Beyond Brussels: Employee Crisis Communications
John Persons (not his real name) was in the Brussels airport around 8 am on March 26, 2016 when two bombs detonated, killing 31 and wounding around 300.
Fortunately for Persons, his family and his employer, a large U.S. insurance brokerage, he was not among the dead or injured.
His employer knew he was safe almost immediately. Expert Care, a service of American Express Global Business Travel, saw from his itinerary that he was scheduled to be in the Brussels airport.
Risk managers confirmed it by geolocating Persons through an app on his smartphone, then sent him a Short Message Service (SMS) message.
He texted back “1,” code for “I’m OK.” Expert Care immediately forwarded the good news to Persons’ employer.
A response other than “I’m OK” — say, “2” for “I need help,” “3” for “I’m not sure” or, more ominously, no response at all — would have triggered a much different scenario, said Evan Konwiser, vice president, digital traveler, American Express Global Business Travel.
“Travelers in the red column of the dashboard may need help,” he said.
Their companies’ crisis and travel managers would next decide how to proceed: phone call, follow-up texts and/or alerts to local authorities. As responses trickle in from travelers who had no or spotty mobile broadband connection, and those who were separated from their devices or were nowhere near the trouble spots, the travel manager would focus on the smaller group who really did need help.
Emergency Notification System “Handshake”
This kind of SMS “handshake” is high among companies’ preferred methods of communicating with its employees who get caught in crisis areas, said Matt Bradley, regional security director for the Americas, International SOS, because it’s fast, requires few keystrokes and transmits more reliably in low-signal situations than more data-hungry methods such as email and social media, although they also have their place in crisis communications.
Travel risk programs and emergency notification systems should deploy on smartphones, the technology every business traveler carries, said Hart Brown, senior vice president, practice leader, organizational resilience, HUB International.
“Local employees know the crisis response plan, but travelers are often left out of the briefing.” — Matt Bradley, regional security director for the Americas, International SOS
“Travelers leave other devices in their bags or forget to charge them.”
Smartphones can contain numerous mechanisms for locating and alerting travelers: GPS, apps, a programmed or installed panic button, email, social media and voice communications, Brown said.
“Every tool has strengths and weaknesses, so we pull in as much data as we can from every source,” Konwiser said. For example, “if a traveler missed his flight to Brussels, the itinerary data might not be updated, but we’d know he’s safe if he swiped his Amex corporate card at a concession stand in Heathrow 10 minutes before the explosions.”
Although social media, including Facebook and Twitter, can help break news — the suspicious package in the Atlanta airport that led to an evacuation on March 23, 2016, for example — it can also broadcast unverified information, such as the tweet about shots fired in the Atlanta airport during the same incident from someone claiming to be there, said Bradley.
International SOS, which provides medical and travel security risk services to many Fortune 500 clients, monitors Twitter for incidents, seeks verification and then takes action if appropriate.
Action may include sending information to clients’ travel managers or directly to travelers about an incident, always accompanied by advice.
During the terrorist shootings in Paris in November 2015, for example, “we told people, ‘Seek shelter. Don’t go back to your house or hotel. Get off the street.’ ” Information without advice, Bradley said, creates counterproductive anxiety and panic.
For those times when smartphone communications fail, companies should have a backup plan that includes instructions to go to a pre-determined rally point, such as a hotel or supermarket that provides shelter against rain, is usually open for business and that cab drivers can find easily. Rally points are never monuments, train stations or office buildings, which may themselves be targets, Bradley said.
Best Practices in Mature Global Travel
Companies whose employees travel extensively should have “overarching” crisis management plans, either housed at corporate headquarters or regionalized to branches, Hart said, and travel risk management plans that include a travel portal that aggregates flights, hotels, meeting times and locations, and arrival/departure dates.
“We want to see that aggregated data bundled and visualized on a map so risk managers can see where their people are.”
Of course, preparing employees before they leave should be part of the plan, said Bradley.
“Local employees know the crisis response plan, but travelers are often left out of the briefing. Before they leave, employees should know where hospitals are. Where the rally point is. Where the backup rally point is.”
Companies should be aware of risks — political unrest, infectious diseases, cultural flashpoints, weather — before they send employees, and those with major operations in a region should also invest in a journey risk plan that probes a region’s details: Is it safe to hail a taxi on the street? Does the employee need a driver? Where does she go and who does she call if there’s an issue?
Most insurance policies that involve foreign and business travel have response capabilities embedded in them, such as who to call and how to get help abroad, Hart said, but clients aren’t always aware of the information. Brokerage houses, he said, should educate clients on what duty of care looks like and how to implement crisis and travel risk plans.
“The broker’s role is to make sure policies connect carriers with response partners so the crisis plan works efficiently from beginning to end,” he said.
Hospitals Struggle with Security Risks
A growing number of health care facilities are foregoing armed security because of insurance carriers’ concerns.
Instead, some facilities are equipping security personnel with intermediate-level weapons, such as handcuffs, TASERs, batons and pepper spray.
“The cost and availability of insurance is almost certainly a factor in the decision,” said Jeff Young, a spokesperson for the International Association of Hospital Security and Safety, and executive director, Lower Mainland Integrated Protection Services in British Columbia.
“Since pepper spray and Tasers are less lethal than firearms, they’re less risky from a liability standpoint … but they’re less effective against an assailant with a gun.” — Michael DuBose, senior vice president, workforce strategies practice, Marsh Risk Consulting
“If insurance coverage isn’t available, the corporation might not be willing to assume the risk on its own.”
Some carriers “take a negative stance on arming staff,” said Michael DuBose, a senior vice president with Marsh Risk Consulting’s workforce strategies practice, particularly internal security staff (as opposed to contracted security personnel, such as off-duty police).
In health care facilities, as in schools, “if you go ahead and arm your staff, you may find out your carrier will drop you or boost your premiums.”
“Since pepper spray and Tasers are less lethal than firearms, they’re less risky from a liability standpoint,” said DuBose.
But there’s a tradeoff. “They imply less liability and require less training, but they’re less effective against an assailant with a gun.”
Shootings at hospitals are, unfortunately, not rare.
In February, an injured man seeking aid fired a bullet into a door at the Reston Hospital Center in Northern Virginia and then fired another bullet once inside the hospital. Medical personnel eventually convinced him to lay down his gun.
In December, a Los Angeles police officer shot and killed a patient at the Harbor- UCLA Medical Center in Torrance, Calif. when he attacked officers and reached for an officer’s gun, according to reports. The patient, arrested earlier in the day, fought ferociously with police at the hospital. Officers tried using a Taser on the patient first to no avail.
That was also a case last summer in Houston, when police were unable to subdue a combative patient with a Taser, according to reports.
The patient, who struggles with mental illness, was shot in the chest by the police, working off-duty as hospital security; that shooting was not fatal.
Determining the Risk
DuBose said many facilities want to equip personnel with some means of protection for themselves and the public.
“They conduct an annual security risk assessment that considers, among other things, the prevalence of gun crime and violence in the neighborhood and the facility’s own history of violence. Then they ask, ‘Is that the right stance for our facility?’ ”
“How many local police officers would feel comfortable pursuing someone into a central sterilization area where there are toxic or flammable gasses?” — Dr. Jeffrey Ho, Hennepin County Medical Center
For example, he said, “firearms may have a role in a Level 1 trauma center that treats victims of violence, mental health patients and inmates. But you have to question very closely the need to arm a small community hospital that doesn’t have that same degree of risk.”
Barry Kramer, senior vice president, Chivaroli & Associates, a health care insurance broker, said that armed security in health care settings is more of a risk management concern than a coverage issue.
“It would be highly unusual for our clients’ liability policies to exclude claims involving security guards, whether or not they’re armed with guns,” he said.
He said many health care risk managers are not equipped to manage exposures associated with licensing and certifying guards or registering the facility’s own firearms.
For facilities that lack the bandwidth to manage, train and track certifications for in-house security staff, Kramer said,third-party vendors, such as local law enforcement or private security companies, can be contracted, since they have firearms experience as well as liability insurance coverage.
Jeffrey Ho, an emergency room physician in a busy Level 1 trauma center at the Hennepin County Medical Center in Minneapolis and a sworn deputy sheriff in neighboring Meeker County, cautioned that armed personnel must be thoroughly trained to work in a health care setting.
“How many local police officers would feel comfortable pursuing someone into a central sterilization area where there are toxic or flammable gasses?” he asked.
“How many would feel comfortable discharging a firearm or Taser, which generates an electric spark? Any weapon can be dangerous in those environments.”
Train for the Worst
“Prevention,” said Young, “is the first line of defense in potentially violent situations. You have only seconds or at most minutes to de-escalate a situation before it can go very wrong.”
Failure to recognize a potentially violent situation and take precautionary steps can lead to tension between security and clinicians.
Training – not just in lockdowns and active shooter drills but in de-escalation techniques and identifying potentially dangerous situations – is essential to preserving safety, said Ho.
Failure to recognize a potentially violent situation and take precautionary steps can lead to tension between security and clinicians, said Ho.
When his facility first undertook a comprehensive violence prevention program nine years ago that included debriefings after forceful intervention, “clinical staff pointed the finger at security and said, ‘How dare you put that patient on the floor, handcuff him, spray him with pepper spray?’ And security would say, ‘The situation was out of hand before we got there. What did you want us to do?’”
Looking back, he said, most situations never should have escalated to violence.
Eventually the entire staff – clinicians, therapists, food service and administrators – were trained to recognize stresses and talk down problems from flash points, which worked well in many but not all situations.
“Maybe the patient was hungry or thirsty or needed a blanket. Failure to recognize a simple problem often led to acting out.”
Greater force may be called for with intoxicated people, he said.
Although security seldom if ever initiates violence but rather responds to aggression, patients may perceive the situation otherwise and pursue litigation, Young said.
“Especially in a psych setting, patients may turn it around,” said Jane Lipscomb, professor at the University of Maryland Schools of Nursing and Medicine, and author of “Workplace Violence in Health Care: Recognized but not Regulated.”
“They can say, ‘I was defending myself because the staff member was being abusive,’ and the staff member is put on administrative leave.”
The most effective environments value staff safety, she said, and see that it’s inextricably linked to patient safety and quality of care.
Hospitals are caught between pressure from the Affordable Care Act to discharge patients quickly to their homes and the financial penalties they face if patients are readmitted.
To mitigate the risk, hospitals are focusing on patient education as well as ancillary services such as case and discharge managers to help patients assume greater responsibility for their follow-up care, including medications, nutrition and use of medical equipment.
This requires a coordinated, multidisciplinary effort that starts with a patient’s admission to the hospital, said Terri Nichols, director of risk management, PeaceHealth.
“In a culture of safety, we think ahead about the discharge environment. We think about home assessments,” she said. “We think about grip bars in showers. We think about who will help an elderly relative up the stairs. We think about teaching family members how to inject medications.”
Planning for discharging patients is crucial because inadequate information or preparation, or discharge into unsafe environments significantly increases the chances of readmission.
“Proactive discharge plans have reduced readmission rates significantly,” said Dana Welle, chief medical officer, The Risk Authority, Stanford, Calif.
Most U.S. hospitals are projected to receive lower reimbursements from Medicare in fiscal 2016 because too many patients return within 30 days of discharge, according to “Modern Healthcare.”
Fewer than one-quarter (23 percent) of more than 3,400 hospitals subject to the ACA’s Hospital Readmissions Reduction Program (HRRP) performed well enough in 2015 on the Centers for Medicare and Medicaid Services (CMS) 30-day readmission program to escape penalty.
Statistics about hospital readmissions are confusing and contradictory. — Pamela Popp, executive vice president and chief risk officer, Western Litigation
HRRP targets higher-than-average readmissions for heart attacks, heart failure and pneumonia, and it stepped up penalties from 1 percent in 2013 for to 2 percent in 2014 to 3 percent in 2015.
The problem, however, is especially intractable among the homeless, Nichols said.
Seven in 10 homeless individuals who were discharged were readmitted, visited the emergency room or returned for an observation stay, according to the National Center for Biotechnology Information.
Interpreting the Numbers
Statistics about hospital readmissions are confusing and contradictory, said Pamela Popp, executive vice president and chief risk officer, Western Litigation.
While the proportion of hospitals receiving a penalty increased to 78 percent in 2015 — up from 66 percent in 2014, according to The Henry J. Kaiser Family Foundation – penalties remain below 1 percent, although the maximum cap rose in 2015 to 3 percent.
It’s unclear what those numbers say about hospitals’ efforts to control readmission because of some changes in the regulations, said Popp.
CMS added two more diagnoses — chronic obstructive pulmonary disease, and hip and knee replacements — to its performance criteria in 2015, significantly raising the potential universe of tracked readmissions.
And the ACA requires more reporting about readmissions than in the past, forcing hospitals to acknowledge that admissions that wouldn’t have been counted in the past – often for sepsis – are related to a prior admission.
About half of the sepsis infections are preventable, and they accounted for roughly the same percentage of hospital readmissions in California as heart attacks and congestive heart failure in 2015, according to UCLA research.
Preventing avoidable readmissions depends on unbroken communications between patients, care providers and care managers, said Popp.
“Make sure patients and families know what normal healing looks like as opposed to an acute condition,” she said.
Often, she said, patients and caregivers fail to comply with follow-up instructions, either because they don’t understand what is necessary or are not able to.
“They can’t afford their meds, or they can’t afford to stay home from work. Then they put a recovering child back in day care, and the providers miss symptoms until there’s another crisis,” Popp said.
An increasing number of hospitals phone patients immediately after discharge to check on their condition and later to remind them of follow-up visits, Welle said. Some send doctors or nurses within 24 hours of discharge to re-evaluate patients.
Some contract with rehabilitation and home health services to provide follow-up care.
Hospitals will also engage their quality control and risk management departments to monitor and implement the new interventions, she said.
“It’s not enough to simply put interventions in place. There must also be a way to measure if they’re helping,” she said.
To prevent misallocation of time, attention and resources, it’s important for the risk management community to understand that “most of the factors leading to a readmission have nothing to do with the quality of clinical care,” Popp said.
“It’s a communications issue.”
Readmissions should be reported all the way up to the board of directors, Welle said, because senior-level involvement may increase funding for external resources such as additional discharge nurses or contracts with rehabilitation and home health services.
The insurance industry also can play a role in reducing readmissions, Popp said, by ensuring that hospitals track and learn from readmissions.
Investigation into its readmission rate should be part of the underwriting process, she said, especially for those related to sepsis.
“Look for adequate discharge instructions and follow-through,” she said.