A time to embrace change

Mary Anne Hilliard is the chief risk counsel and vice-president of safety & patient experience at the Children’s National Medical Center in Washington DC. She discusses with HRMR the challenges facing her profession and how she is tackling some of them.

Risk managers in America at the moment are operating against a backdrop of what, thanks to the Patient Protection and Affordable Care Act (PPACA), must be the greatest systemic change the healthcare system in America has ever experienced.

And at the sharp end of the healthcare industry’s rapid pace of change are risk managers themselves. They have never before had to tackle such fundamental reforms and in a manner that will change the very way in which they must work and the roles they hold within their wider organizations.

Mary Anne Hilliard is a progressive risk manager. She wants to encourage risk managers to embrace change and to positively influence achievement of goals that are universally accepted, such as safe and trusted care.

When asked about the future for risk management, she said she sees risk managers moving from fulfilling important but distinct roles within organizations to playing a much more central role: from risk management to enterprise risk management (ERM).

The move from a more defensive model to evidence-based healthcare that establishes and then follows pathways of best practice across the board, will mean this will become a necessity. Risk managers will become more important within organizations and they will need the understanding and the skills to make their presence count.

Hilliard is a big supporter of more specific risk management goals, including the goal adopted by many risk management bodies of virtually eliminating serious injuries in healthcare facilities in the future. ‘Getting to Zero: Eliminating Serious Safety Events’ is a patient safety and healthcare risk management program that aims at driving down incidence of preventable serious safety events in healthcare organizations.

Hilliard says this goal is personal to her and many of her colleagues; perhaps a natural consequence of spending a career immersed in studying and learning about patient harm. She believes emphatically that the journey to zero is a realistic target.

Here, Hilliard discusses what she sees as the biggest challenges facing her profession.

What will be the impact of Obamacare on your profession?

It has huge implications for risk management and for all parts of healthcare. It has particular importance for risk management as it relates to the nature and character of the risks we are asked to identify and prevent.
For example, we are meant to be making the transition from a kind of ‘all you can eat’ healthcare system (volume-based) to one that is more evidence-based and less wasteful (value-based). But that brings challenges. Today, there are challenges with too much care, sometimes referred to as ‘defensive medicine’. That causes waste and exposes patients to unnecessary risk. In a value-based system, the risks may involve undertreating a patient or otherwise failing to offer the care needed as providers learn more about determining what is and isn’t necessary care.

Until now, America had been notorious for practising defensive medicine. This changes all that. We now have a new kind of risk as a result of something not being treated fully, or if there has been a delay in diagnosing something. These are the risks of the future.

Risk managers will have to deal with immediate changes in the way we deliver care and work out whether treatment ends up being based on hard evidence or on money.

What do you encourage risk managers to do?

We believe that people are appreciating and embracing true evidence-based medicine. The standardization of best care will deliver better results for less money. We believe we must all follow this pathway and if we deviate from it, we need to justify that.

Over time, it will reduce risk, save money and give better care to the patient. There is a guarded hope in the industry that this approach will ultimately deliver all the things it’s supposed to deliver.

The risk is that some institutions, instead of following the evidence-based route, just look to cut costs. If they did 500 MRI scans one year, they will look to do 200 the next. That’s a crude cut. It’s not based on the standardization of best practise but just on saving money, and someone’s going to get hurt.

With these challenges, you can see the nature of the risk manager’s job changing. We have to be able to understand and influence our companies so that they offer care in a manner consistent with the intent of the new laws.

What do you see your peers doing to adjust to the changes?

They are doing many things. Our education platform has been modified to accommodate learning topics such as the law, what it means and how to interpret it. It also reflects how we see the changes we anticipate happening in practice. For example, you will see more focus on ambulatory care and risk in this field. The nature of risk is changing and education reflects this.

Another example is where organizations are managing patients through their healthcare journey, there’s going to be more focus on prevention and treatment outside hospitals: in people’s homes and in outpatient settings. That means the risk will shift and we are going to have to learn to manage that risk.

But the most significant change is a renewed focus on ERM. Because of the way healthcare reform is challenging communities to consolidate and work together, I believe the competence of risk management should become a more hard-wired part of the way that hospitals and health systems make decisions generally.

How will you achieve the goal of virtually

eliminating serious injuries?
The virtual elimination of serious safety events is achievable, but only with proper focus and commitment. There is not a silver bullet or simple solution. I’ve observed that the hospitals that best eliminate serious injuries are those that have a comprehensive approach to safety and which measure all adverse events, not just those events that fall in a mandatory reporting category.

It has to be a combination of a tactical focus, targeting specific things like hospital-acquired conditions, complemented by a cultural focus on safety that is instilled in the workforce. It comes down to how you train the workforce—there are some really powerful techniques to help drive down the rate of serious safety events.

For example, a nurse who is empowered and taught to question things can make the difference between a good and a bad outcome. Doctors should create an environment where it’s safe to report and providers should routinely do peer checks and peer coaching.

You want people who validate and verify and you want skeptics in the organization who are always looking for something that might go wrong. Just as the police can really drive down crime with the support of the community, the same thing is true in a healthcare setting: an empowered workforce can drive these events down.

Finally, we need to spend more time looking at what I would call adverse event data—we should track this and learn from it. If you look at all the serious events and serious injuries caused in a hospital, many are not easily categorized. But unless you look at them, you’re not measuring the total safety of the organization.
The best hospitals have found if you want to virtually eliminate serious safety events you’ve got to be cultural, tactical and share learning about adverse events—all those things have to be part of your equation.

Why are you passionate about this goal?

Seeing the reality of these incidents close up it can be frustrating to realise that we are focusing only on a small category of those types of injuries. For example, in pediatrics one of the real drivers of injury, according to the PIAA (Physician Insurers Association of America), is a failure or delay in the correct diagnosis because you were sent the wrong information.

These events are generally not recorded as a hospital-acquired condition and in many states you don’t even have to report them. But I would like to see a more authentic measurement of harm and a more comprehensive focus on the different ways that patients get harmed in hospitals and other healthcare settings.

What are the other hot topics in healthcare risk management?

The focus on managing risk in the ambulatory setting is a hot topic as is driving down serious safety events. ERM is a hot topic while I’m personally interested in workforce wellness as part of a strategy.
Another big one is the challenge of integrating physicians into the healthcare system. The old model of physicians being separate from the hospital is beginning to change. There is greater appreciation for the power of teamwork in the context of offering safe care. That’s a hot topic in the insurance industries too.
Are you seeing an increase in insurance companies appointing healthcare risk managers?

Yes. In fact, I’m seeing a lot of positive improvements and leadership on the part of the insurance industry. They are more engaged in the safety movement. For example, there are more companies offering discounts on the premium if a health system meets certain standards in their patient safety intervention program.

Another very progressive version of this is instead of giving you a discount when you take the coverage—which may be just a negotiating tool—they actually give you money back if you’ve accomplished certain goals over that year.

It rewards improvements and it’s fabulous for a risk manager to be able to say to the board of directors that if the organization achieves a certain goal you get, say, $100,000 back from the insurance company. It tightens that relationship with the insurance company, creates incentives for improvement and leverages the risk manager’s ability to be persuasive in advancing safety as a priority. It’s a powerful concept for driving down risk.

What will be the main challenges in healthcare risk management over the coming years?

Keeping pace with change and keeping healthcare organizations informed and empowered to meet the needs of the future. It’s a little hard to know about the future but there are some things about the future that are more likely to happen than others. We should focus on those.

For example, the standardization of care is likely to happen—the use of pathways and the better standard of care. Risk managers should focus on that. But let’s move with caution. Let’s focus on what is likely to happen and make sure people are moving forward but moving with caution. We want to test ideas in small ways before we take them out in big ways. Still, we want to encourage new thinking and research.

And let’s focus on developing risk managers in ways that we think will empower them and offer them the skills they need to support their own environment where change is happening at a fast pace because there will be more choice. You could have similar captive activity domestically to that in Bermuda or Cayman.
And let’s focus on developing risk managers in ways that will empower them and offer them the skill sets they need to support their own environment where change is happening at a fast pace.