Many of the current changes to healthcare will have a direct impact on the work of healthcare risk managers. HRMR asked Barbara Youngberg, a risk expert for insurance and risk management brokerage Beecher Carlson, which issues are preoccupying her clients.
For Barbara Youngberg, the effects of the Affordable Care Act (ACA) are evident on a daily basis. A particularly strong theme among her clients is the need to take a broader view of the care provided to patients, ensuring consistency and seamless transitions as they move through the system.
“The models of care delivery under the ACA are quite foreign compared with how we are used to doing things, certainly in the larger hospitals. As a result, coordinating care and managing patients across the continuum rather than just in each episode of care is a real challenge,” she says.
This challenge is compounded by the need to embrace electronic health records (EHRs) and make those records available to other providers on the care team while protecting patient privacy.
“My biggest advice to risk managers is that this issue is beyond the scope of a risk manager’s own expertise,” she advises. “They need to have a team—including the compliance officer, a privacy and security officer, their general counsel and a lawyer—to look at how they’re establishing access to a medical record.
“There should be very clear guidelines on who can access records and, if anyone goes into EHRs without the access rights, there needs to be the expectation of termination. The problem is complex and requires a team approach, but a trend throughout hospitals is that every department thinks they can tackle the problem autonomously. Many problems are more enterprise-oriented and require the skillset of many people beyond the risk manager.”
Her comments reveal a lot about Beecher Carlson’s customised approach to risk consulting, which recognises that in healthcare, one size most certainly does not fit all, and many issues are best addressed by involving multiple departments.
“Often risk management consultants take a very traditional approach and focus on a single clinical service or risk without looking at either the root causes giving rise to the risk or the impact on all aspects of the organization,” says Youngberg. “The buzz words in risk management today are ‘enterprise risk management’ but many still focus on isolated risks in an organization.”
“We start from the position that every client is unique. We often build very specific risk management support services into each client’s proposal after learning about their business and environment, as well as determining their specific vulnerabilities in our initial client meeting,” she says.
Youngberg’s focus is academic medical centers, just one of the distinct practice areas within Beecher Carlson’s healthcare practice. She has notched up 25 years as a vice president of risk, quality and safety in that field. She has experience as a nurse, as well as a law degree and a master’s degree in social work.
“Each practice area includes staff with many years of experience with these specific types of business entities and with solid reputations among their industry peers,” she says. “Of course, we also work in teams across our organization to bring in the needed expertise so that as healthcare entities evolve to accommodate changes in the market, it’s possible to think holistically about how emerging risks impact the entire enterprise.
“In the 25 years that I have been doing this work, I have realized that healthcare organizations often know what their problems are, so they may not need assessment type services. Often, they don’t know how to fix them, so they do need specific tools, policies or best practice examples and how to operationalize them,” she adds.
An emerging risk that many of Youngberg’s clients are asking about is the need to encourage patients to play a part in their care. Providers run into problems when patients either are unwilling to follow medical advice or become disruptive.
“This is something I get calls about on a weekly basis,” she says. “The question is: now that you have to be responsible for patient outcomes, how do you get patients to want to be partners in their care? What do you do about disruptive patients who don’t agree with the plan of care and don’t follow it? Or patients who can’t afford to follow it because they can’t afford their meds?
“How do you, as a provider, create a contract with patients to make sure they are doing the things you need them to do in order for them to get better?”
Dealing with violence
Youngberg has observed a rise in aggression and disruptive behavior from patients, and is able to advise clients on how to navigate the situation without facing legal repercussions. “Clients want to know, how do you create an agreement between a patient and a provider, and how do you terminate care without being charged legally with abandoning a patient?” she says.
“First, you need to make sure the patient doesn’t have a clinical problem that is causing them to be disruptive. That can be a psychiatric problem or they could have a head injury—there are a lot of possible reasons.
“Once you’re clear that there is no clinical problem giving rise to that behavior, you need to set very clear expectations with consequences for the patient. Someone should be appointed within the organization, such as a primary care provider or a nurse manager, who manages that patient’s care, can advise people on the conditions for that patient’s care and then help draft these agreements so that patient also knows the situation.”
She says it is essential for providers to be very clear about what behaviors they will not tolerate and about the consequences for those behaviors. While the process has to be handled properly to avoid allegations of abandonment, providers can legitimately terminate care if patients are either going to be threatening to your staff or are not going to achieve the outcomes you’ve set for them. However, Youngberg notes, many providers are reluctant to take this step.
“Not dealing with this problem has a huge impact on the morale of staff,” she warns. “I’ve gone into emergency departments where nurses report being beaten or hit by patients and then are told that nothing can be done about it. There needs to be the message that you are there to protect patients, but you also need to be willing to step up and protect your staff.
“It sounds simple but you’d be surprised how many organizations allow their staff to be abused by aggressive and threatening patients—and that should never happen.”
From non-compliant patients to the challenge of embracing EHRs, it can pay to bring in a set of outside eyes to the problems that exist in a healthcare setting
“Over the years, I have seen a recurring problem in risk management. There is a lot of information available, such as articles, but hospitals don’t always know how to take that information and make it work for them,” says Youngberg. “At Beecher Carlson, we identify best practices and create solutions that work for each client.”
Contact: www.beechercarlson.com, tel.,800.657.0243.
Barbara Youngberg, Beecher Carlson, ACA, US