Driving change

After years working in hospital-based quality, safety and risk management, Laurel Kleinsorge moved into the field of home health. She tells HRMR what she learned from the new role—and why using outcomes to drive future change is the way forward for risk managers.

Before taking on the role of quality manager for Centura Health at Home, Laurel Kleinsorge worked as a patient safety manager for St. Anthony Hospital and OrthoColorado Hospital in the Denver Metro area. In her present role, as in her previous job, she is also responsible for risk management.

While she has stayed within the same health system, her move from a hospital to a home health setting brought plenty of new challenges—but this was part of the appeal.

“I was looking for something possibly in the same system that would enable me to make use of my acute hospital and ambulatory experience in a different way, so when this opportunity in home health arose I was really interested in it,” she says.

A challenge that became evident as soon as she started the job was the need to create seamless care for the patients. “That’s the real challenge for the home health agencies,” she says. “It can make it difficult to maintain quality, because many adverse events have their root causes in transitions of care. If you’re going between systems, between hospitals, and/or between levels of care, there are so many things that can go wrong. If you’ve worked on the other side of the continuum it helps you a lot.”

She also discovered that it was harder to determine compliance, because many of The Joint Commission’s monitoring tools are designed for clinics or hospitals, not home health or hospice settings.

In order to address this issue and prepare for Joint Commission surveys, she and her fellow quality manager decided to emphasize compliance as part of the performance improvement process. The aim was to get staff to gain their own understanding of which regulations they did (and did not) comply with and what changes had to be made.

“It gave them a sense of ownership of the plan of correction,” she says. “We also have performance improvement projects just like you do in other settings, but the topics may be different—for example, we had a huge project that we wrapped up last year on driver safety.

“Other topics are very similar to those faced across the healthcare continuum—violence, for example. In home health it’s about getting the nurses and staff to recognize when a home is not safe, in which case they are instructed to leave the home immediately, and to close the case if safety issues are not promptly resolved so that home visits are possible.”

In the home health environment, it can be difficult to get staff to see the value of performance improvement, if patient outcomes cannot be readily obtained and promptly presented back to staff for discussion and improvement plans. Also, a higher staff turnover rate and lower pay scale compared to many acute settings can make it a challenge to keep all positions filled, and all staff oriented to current policies and procedures.

Near-misses

A parallel challenge is getting staff to see the value of reporting near-misses. This is a problem Kleinsorge has also encountered in the hospital setting.
“It seems that in every kind of patient safety/risk position I’ve been in, I’ve had to start by addressing that issue,” she says. “You walk in there and the mindset is that unless there was an adverse event you don’t need to report it because no-one got hurt.

“You have to increase the reporting of both actual and near-miss events in order to see patterns. Staff need to understand this fact, and they need to understand administration’s non-punitive approach to reporting—reporting is their job and will not be met with punishment or some kind of retribution.

“That’s how I plan to make a difference,” she adds. “If you’re collecting data, more data isn’t always better, but getting the right indicators, a few of the most sensitive indicators for a given setting, and then using that to push change—that’s the challenge for all these big systems that are undergoing huge structural changes.”

She is helped in her mission by her fellow quality manager, with whom she has collaborated to create plans, set goals and formulate tools to assist directors in the system’s home health agencies and hospices.

“Teaming with another quality manager is one of the things I’ve enjoyed most about this role,” she says. “So often the role of risk manager tends to be a ‘Lone Ranger’ sort of job. You don’t always have the opportunity to try the team approach.”

 Asked what she has learned during the course of her career, in which she has worked as an independent consultant/expert witness in risk management, patient safety, and quality care; as a quality improvement director for VHA Mountain States; and as a senior consultant for Healthgrades and Quantros, she says she has discovered that it is important to build from the top down and from the ground up.

“That means you’ve got to be able to create ownership at the staff level and create tools for them to collect information for the needed change. Then you need to build from the top down by making sure your senior leaders are educated about what you’re doing in quality and putting that in the form of strategic initiatives that are linked to specific outcomes. You need to be able to deal directly with the senior leaders involved and create a partnership with at least one person on the next level up.”

Another key lesson is that attorneys are risk-averse, and that their priorities may sometimes clash with the need to be transparent, and to use lessons learned from adverse events to drive change.

“A lot of risk management departments may report to a lawyer or attorney and not to an administrator. That makes a big difference because the job of an attorney is to protect the organization at all costs, so there’s always this discussion about how transparent you want to be.

“Not saying anything about an adverse event is always a good initial approach until all facts are investigated and known, and a course of action determined. However, to promote a culture of safety you have to have transparency—at some point you’ve got to be able to say, ‘We made a mistake and we’re going to correct it’. An attorney’s legal perspective might be ‘don’t admit to anything, don’t say anything’, and to remain silent in the long run to avoid any liability.”

She says that the hospital’s decision-making teams need to be balanced between the legal perspective and maybe more of an organizational patient safety perspective.

“That’s essential because unless it’s balanced you’re going to miss some huge opportunities for performance improvement and the building of trust between staff, administration, patients/families, and the community. Not only that, when you’re transparent and you apologise, you avoid a lot of litigation.”

Hospice care

During years of driving change in healthcare, one of Kleinsorge’s most satisfying achievements has been working with hospice services to help them optimise their services while meeting regulatory requirements. The hospice setting is markedly different from the rest of healthcare in that patients are not expected to get better. However, this does not mean that there is any less room for risk management.

“Being able to work with hospice services to help them adapt their guidelines for reporting infections and outcomes back in an appropriate way was very rewarding,” she says. “We helped them identify realistic outcomes and get back to tracking them.”

As she looks forward to future challenges in her career, Kleinsorge has one thing on her wish list: a user-friendly integrated electronic medical record and occurrence reporting system.

“Right now in home health we have an electronic medical record system, but reporting features make it difficult for regulatory reporting and for monitoring outcomes across settings or episodes of care.

“We have no electronic occurrence reporting system oriented to home care and hospice—if we did, we could more easily aggregate data and feed back results promptly to staff for performance improvement.”

In the meantime, she will continue to work to improve the quality and safety of care provided within her system in whatever way she can.

“The appeal of the career is the potential for saving lives and impacting care, and the chance to coach the staff to make the right decisions,” she says.

“You may be an expert in everything but it doesn’t do any good if you can’t pass that skillset on to select leaders and frontline staff.”

Since being interviewed for HRMR, Kleinsorge has left Centura Health at Home, and plans to continue with independent consulting in quality, patient safety, and/or risk management. For questions or comments, she can be contacted at: ldkleinsorge@gmail.com