Risk Management & Patient Safety

September / October 2009

Risk Management & Patient Safety

Efforts to improve patient safety have intensified over the last decade, acting as a strong catalyst for change in the structure and daily work of hospitals. In particular, improving safety often means fostering collaboration among healthcare professionals and disrupting the traditional silos within which many established professions, including risk management, have worked comfortably for years. As those silos have been giving way to new models, the responsibilities of risk management have evolved to include proactive efforts to prevent patient harm, collaborative efforts to address system-based deficiencies that may lead to adverse events, and open communication with patients and families when things go wrong. Some hospitals recognize further that providing patients with safe, high-quality care is fundamental to protecting the financial assets of the institution and, therefore, falls within risk management’s role. In this new landscape, risk management and patient safety professionals are engaged in a close working relationship, which may be characterized by smooth integration, wary cooperation, or conflict.

For this issue of Patient Safety & Quality Healthcare, we asked professionals in risk management and related positions to reflect on their roles in patient safety and to report on the dynamics they see among their colleagues in risk, safety, and quality. This collection of essays — which continues at www.psqh.com — reveals their complex work environments, thoughtful approach, and professional dedication. Thank you to all who contributed!

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Director of Clinical Risk Management
Aurora Health Care

Patient Safety Officer
Medical Director, Care Management
Aurora Health Care

It is difficult, if not impossible, to define and separate risk management and patient safety roles. Both track and mitigate patient care error and improve processes with the goal of improving patient outcomes. At Aurora Health Care, risk management and patient safety are intertwined throughout the system. In the course of clarifying function, we have attempted to delineate risk management from patient safety, only to conclude that it is difficult to identify where one ends and the other begins. The structure and process that we are developing at Aurora Health Care offer advantages as well as challenges, but the organizational commitment to putting the patient at the center of care provides clear guidance and direction.

Organizational Structure and Goals
Aurora Health Care is an integrated system with 13 hospitals, 2 new hospitals under construction and scheduled to open over the next 2 years, 100 outpatient clinics, 120 retail pharmacies, a clinical laboratory, and a statewide home health program, the Visiting Nurses Association (VNA). Aurora employs more than 27,000 caregivers, including 1,200 employed physicians and more than 7,000 affiliated physicians geographically dispersed throughout eastern Wisconsin.

The organizational structure includes two system leaders: the patient safety officer and the director of clinical risk management. A system-level patient safety program was first established in 2003. The site-based patient safety programs matrix up, but do not directly report to the system patient safety officer through their membership on the system-level Patient Safety Team. The risk management program has a similar structure: site-based risk managers either report directly or matrix to the system-level director and coordinate activities through the system-level Risk Management Team. Reflecting the integrated structure of Aurora, patient safety and risk management are present in all services, including outpatient clinics, lab, retail pharmacy, and VNA.

The Aurora strategic framework is consistent with high reliability organizations: design care with patient needs in mind, rapidly adopt best practice and research, and simplify care so that it is easy to use. This framework provides the foundation for our risk management and patient safety programs.

The processes and outcome goals for risk management and patient safety are similar: identify, analyze, mitigate, and prevent clinical risk, with the overall objective of improving clinical outcomes throughout the organization. The process is multidisciplinary and collaborative. Data sources include patient and caregiver concerns; voluntarily submitted patient incident reports; sentinel and significant events; coded information such as the DRG-triggered hospital-acquired conditions; claims; write-offs due to service or potential errors; risk and quality assessments; literature and evidence-based practice; and external alerts from national and international sources.

Analysis of the data often identifies multiple causative factors requiring corrective actions. These interventions may be identified and developed by the Risk Management or Patient Safety Teams, or through collaborative efforts with other departments such as nursing, quality, information technology, or even the supply chain. Each year, patient safety initiatives are selected according to a matrix of factors such as severity, volume, and/or regulatory requirements. Metrics and targets are set for each goal, published in the Patient Safety Dashboard and incorporated into performance evaluations for all caregivers.

Synergy and Challenges
At Aurora, our risk management/patient safety systems have a number of advantages. Leadership support for patient safety is loud and clear to all our caregivers, evidenced by tasking two system-level leaders with improving safety. As we are both graduates of the American Hospital Association/HRET Patient Safety Leadership Fellowship program, our theoretical framework and knowledge base are consistent and complimentary (Health Research & Educational Trust, 2009). Fellowship colleagues provide a vital resource to us and to our organizational development of safety and risk.

With professional differences, as a nurse and a physician, we approach and analyze clinical situations with a balanced perspective. The structures of the risk management and patient safety programs provide us with the flexibility to align our goals with the organization’s strategic model. Though the risk management and safety programs often parallel each other, the distinction between the two is evident in our approach to our culture of safety evolution. Risk management leans on patient safety to address cultural issues such as communication, fair and just culture, and disruptive behavior, while the patient safety program needs risk management to provide data for prioritizing initiatives.

As the two programs evolve, challenges have emerged, consistent with tensions felt in other organizations evolving from the traditional “reactive” risk approach to one of prevention. Facility and practice size, geographic dispersement, communication challenges, and resource allocation add a layer of complexity to our work. From a system perspective, risk management and patient safety processes have to be efficient and non-redundant. At some of our sites, risk management and patient safety are managed by the same person, and at others, there are two people with distinct roles and responsibilities. Thus, our processes have to be usable and understandable for our diverse system, from the smallest hospital to the largest clinic.


Aurora Health Care, www.aurorahealthcare.org

Health Research & Educational Trust Patient Safety Leadership Fellowship Program, www.aone.org/hret/programs/fellowships.htm 


The matrix structure at Aurora, where working relationships rather than hierarchical structure are the norm, creates challenges when attempting to establish policies and norms that are controversial or complex. The flexibility and overlap of the job roles and responsibilities of risk managers and patient safety officers, both at the system and site level, can create confusion and tension at times. Individual differences between the two of us, as system leaders, require careful consideration and coordination to assure clarity of purpose and effective, efficient use of resources. As one of us is process oriented, and the other conceptual in nature, we take care to balance our efforts.

With all of the complexities of our system and healthcare in general, we always come back to our organization’s cornerstone: What is best for the patient? As risk management and patient safety continue to evolve at Aurora, we recognize the overlap and interdependency of these roles. We expect the roles of patient safety and risk management to mature over time. Our structure may look different in a year, as we learn more, improve more, and strive to produce the best outcomes for our patients. What is best for the patient provides our equilibrium.


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Motivation Brings Us Together

Careers only make sense in the rear view mirror. I suspect that most of us could never have foreseen the winding pathway of jobs, roles, and responsibilities that bring us to this moment, yet in hindsight the continuity can be quite stunning. My journey into the field of risk management and patient safety started over 20 years ago when I left critical care nursing as a young mother in pursuit of a “normal” job—no more shifts, on-call, missed holidays, etc. I quickly realized that this new field was far from “normal”! The types of problems that came across my desk were complex, emotion-laden, and politically charged. Some days, it appeared that the very definition of a risk management problem was one that no one could resolve and, of course, the most challenging issues always seemed to happen in the middle of the night, during the weekend. Fortunately, with good mentoring, I was able to find my bearings in seeking the right balance between what was best for the patient and the organization. The longstanding positive relationships I had with several staff physicians and department managers proved to be tremendous assets as I sought to share risk management lessons and improve practices.

A few years later, I was drawn to a small company with a big idea: to become a nationally recognized risk management company that offered professional liability insurance as one of its solutions, rather than as its primary product. The dozen years I spent there were some of the most rewarding of my career, for it was during that time that I discovered my love for data and technology and how they could drive meaningful change in the delivery of care. This was the time of the first IOM report, which heralded the modern patient safety movement. I became an avid student of patient safety theory and incorporated its principles into my daily work and practices, which I found to be a natural extension of what I had always done in risk management.

Then came September 11, which, along with our national upheaval, generated tremendous turmoil and uncertainty in the financial and insurance markets. Compounded by the investigations and indictments of the Elliot Spitzer regime, I rode the wave of corporate acquisitions, sell-offs, and new opportunities, including being part of some of the largest nationwide carriers. Throughout it all, my focus and core purpose remained the same—to help healthcare organizations create a safer environment and reduce harm. The tools I used changed from time to time, but my objective did not. My ability to view healthcare from an “insider yet outsider” perspective, coupled with the richness of the business acumen I gained, was priceless. I experienced the joy of discovering new interests and talents and learned that one can achieve one’s life work through a wide variety of job roles and opportunities.

Through observing healthcare organizations from hundreds of visits over the years, certain patterns emerge. The one risk management and patient safety challenge I’ve most consistently observed is the difficulty of attaining, and then sustaining, meaningful change. All too often, healthcare organizations spend their time and resources identifying the changes they want and need to make, but then don’t have the tools to effect those changes or sustain them. We often hear of the need for leadership to achieve an organizational culture of safety; however, there also is a need for effective tools and processes to hardwire best practices and lessons learned at the point of care in a dynamic, real-time way. Transformational change takes more than iterative improvement and often calls for a dramatically new and bold way of approaching the problem. It is this realization that has led me to my current role, senior vice president for risk management and patient safety, at another small company with a “big idea.”

You may think my story is quite romanticized and rather naïve. What a way to look at a 30-year career in healthcare—trying to make a difference in the lives of others! If you were to look at my titles and employers, you might see me as an “insurance person,” a “solution provider,” a “partner,” or even a “vendor.” Sometimes, these labels create invisible but tangible barriers to working together on collective solutions to our common challenges. I call these the “glass walls” that exist between us. Whether you work in a hospital, a non-profit company, a privately owned or a publicly traded organization, all are businesses that have to “sell” something to support the organizational mission and goals. In my experience, it’s not been a function of the place of employment but, rather, the central motivation of the work that makes us risk management and patient safety professionals. I hope that this essay helps to open up more avenues of understanding between industry and healthcare on the ways we can work together to continue to address the significant challenges we still have ahead of us in patient safety and risk management.

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Being a risk manager or quality manager is not an easy job. Being responsible for improving quality and mitigating risk in today’s healthcare setting may feel like driving an old bus on a treacherous and winding mountain road. The road ahead is marred with potholes, and you certainly may not take your eyes off the road. The odds of bringing the complex busload of patients, families, and providers to a safe destination can seem slim at times as the obstacles seem to only increase. Some risk and quality managers, recognizing seemingly insurmountable barriers and burdensome requirements imposed by regulatory bodies may think about getting off the bus. That may be the right decision in some cases, but deciding to stay can yield great rewards and a sense of meaningful accomplishment.

Historically, quality management efforts in healthcare services have not been as successful in reducing error and achieving standardization in processes as in other industries. Initiatives facilitated by the Institute for Healthcare Improvement and others have helped many organizations improve quality of patient care and turn obstacles into opportunities. Additionally, the demands imposed by pay-for-performance mandates have pushed initiatives that positively impact consistent achievement of favorable outcomes for the patient. Perhaps out of impending economic necessity and a heightened focus on the tie between improved quality and risk reduction, quality and risk leaders are becoming more collaborative and skilled at identifying, understanding, and managing the interrelated processes that link quality and risk management. Their partnership and dedication to shared goals contribute to the organization’s effectiveness and efficiency and promote patient safety.

Preventing risk and reducing the frequency and severity of adverse events have long been recognized as necessary components of risk management programs, but the time for proactive, patient safety endeavors is scarce for risk managers in many organizations. As budget cuts drive the decision to eliminate FTE’s, risk management is one department targeted in some organizations. The demand to do more with less forces risk management leaders to juggle many competing priorities. Stresses associated with handling everything from lost dentures to loss of life and subsequent exposure to liability require a steady hand on the wheel to effectively navigate the challenge of patient expectations. Interactions with patients, families, care providers, insurance carriers, and legal counsel are part of the terrain. The desire to proactively address patient safety can go unmet in many organizations because of time constraints and demands of reactive risk management activities and regulatory requirements.

On this road leading to patient safety, although fraught with obstacles, one signpost flashes a clear message: Patient safety is everyone’s responsibility and requires a team effort. Risk management and quality management must work together for the cause of patient safety.

Overcome Silos
In some organizations team efforts between risk management and quality management have been weak, not producing substantial winning outcomes. Stories shared by risk and quality managers across the nation reveal one of the most predominant barriers to progress in patient safety can be territorial perspectives that create division between departments rather than cohesion. Political enmity between risk management and quality management can truly impede improvements in patient safety as revealed by historical perspective in some organizations. Siloed departments and isolated approaches toward patient safety are counterproductive.

Increased awareness of the need for better integration between risk and quality management is paving the way for more effective and collaborative strategies in addressing patient safety. In many organizations, risk and quality managers are learning to collaborate and share information more fully with a new appreciation and respect for their collective expertise. Emerson had it right when he said, “There is no limit to what can be accomplished if it doesn’t matter who gets the credit.” Risk and quality managers must take this to heart to overcome any potential non-collaborative undercurrents or hidden agendas, remaining mutually committed to the shared goal of advancing toward more reliable, safe patient care.

Overcome the Odds
Risk management and quality management leaders have known for many years that something has to be done to positively impact patient safety. The obstacles seem more foreboding now than ever as the economic pressures and regulatory impositions negatively affect revenue. Time constraints, ever changing quality indicator requirements, compliance and regulatory reporting requirements, and ongoing interactions with patients and providers over a myriad of issues stretch each risk and quality management team member to the breaking point. Some will get off the bus; some will drive on. When the obstacles and opponents seem insurmountable, remember the words USA Olympic Coach Herb Brooks delivered prior to the final game in 1980 at Lake Placid. Despite the odds they faced, he charged his team to play for something larger than themselves, saying, “This is your time.”

This indeed is a special time in healthcare history and for risk management. Patient safety is something much larger than any individual or any one department. Seize the opportunity to mitigate risk and achieve better outcomes for patients. Claim victory in eliminating adverse events that lead to patient harm. Adversity makes a team work together to overcome, survive, and bond for a common cause. Perhaps adversity in healthcare of the past did not rise to the degree of the present. Most certainly now though, those positioned in risk management and quality management must partner their expertise and effort to maximize performance, efficiency, and team work. Now is the time for patient safety. Now is your time.

Brooks, H. The underdog, Pregame speeches, Available at http://pregamespeeches.com/theUnderdog.aspx

Ralph Waldo Emerson quotes available at http://thinkexist.com/quotation/there-is-no-limit-to-what-can-be-accomplished-if/406865.html

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Nurses as Frontline Risk Managers

The growing number of patient deaths caused by preventable medical errors has reached crisis proportions. The National Patient Safety Foundation and others attribute this crisis to a failure to overcome systems problems, exacerbated by the growing complexity of our healthcare system.

Nurses do as much as they can to protect patients in individual situations, but rarely do they have the power to change the systems that influence outcomes. Managers, faced with growing financial constraints, have also been unable to stem the tide of preventable medical errors. Should we throw up our arms in despair? No! Positioning nurses to function differently, as frontline risk managers, can improve patient safety.

Nurses—as frontline care providers—are ideally positioned to act as risk managers because they notice safety problems early. But their effectiveness depends on whether they are given the tools, time and respect to do that job.

Researchers at Harvard have reported, “We did not observe any instances where the nurse contacted someone about a trivial or insignificant exception. In fact, we observed several occasions where we were surprised that the nurse did not raise awareness around a problem that we felt could have serious consequences. (Tucker et al., 2002)”

Their recommendations include the following:

  • Root cause removal must be an explicit part of a nurse’s job. Enough time must be allocated for them to resolve the problem.
  • Nurses need frequent opportunities for communication about frontline problems with individuals who are responsible for supplying then with materials or information.
  • When a nurse identifies a problem, managers must pay immediate attention to it. Often the best that the nurse can do is to merely raise the issue, but too often this nurse runs the risk of being considered a complainer.


Build a Culture that Supports Patient Safety
We need cultures that sustain frontline safety efforts. Ideas for change are:

1. Build respect for nurses functioning as frontline risk managers.
The Harvard study indicated that nurses have a lower status compared to managers and physicians. This status difference reduces nurse credibility and results in the loss of essential safety information.

What can we do? Respect nurses as valuable healthcare professionals. Delegate authority for nurses to make decisions at the point of care; then support those decisions. Nurses can prevent medical errors if they are empowered to respond quickly and decisively to patient needs. Insist on courteous communication and collaboration between healthcare professionals and a level playing field where every healthcare worker is equally valued.

Disruptive behavior wastes valuable time that nurses can better use for patient care. The Joint Commission (2008) made a strong case for change in its Sentinel Event Alert #40, “Behaviors that Undermine a Culture of Safety.” These changes must occur on the frontlines if we expect to see improvements in patient safety.

2. Allow for the intelligent use of tools.

A number of tools such as SBAR (situation, background, assessment, and recommendation) and critical paths have evolved, but they are only as effective as their organizational cultures will allow. Organizations list various tools as a way to document their commitment to patient safety, but even good tools are rendered ineffective when practiced in a negative culture.

3. Provide time for quality patient care.
Nurses need time to maintain safety standards exactly as intended. It only takes a few extra seconds for nurses to “do it right the first time,” but those few extra seconds result in extraordinary patient outcomes. It takes time to recheck patient conditions thoroughly and often, and it takes time to solve the root causes of problems.

Calculate the value of using nurses as frontline risk managers. Adopt the elements of positive cultures. Recognize nurses as key contributors to patient safety. These changes will enable you to write a new list of commitments to patient safety, one that will affect every patient and every staff member on the frontline of health care organizations. Only then will our patient safety record begin to improve.

Fabre, J, (2008). Smart nursing: Nurse retention and patient safety improvement strategies, 2nd edition. New York: Springer.

The Joint Commission. (2008, July 9). Sentinel Event Alert #40, Behaviors that undermine a culture of safety. Available at http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm

Tucker, A. L., Edmonson, A. C., & Spear, S. (2002). When problem solving prevents organizational learning. Journal of Organizational Change Management, 15(2), 135.

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Many birthing hospitals across the country have invested significant resources to ensure adequate security for newborn infants in the obstetrics department and children in the pediatric department. They are taking these steps to guard against abduction, by either a stranger or a family member.
Measures to prevent abduction typically include a written policy that lays out the hospital’s security provisions, staff training and awareness, and specialized security technology — called an infant protection system — to provide individual protection to each patient.

For the most part, infant protection remains the responsibility of either the obstetrics department or security, which have the most direct stake in managing this threat. Yet more and more hospitals are evolving a multidisciplinary team approach, recognizing that effective infant protection requires the active participation of a wide range of groups. Security and the obstetrics unit form the “core” of the infant protection team, but they should not be the only members. Risk management also has a critical role to play.

First and foremost, infant abduction is a risk that must be managed, just like any other. The likelihood of an occurrence is low — a typical year sees only a handful of cases, with just two abductions from hospitals in 2008, according to the Center for Missing and Exploited Children (NCMEC). However, the repercussions can be staggeringly high for both the family and the institution. The infant may suffer physically (and possibly mentally, although no longitudinal studies exist), and severe anguish is typical for the parents.

Staff members in the obstetrics department often feel guilty, as if they have failed to do their duty; high staff turnover may result. The hospital must contend with an instant nation-wide media storm, investigation by the Joint Commission and state regulators, the loss of reputation, and the potential for legal action against it on the part of the parents. For these reasons alone, the risk manager should be aware of the infant abduction threat, and know what steps have been taken to manage it.

A Unique Perspective
But beyond this, risk management should be actively engaged because good infant protection is in fact quite complicated, and goes well beyond just installing an electronic system. Risk management is well placed to coordinate the multi-departmental effort to embed infant protection into clinical practice and security procedures, because it brings a unique perspective to the issue. Its specific expertise is in assessing risks and putting in place appropriate measures to counter them. It can therefore help answer the tricky question, “Are we doing enough?”

Risk management also is familiar with continual assessment of current practice. It is human nature to fall into an accepted routine without thinking too much about it; in fact, we need routines to get things done efficiently. But it is risk management’s special task to make sure that routines don’t just become a matter of habit and that they rest squarely on regularly reviewed best practices.

Where to Start
So how should risk management get involved in infant protection? Start with the basics. Learn about infant abduction (the NCMEC has many useful resources), and infant protection technology: how systems works, what regular maintenance and updates are required, etc. Then make contact with obstetrics, security, and any other users of the system to learn about the institution’s current practice. From there, it is possible to start building the framework for a facility-wide infant protection procedure that is sound and meets community expectations.