams.
The risk manager also should explain tion, placing blame, and technical insurance- that the program focuses on patient safety related issues. With the change in focus of issues and helping physicians to identify risk management, physician involvement is types of behaviors and practices, as well as no longer a luxury—it is a necessity. Clini- systemic frailties, that have historically cally based programs will be endorsed only resulted in malpractice claims and litigation. In-service seminars specifically nificant to them.
Their active and ongoing related to issues that concern physicians how involvement in department-specific pro- to avoid malpractice litigation is a popular grams can help to determine potential prob- item , as well as copies of relevant articles and lems and make necessary changes before other printed material, may also help risk patients are injured.
When selling the con- managers to gain credibility. If physicians per- cepts of risk management to physicians, the ceive the program as useful and important, risk manager must stress that the discipline they are more likely to become involved in it. Creating Meaningful Risk Management Reports This device can also help the risk unit staff?
This might be neces- weaknesses? Directors or the prior year, if available. This aspect of risk management has claim. These incidents also should be emerged with landmark legal decisions such compared with prior-quarter and prior- as 1 Darling v. Charleston Community year statistics. Memorial Hospital, N. Misericordia, N. These cases established the con- during the quarter with a brief narrative cept of corporate liability, which allows as to how they were resolved e. Reports should be prepared in a manner that allows recipients to gain necessary infor- To maximize the ability to protect informa- mation without becoming overburdened by tion, it is suggested that a separate report be unnecessary details.
Graphics are appropriate prepared to discuss near-miss events, root- when presenting statistical data and informa- cause analysis, and information relevant to tion showing changes over time. There is lim- patient safety but unrelated to liability or the ited value in providing raw-number data litigation process. See Chapter 8 for a more e. It is also helpful to Some boards or administrators may wish provide the board with data that indicate to see data that compare their organization changes e.
The risk its care or is it getting worse? Reports that manager should stress that such comparative demonstrate changes and improvements are data can be misleading unless the other orga- more actionable than those that merely pro- nizations 1 offer similar services, 2 have vide numerical information. This type of information helps the vision. Competitive strategy, i. With healthcare efficiency of service spending continuing to rise, consuming an 2.
Operating strategy, i. Providing higher-quality 3. Financial strategy, i. Compounding the patient injury, and customer dissatisfac- challenges faced by risk managers is the tion are substantial higher potential risk of injury to patients resulting from elimination of support ser- The benefits of intertwining risk manage- vices, dwindling staffs, and shrinking health- ment strategy and organizational strategy are care budgets.
For the healthcare risk manager, link- With organizational and personal stakes so ing the two provides an architecture for high and resources so precious, it is more designing a risk management strategy that is important than ever for a risk manager to comprehensive, cohesive, and consistent. Meanwhile, the organization benefits meet its goals. It is the interplay of these three disciplines that Risk management strategy begins with risk determines risk management strategy Fig- assessment.
In turn, risk assessment— ure 5—3. In the healthcare setting, because risk is potential problems and makes necessary often closely linked to patient injury or harm, modifications before an injury occurs. Risk Management Strategy To per- 2. Its policies, statements, tively affect the quality of care, the and actions that contribute to attaining or volume of lawsuits or patient complaints, preserving this place define the mission and and the dollars required to resolve claims competitive strategy.
Michael Porter, in his or lawsuits. Achieving superior outcomes book Competitive Strategy, identifies five through quality service at a competitive forces that influence competitive strategy:1 price is the key to survival of hospitals today, and this can only be achieved 1. The threat of new entrants to the through the collaborative efforts of risk industry management, quality services, hospital 2. The threat of substitute products or administration, and clinicians. The healthcare organization may 3.
The bargaining power of suppliers choose a specific product line, often 4. The bargaining power of customers referred to as a center of excellence. The role of risk management 1. Cost leadership. The healthcare organiza- in assisting with the proactive analysis tion must become increasingly cognizant of the risks inherent in particular ser- of the need to provide value as well as vices offered should be stressed.
The central question facing a risk man- payers , quality is also considered. Its earnings? Its assets? Its in 1 insurance costs, 2 the dollars continued growth? This could place the entire organization in be modified or moved into a setting financial peril. Although the procedure may be of an organization that has two deeply viewed as being very desirable to patients ingrained operational strategies: and to the organization, if the procedure is not offered elsewhere , the cost of providing 1.
It uses the technique of stockless inven- the service or the risks associated with it tory, or just-in-time delivery of supplies when staff is improperly trained or when for surgical services. It has recently instituted a comprehen- erly may lead to a decision not to offer the sive patient safety program focused on service.
Furthermore, a risk assessment rooted in The second element of a risk management its mission and competitive strategy would strategy is risk control. Doing so will lead not only to mea- safe, high-quality care and timely service.
Firstly, any surprises in the form of influences its ability to survive in the future. Thirdly, ity to survive. Any scenarios that did not measure up products they provide. In the hospital to its cost of capital or other appropriate cost- setting, patient mix, payer mix, and of-funds benchmark would likely be rejected. Some hospitals seek to maxi- Furthermore, although it may be simple, the mize current deductions, whereas others example reinforces the need to match risk those experiencing operating losses, for finance with financial strategy, and it high- example do not.
Revenue Service scrutiny. Each organization risk management strategy and operational has a distinct risk personality when it strategy, another way for risk management comes to the kinds of businesses, assets to gain currency among senior managers is e. A basic exam- Accounting ple of the importance of accounting consider- ations is that of the organization weighing Tax the benefits of a loss-portfolio transfer.
If the cash required to transfer the presently self- Legal insured liabilities to an insurer is less than the book value of those liabilities on its bal- Very Important Important Not Important ance sheet, the organization can recognize Figure 5—5 Linking Risk Management an accounting gain, and thus boost profits.
If, Strategy to Organizational Concerns however, the book value of the liabilities is less than the cost of risk transfer, the transac- financial, accounting, tax, and legal consider- tion will have an adverse effect on earnings. An exception to this Financial Considerations might be if an investment in risk control were to provide an investment tax credit.
In As has been discussed already, financial con- this case, a risk-control decision should incor- siderations are very important when assess- porate its relevant tax consequences. Identifying and considerations are very important to risk quantifying the potential losses of earnings finance decisions, as is illustrated in the sec- and resources arising from operational expo- tion on financial strategy and risk finance. They are impor- Legal Considerations tant, too, when designing and implementing risk-control measures.
Key ques- spectively, of an investment in risk control is tions include: What is the legal climate in the to quantify its cost and its benefit.
What types of tort reform are available in Accounting Considerations those jurisdictions? What legal liabilities could arise from the pursuit of new or additional ser- Accounting considerations generally are not vices or marketing strategies, now and in the important when assessing risk.
They are future e. Appendix 5—A: Sample Job Descriptions Federal and state medical- with less. Furthermore, with flattened and product safety laws help guide liability risk more decentralized organizational structures, control, and federal Environmental Protection they must influence through persuasion Agency requirements and state laws drive rather than fiat; therefore, the advantage environmental risk control. The central question to answer is: What are In the end, effective risk management the state and local legal requirements, restric- requires top-management commitment and tions, and opportunities with respect to any is the result of a sound risk management proposed risk financing program?
Qualifications insured funds; evaluation of financial feasibility 1. Reports to legal counsel on matters involving environmental safety personnel hospital professional liability 3. Coordination with hospital quality management Responsibilities and patient safety programs: 1. Resource for education on risk management: 5. Qualifications error. Discuss incidents with individuals involved and challenge them to explain how the process 1.
Maintain statistical tabulations and sum- human-factors engineering. Training in Six maries of patient-safety-related occurrences and Sigma or Lean a plus.
Healthcare and patient safety experience Patient Safety Organizations as required by law preferred or determined by the organization.
Knowledge of other high-hazard industries that 2. Develop a process to share lessons learned have incorporated high-reliability concepts to across the entire organization so that problems create a culture of safety resolved in one area of the organization do not reappear elsewhere.
Excellent interpersonal skills 3. Serve as coach or primary data resource for 5. Good oral and written communication skills individual units seeking to engage in focused 6. Ability to make independent judgments and pay patient safety projects. Encourage collaboration close attention to detail with other areas as appropriate. Ability to analyze large data sets and design a 4. Conduct routine tours of the entire hospital to process to identify cause and solution may foster transparency and to hear from staff what require the ability to perform analytic root-cause their greatest concerns are about the environ- analysis, failure mode, and effects analysis, or to ment in which they work.
Use this process to institute detailed analysis to determine the ori- develop a list of priorities for staff education gin of errors and resource allocation. Reporting Relationship 5. Chair and document the proceedings of the hospital patient safety committee and disaster- 1.
Reports directly to the chief medical officer planning committee. Reports indirectly to senior administrative staff 6. Develop, implement, and maintain educational and chief risk officer patient safety programs for all hospital Responsibilities personnel. The person would be responsible for all aspects of 7. Perform other duties as related to the risk the hospital patient safety program, including the management and patient safety programs as following: assigned.
Review and analyze all near-miss and sentinel 8. Prepare formal reports for senior management events to identify system factors contributing to and hospital board as required. Qualifications by state law and internal hospital guidelines. Spe- cific duties include the following: 1. Bachelor of Arts or Sciences, or the equivalent in experience 1. Coordinate and process work-related incident reports, claims, and related expenses. Maintain 2. Excellent oral and written communication skills fied and resolved.
Excellent judgment 2. Establish and maintain employee claim files and files related to occupational safety and health 5. Ability to work independently administration requirements. Reporting Relationship 3. Design reports using the risk management infor- 1. Reports directly to the director of risk mation system for analyses, trend tracking, and management interdepartmental communications.
Reports indirectly to patient safety officer 4. Responsibilities 5. Act as liaison with health, safety, and security personnel, and with the human resources department. Qualifications Responsibilities 1. Minimum of 5 years of professional liability- claims experience 1. Evaluating the litigation potential of all inci- dents and adverse outcomes occurring within 3.
Database-management experience desirable the hospital 4. Excellent interpersonal skills 2. Conducting a thorough investigation to deter- 5. Good oral and written communication skills mine elements of disclosure and whether an early offer of settlement is appropriate 6. Ability to communicate effectively with physi- cians, nurses, and other healthcare professionals 3. Establishing claim files and estimate reserves.
Excellent negotiating skills 4. Coordinating the preparation of staff who may be called as witnesses at trials or depositions; 8. Working knowledge of insurance coverage a identifying those who may need emotional plus support in light of being involved in the event Reporting Relationship 5. Acting as a representative of the hospital at 1. Reports directly to the director of risk selected legal proceedings management 6. Assuming responsibility for settlement negotia- 2.
Identifying problem areas related to particular Designing claims reports for use by hospital claims that may indicate staff educational department heads, administration, and appro- needs priate committees 8. Preparing and reviewing all disbursements for approval from the various self-insurance funds. Qualifications patient injury or suit. The following duties are required to accomplish these goals: 1.
Implementing an early-warning system to iden- tify areas of potential clinical exposure 2. Clinical expertise in critical care, obstetrics, or emergency department a plus 2. Reviewing all quality-assurance or performance- improvement data with quality-assurance per- 3. Minimum of 5 years of clinical or teaching sonnel to identify significant risk trends experience 3.
Coordinating of communications among various 4. Performance-improvement or quality-assurance departments and committees to enhance prob- experience desirable; must be able to analyze lem resolution, facilitate corrective action, and large data sets and understand processes for prevent recurrences statistical analysis 4.
Processing reports of incidents, claims, suits, 5. Excellent interpersonal skills and complaints for review by medical staff and 6. Good oral and written communication skills quality-assurance committees; referring specific behavioral issues to appropriate peer-review Reporting Relationship committees to ensure that staff are accountable 1.
Working closely with individual clinical depart- 2. Direct working relationship with the director of ments and assisting in the development of risk management and patient safety officer appropriate department-specific clinical monitors Responsibilities 6. Assessing the educational needs of the hospital This position focuses on the identification, evalua- staff and participating in risk management edu- tion, and modification of high-risk clinical activities cation programs occurring within the hospital that may give rise to 7.
Serving as a resource to staff and department heads. Porter, M. Competitive strategy: Tech- niques for analyzing industries and competi- tors. New York: Free Press. It is now more than 10 years IOM report. Presentation of these changes, later and the number of deaths related to many of which align closely with the tradi- medical errors remains a significant health- tional role of the healthcare risk manager and care concern.
Health care has under the four-tiered approach as a guide. Medical- The four tiers are as follows: 1 leadership malpractice litigation continues to be a major and knowledge in the causes of medical contributing factor to the expense of health- error; 2 identifying and learning from errors; care.
According to Statehealthfacts. The goal of the CQuIPS is to con- The second tier, identifying and learning duct and disseminate patient safety research from errors, recommends a nationwide through collaboration with healthcare sys- mandatory reporting system and encourages tems to implement evidence-based prac- voluntary reporting of medical errors.
The tices. Most other things, trends in patient safety and are also contemplating how they become present, in chart format, data on quality and part of the national database established access to care. This four-volume 1. Provide for the certification and recerti- set of articles put together by patient fication of Patient Safety Organizations safety researchers and others includes, 2. Collect and disseminate information among other topics, articles on reporting sys- related to patient safety tems, risk assessment, safety culture, med- 3.
Facilitate the development of consensus specific limitations that relate to information among healthcare providers, patients, gathered in anticipation of litigation.
Provide technical assistance to states lished in to improve the quality of that have or are developing medical- American health care by setting national error reporting systems, assist states in standards, is a non-profit organization based developing standardized methods for in Washington, D.
Members of the NQF data collection, and collect data from include hospitals, physicians, businesses and state reporting systems for inclusion in policymakers, and national, health, govern- the patient safety database. The NQF of events that adversely affect patients. As of the report, there are 30 Patient and Safety Quality Improvement final identified safe practices ranging from creat- rule on November 21, 73 FR , ing and sustaining a culture of safety to and it became effective on January 19, medication reconciliation and specific 42 CFR Part 3.
The United States Department of events. Additionally, clearly preventable, and if allowed to occur, it many states have enacted specific statutes indicates a problem in patient safety within a specifying adverse-event reporting and moni- healthcare facility. The Centers for Medicare toring, investigation, and inspection require- and Medicaid Services CMS announced in ments in response to patient safety problems denial of payment for selected never within the individual state.
Chapter 8 events and hospital-acquired conditions. It is essential that risk NQF-endorsed standardized taxonomy for managers be aware of the type of data that is patient safety. Standardizing the for initial processing in the legislative terms across reporting systems will assist in chain. This innovation. The board and Expectations for Patient Safety advises the director of the Center for Drug Evaluation and Research, FDA, on drug- The third tier, setting performance standards safety issues and works with the agency in and expectations for patient safety, includes communicating safety information to health a recommendation for professional societies professionals and patients.
The AMA also aggressively lobbied in approximately 13 goals with multiple ele- support of federal legislation that would cre- ments of performance. The goals were devel- ate voluntary confidential error-reporting oped based on an analysis of sentinel events systems, specifically, the Patient Safety Qual- and common issues in health care that give ity Improvement Act of In the past presumably because current goals are not decade, the ANA launched a campaign to being met.
Since , the ANA has been relent- improving safety in health care, with over less in support of legislation establishing safe half of its standards directly related to safety.
The uni- facility as compared with similar facilities versal protocol was updated in and across the United States. This chapter summarizes just a few of the Hospital staff provides their opinions about most prominent patient safety initiatives various patient safety issues as well as since the publication of the IOM report medical-error and adverse-event reporting.
It is clear that the IOM report The purpose of the report is to 1 allow hos- spurred the nation to action with the publish- pitals to compare themselves with each ing of numerous reports and publications other, 2 facilitate internal learning in patient that discuss the problems identified.
Patient safety improvements, 3 assist hospitals in safety and medical errors continue to be identifying strengths and areas for improve- national problems with slow progress in cor- ment, and 4 show trends in patient safety recting deficiencies. Continued efforts by the over time. The second report was sumer organizations are required to improve released in and included data from patient safety.
Standardizing collected data hospitals. The tool is still gaining momentum, and effective use of technology are necessary because the report included data from to realize progress. It will be interesting to hospitals. Agency for Healthcare Research and Quality.
To err is human: Building a safer n. Center for Quality Improvement and health system. In the case of both of those risks, there are steps that can be taken to mitigate the damage they would do and be prepared in the event that they do occur. For example, having redundancy within your team can help to limit the damage if a team member moves on to another job partway through the work, and building the project in such a way that it can be 'paused' while waiting for more funds could prevent it from being completely wiped out by a temporary lack of funding.
Evaluating the Risks With a list in place that highlights which risks you will be taking on during the project, you can start looking closely at each of them and deciding what kind of threat they actually are.
Is the risk something that would do long-term damage to the organization if it came to pass? Usually, risks that fall into this category are of the legal variety. A project that could put you in legal trouble for one reason or another is often one to be avoided. However, if the worst-case for a project is simply some wasted time and a small amount of wasted capital, you may decide that those risks are worth the potential reward.
It is all about balance in risk management, so the pros and cons have to be weighed carefully with respect to each potential risk. Both qualitative and quantitative analysis must be performed for each risk. Firstly, each risk is assessed and rated according to its likely probability and then secondly on the impact it would have on the project if it happened.
There are a variety of tools that are used to assist in these processes:. Beyond what kind of damage a certain risk could do is the consideration of how likely that risk is to occur. For example, a risk that is very likely to occur and would also be highly damaging to the company is one to take very seriously. On the other hand, a risk that is unlikely to be realized and also wouldn't do much harm is one that you can mostly ignore. Mitigating the Risks This was touched on briefly above as far as taking steps to limit the damage that any of your potential risks would do.
The easiest example to understand is the one regarding members of the team. When you are building a team to work on the project, keep in mind that not every team member will see the project through from start to finish. If you only have one person who is capable of performing a vital portion of the work, you are exposed to risk if that person should leave for any reason.
Different projects, organizations and situations require a variety of approaches to risk management and there are several specific ways to conduct risk management that are in agreement with principles of Project Risk Management as presented in this practice standard. It defines ERM with a particular focus on understanding the nexus between risk, uncertainty, knowledge and performance. The book argues that there is critical need for ERM concepts, principles and methods to adapt to the latest and most influential risk management developments, as there are several issues with outdated ERM theories and practices; problems include the inability to effectively and systematically balance both opportunity and downside performance, or relying too much on narrow probability-based perspectives for risk assessment and decision-making.
It expands traditional loss-based risk principles into new and innovative performance-risk frameworks, and presents fundamental risk principles that have recently been developed by the Society for Risk Analysis SRA.
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