Drawing the line


Drawing the line

Where does risk end and quality begin? As a chief quality officer who is also a licensed risk manager, Lynda Dilts-Benson is well placed to comment. She gave HRMR her perspective.

No two healthcare organizations are alike and throughout the US there are almost as many different ways of dividing up the risk management/quality management responsibilities as there are healthcare providers. In many cases, especially in smaller organizations, one individual takes on both roles; in others, the roles are clearly divided.

At Florida-based Access Health Care, chief quality officer Lynda Dilts-Benson is responsible for issues such as responding to member concerns and ensuring that the care and treatment provided to members is based on accepted evidenced-based medical principles, standards, and practices. She also happens to be a licensed healthcare risk manager, but corporate issues, audits, reinsurance, malpractice and other legal issues are dealt with by an outside company, or companies, one of which is MagMutual.

“We do have another risk manager within the company,” she adds. “In some organizations the corporate side of risk management is certainly part of the risk manager job description, but in this company it is not part of what the internal position does—we are more physician, office practice, customer service and patient-driven.”

Prior to April this year the responsibilities for compliance, quality and risk were all rolled together and it fell to Dilts-Benson to help define the new, separate roles.

“We pulled the compliance aspects and duties out from quality as they really should have been from the beginning. When you talk about risk you have to further define what risk: are we talking about insurance risk, patient care and patient safety risk, and/or documentation, coding and billing, malpractice, financial, contractual risks—what risk are you talking about?

“From my experience with this company the coding, billing, documentation, patient safety, and quality measures all carry with them a large amount of risk which I look at as being totally separate from your corporate risks which lie in insurance, reinsurance and malpractice—to me they’re completely different entities.”

From the beginning, Dilts-Benson’s involvement has been with the clinical documentation, coding, patient safety, customer service and quality measures rather than corporate risk. The need to define these roles within the organization has coincided with some major changes to the organization itself.

“We went from a ‘mom and pop’ multi-specialty group practice to an MSO (management services organization) and then we went from that to participation in an ACO (accountable care organization)—there are so many different entities all having their own similar but different aspects of financial and clinical risk.
“All the risks and all the things you have to do are basically the same but the question is, who do you do them for and how do you now provide the oversight, guidance, and direction for so many providers in so many different medical models throughout the entire state?”

Even within Dilts-Benson’s job the roles are shifting. Compliance has just been split so that regulatory compliance has its own department under the chief compliance officer, and quality has become its own department under Dilts-Benson. The issue of risk permeates everything.

“Both roles deal with risk: one deals with identifying it, the other deals with studying it, changing processes, making things work and then re-auditing. You’re setting up that whole quality improvement cycle where you identify an area of risk, you do a corrective action plan, you do your training and due diligence to see if you can change that process or improve that process and then you audit again,” she says.

“Although we split the department into those two different areas in order to better handle that cycle, they work very closely to make sure that the whole cycle happens. Both departments are critical to the smooth and compliant operation of any large corporate entity, but especially, those entities that are involved in medicine.” It is the model that has proved to be most successful for high-powered corporations over time.

Having taken on the role of chief quality officer, Dilts-Benson has found no shortage of ways in which the quality of care could be improved. She has made it a priority to ensure her organization is meeting all 33 quality measures required of ACOs—meeting the ACO standards automatically allows them to meet the Medicare PQRS (Physician Quality Measure System) measures, in addition to making sure that the providers who manage Medicare Advantage patients meet all of the quality measures covered in the Five Star initiative from CMS—all of this while also taking the time to create trusting relationships with patients so as to engage them more in their own decisions and health outcomes.

“There are many facets to this whole approach but the biggest reward—emotionally and psychologically for both the caregiver and the patient—comes from engaging them in their own healthcare. It’s got to become a partnership, and that’s the biggest challenge.”

Another major challenge is physician education—specifically, getting them to understand what you expect from them and giving them the tools to meet those expectations.

“When it comes to things like quality measures, it’s all about data, it’s all about quantifying what they actually do in their offices so that it can be validated somehow,” she says.

Dilts-Benson may not be her organization’s risk manager but an understanding of risk permeates much of what she does.

“Because of my risk management training I understand how to recognize an area where we’re at risk and how to use tools like the root cause analyses. All these things help me to create the necessary tools for the doctors, they help me to teach the doctors, they help me to understand the issues and try to come up with an action plan that is actionable.”

Dilts-Benson says her risk management training has been a valuable stepping stone but the real secret is to learn how to put the tools you have been given into operation. In her case this has included creating everything from incident reports to the You Matter hotline, an 800 number that patients, vendors and employees can call anonymously if they’ve got an issue.

“You can read all the books you want but if you can’t take what you read and turn it into a functional program then you really haven’t got anything out of it,” she says. “The risk management training was a fabulous course and it broadened my way of looking at things—I had never been aware of the corporate side, the side that’s being taken care of by Mag Mutual and other entities. Now I know that aspect of the business and I’m very happy I’m not handling it!” 

risk management, Dilts-Benson, ACO, You Matter hotline, risk