Exciting times

An expert in claims management for self-insured programs, Kara Knowles is enjoying supporting risk managers through a period of exhilarating change, not only through her day job but also as president of the Colorado Society for Healthcare Risk Management, as she tells HRMR.

During her years in the profession, Kara Knowles, president of the Colorado Society for Healthcare Risk Management (CHARM), has seen risk management face a diverse range of new challenges, from the struggle to access adequate resources to the changes in the risk manager’s role:

“Over the last few years, risk managers have experienced an expansion of their duties,” she says. “The role may also include compliance or privacy, which is an exploding area, plus management of contracts or additional insurance products.

“Another aspect of the expansion has been the inclusion of physicians as employed providers. Traditionally, the risk management efforts of the physicians have not been part of the hospital, but as hospitals are employing more physicians, risk managers have had to take on those roles as well.”

As an executive with Western Litigation, Knowles has to help clients deal with these kinds of challenges on a regular basis. From claims management to trending analysis, and from training to risk assessments, Knowles and her team set out to provide a depth of support to risk managers.

“We don’t replace the role of the risk manager but we augment what they do and provide additional services to them,” she says.

Diverse clients

Knowles started her career as a practicing attorney, first in Chicago then in Denver, where she focused on defending medical malpractice litigation. Then, in 2009 she moved over to Western Litigation.

“The primary driver for the change was to become more proactive: litigation is  adversarial and reactionary and I really wanted an opportunity to get ahead of things, to help educate, and to help hospitals institute best practices. The goal is to avoid litigation.”

Her clients range from standalone hospitals through to multi-hospital systems. “Our level of engagement can vary depending on the sophistication or size of the organisation, but really we are there for anybody that might need extra help.”

An area of special interest for Knowles is early intervention, which requires managing the lawyers—both the plaintiffs’ and the defense lawyers. “It often strikes me that when there’s a bad outcome, the risk manager and the patient could work towards an early resolution, but once you inject lawyers into that situation it makes early resolution and even disclosure much more difficult,” she says.

She is seeing more risk managers getting involved at the earliest stages in order to prevent a claim from escalating to mediation or legal action. Here, the general move in healthcare towards transparency and disclosure really demonstrates its worth.

“We’re seeing more informal disclosure conversations where the risk manager is sitting down with the patient or the family and talking about what their needs are, what they’re looking for and really trying to start a conversation even before mediation,” she says.

The role of CHARM

In terms of sharing good practice, Knowles sees CHARM membership as vital. Its regular meetings give risk managers the chance to network and learn from each other. An awareness of how lonely the risk manager’s job can be has driven CHARM’s board to initiate a special rural outreach program this year.

“The networking is really important. Risk management can be a single department so you may feel as though you’re reinventing the wheel every time a new issue comes up. CHARM provides an immediate network of folks who might be dealing with the same issues, or you can bounce ideas off them and provide additional resources.

“A lot of our hospitals are in rural areas where the risk managers may feel they don’t have a network. They may also lack the resources to institute risk initiatives. We are hoping to do a better job of outreach to those people, for example through webinar education.”

In line with risk managers all over the US, one of the top subjects of concern to CHARM’s members is behavioural health and how to keep patients with psychiatric problems safe while addressing their other medical needs.

“That is certainly one of the top challenges for both our CHARM members and Western Litigation’s clients: how do you treat a patient’s complex medical problems in conjunction with psychiatric conditions? And how do you find a long-term solution for these people?

“The first piece of advice I would give is that we need to take every step we can to keep those patients safe—we need to ask ourselves whether we are taking the right steps in evaluating someone in terms of potential harm to themselves and others. 

“It’s important to put them into a room or a location that best addresses safety, and it’s also important to not forget the medical treatment of those patients: the psychiatric piece can be overwhelming and make treatment difficult.” 

Decreased reimbursement

Compounding the problem is a decrease in reimbursement rates, which can translate into decreased staffing levels, a decreased security presence, and an inability to upgrade equipment—all of which can have an impact on risk and patient safety. 

“If you don’t have optimal staffing then there may not be many people to keep eyes on the patient in terms of fall risks, or people may step in, feel rushed, and not take the double checks in terms of medication administration. This is the new reality and there certainly is a risk impact.”

Knowles has also observed healthcare reform impacting on risk management through the shift to electronic medical records (EMRs). She sees this as a double-edged sword: the positive side is that it provides continuity of care, or can provide the patient with a portal for access to their healthcare information.

“The area where we’re seeing challenges in risk, and certainly litigation, is the documentation,” she says. “There’s a lot more box-checking as opposed to the traditional physician narrative, so the quality of documentation has gone down. Also, there can sometimes be competing documentation—clicking this box as opposed to that box, so we’re seeing some challenges in terms of having to defend cases based on the EMRs.”

Demonstrating value

Against this backdrop of change, Knowles believes risk managers are challenged to demonstrate their value to senior leadership: “Risk management is not a revenue department, so the question is: how do you prove a return on a risk initiative? What does the CEO look for from risk and how can you advocate for yourself?” 

One very productive development in risk management and patient safety, in Knowles’ opinion, is the inclusion of the patient as a member of the care team.

“This is something we’re starting to see and I think it’s really exciting: get the patient and/or the family involved as a member of the team because they know that patient the best. They’re the ones who are in the room 24/7 so they can be additional eyes on the patient. 

“Treating the patient and their family really as an equal—as part of the care team—is going to do great things for patient safety.”

This comes at a time when risk managers are starting to see patient safety integration throughout the facility as part of enterprise risk management (ERM). 

“These days you might see banners that say, ‘I’m responsible for safety too’, making it clear that every staff member has an obligation to think about patient safety and improving patient safety,” she says. Responsibility for risk is certainly being shared out—and Knowles believes this has the potential to reap huge dividends in terms of decreased incidents and declining litigation.

Meanwhile, the risk management workforce is in a state of flux. This, too, is an exciting prospect:

“Hospital risk managers are somewhat of an ageing workforce so we’re now seeing some turnover, with retirements, and a lot of new people getting into risk management who perhaps don’t have a strong risk management background. 

“They might, for example, be clinicians who are interested in risk management. I enjoy helping to mentor them and watching their engagement and excitement around risk management and patient safety.”