By JULIE LIEDMAN, a freelance writer and editor
It used to be that healthcare providers' risk management meant how an organization dealt with adverse events and how it could reduce the cost of those events in the future--and the insurance to cover them.
After all, the mission of healthcare providers is to improve patient health, or at the very least to "do no harm." Nevertheless, scores of people are harmed each year in hospitals and other healthcare institutions.
Now healthcare providers are coming to realize that errors affecting patient safety are not necessarily the fault of one person who makes a mistake. Rather, they are coming to realize that many errors result from human factors such as communications lapses or lax work environments.
And because safety is linked to these human factors, hospitals and other healthcare providers are looking at trends within their own institutions in an effort to understand how these human factors cause medical errors; and they are considering a variety of available benchmarking opportunities to determine ways to prevent them.
Most healthcare organizations collect safety data in an effort to identify trends and prioritize which risks to address. But that is only part of the solution. The other part involves adopting a "culture of safety" that involves every layer of the institution, from leadership to volunteers, and everyone in between.
"This is something that's been going on for several years," said Nick Williamson, vice president, healthcare, for Hiscox, a Bermuda-based global insurance company, "but it has accelerated in recent years as healthcare providers become more focused on patient-centered, quality care rather than on the reduction of claims.
"What has happened in the past few years," he said, "is that there's much more buy-in from senior management for risk-management initiatives, which long needed to get to the forefront."
The process may have taken longer than necessary, but in the end improving quality also improves the bottom line. "They are actually able to reduce claims, but that really is secondary to them following all standard protocols," he said.
Healthcare providers have access now to plenty of published data that measure safety standards. "We hear most about CMS core measures," Williamson said. "They are out there publicly."
He is referring to the Centers for Medicare and Medicaid Services (CMS), a branch of the U.S. Department of Health and Human Services; it is the federal agency that administers the Medicare program and monitors the Medicaid programs offered by each states.
Its quality measurement tools help healthcare providers quantify healthcare processes, outcomes, patient perception and organizational structure and/or systems associated with the ability to provide effective, safe, efficient, patient-centered, equitable and timely care.
Another is Risk Management Foundation (RMF) Strategies, an outgrowth of Harvard's CRICO/RMF--Controlled Risk Insurance Company of Vermont Inc. (a risk retention group) and Controlled Risk Insurance Company LTD--the patient safety and medical malpractice company owned by and serving the Harvard medical community.
The Risk Management Foundation was incorporated by the Harvard Medical Institutions in 1979 as a charitable, medical and educational membership organization. Today, CRICO/RMF is a leader in evidence-based risk management services to healthcare systems and medical malpractice insurers as part of an integrated strategy that uses both qualitative and quantitative data to focus patient safety initiatives.
Stanford University Medical Center, which comprises Stanford Hospital and the Lucile Packard Children's Hospital in Stanford, California, uses RMF methodology for benchmarking.
"We engage leadership. We take information from Harvard and sit down with a core group of leaders, usually in interdisciplinary teams, to do deep-dive analyses of both of our hospitals," said Ed Hall, senior director, loss control and education in the risk management division of the medical center.
"We test our systems through simulation," he said. "There are a lot of studies that prove the value of simulation versus computer-based training. Then we track and trend our systems each year to see if we've made progress."
Indeed, Williamson said, these initiatives are paying off. "We're studying the value of our loss and risk programs, and it shows significant return on investment.
"We want our people to understand why it's important to follow procedures, and what the cost of not following them is," he said. "Not to toot our own horn too loudly, but we know that our risk programs have bottom-line value.
"From an insurance and cost perspective," he also said, "proactive is the way to go. There's no free lunch. Either you pay on the front end, or you pay for the cost of claims."
Sometimes the simplest strategies are the most effective.
Lee Patrick, webmaster for the Philadelphia Area Society of Healthcare Risk Management (PASHRM), a networking organization for healthcare professionals concerned with risk management and safety activities, said that healthcare providers are becoming more customer-focused.
A former corporate director of risk management, quality improvement and patient safety at a large post-acute care hospital, Patrick said she did "a lot of extra teaching about why hand-washing is so important."
Incidents of methicillin-resistant Staphylococcus aureus (MRSA), a bacterial infection highly resistant to some antibiotics, have been growing across the nation in recent years, and about 85 percent of all invasive MRSA infections are associated with healthcare. Therefore, many hospitals have initiated stringent programs to promote hand-washing--the best way to prevent the spread of MRSA--among hospital personnel. Here, again, taking the initiative rather than reacting pays off.
"We did a lot of education," Patrick said. "Everyone needed to be told how infections were spread, and when and why hand-washing was important. And it wasn't just nurses. It was everyone, food service, housekeeping, everyone."
But education wasn't enough, she said. "We started to do surveillance. We had 'secret shoppers'--nurses, rehab people; it was an effort across all disciplines, people who were not used to be on the units, walking down the hall.
"If they saw a nurse giving meds, they'd follow the nurse, look to see if she left the cart at the door or took it all the way into the room. You don't want to take carts from room to room. They could spread infections that way.
"Did the nurse wash his hands when he entered the room and when he left? Did the nurse leave her gloves on when she left one room and entered another? Did housekeeping change the water every time they went to another room? Did they take down the curtains between beds and put up clean ones?"
If hospital personnel were not complying with the standards set, they would get feedback. Improvements were mentioned in the hospital newsletter, to reinforce proper behavior.
"At first, compliance wasn't so good," Patrick said. "We really had to work with all of the staff. We really had to change the culture, change it to a culture of safety. It took a lot of effort and time. It was like trying to turn the Titanic around. But once we got the staff on board, compliance went up dramatically."
Such hospital-acquired infections--indeed, all hospital-acquired conditions--have led many hospitals to focus on decreasing the number of hospital readmissions as a way to mitigate risk.
"Some of it came out of healthcare reform and some from hospital benchmarking studies," said Sue Chmieleski, a nurse-attorney who is senior vice president for risk management and loss control for Allied World Assurance, a Bermuda-based global insurance and reinsurance company. "It's certainly a matter of patient safety, but also a component of healthcare reform. Hospitals that have high incidences of Medicare patients being readmitted will be penalized."
Chmieleski said surveys show that one in every four liability claims in the United States is associated with five specific hospital-acquired conditions: infections, injuries such as falls, medication errors, objects left in during surgery and pressure ulcers.
"Instead of waiting until a claim is filed, hospitals are now using evidence-based best practices to implement changes in processes and procedures. What we're talking about is changing the culture of an organization," she said.
Institutions that focus on issues in silos are not going to create an environment that prevents repeats, Chmieleski said. "We're talking about changing the culture of an organization from the top down, and making everyone understand what part they play in patient safety.
"Hand washing is huge, but there are other initiatives, too. For us, as an insurance carrier, we like to review an organization's data with respect to hospital-acquired conditions and talk about what sort of surveillance programs are in place, what kind of strategies there are for prevention and what kind of data is collected before something becomes a claim.
"And we're not only responding to these issues, we're doing predictive modeling. Now that we have this data, we can make assumptions: 'What type of patients are more disposed to having these things happen? What can we do proactively to prevent them?'"
The dollar savings to healthcare providers is the hardest piece to quantify. Hiscox's Williamson said implementing quality and risk management initiatives has led to a demonstrable decrease in claims.
"The general view is that the frequency of claims is down somewhat and our hospital clients have seen some over-reserving in trust funds or captives. People can see some savings there," he said.
But the cost of implementing far-reaching programs can be expensive, too, especially if technology is involved.
An example is the concept of an electronic intensive care unit, where hospitals have the ability to monitor the vital signs of an extraordinary number of patients on high-quality monitors without medical personnel being in the room. "It's quite expensive, but I've seen many organizations that have implemented them," Williamson said. "And they report a reduction in mortality has been demonstrated.
"The mortality has decreased, but the cost to do this is great. So you have two problems: What is the cost savings in saving a life; it's difficult to say. Do I think I am saving money by implementing this? The answer to that, generally, is no. You're never going to get your money back.
"But it's the right thing to do."
October 1, 2010
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