Getting to zero

Risk managers need practical tools to help them deal with the unexpected. Lee McMullin, president elect of SCAHRM, and senior risk management & patient safety specialist for the Cooperative of American Physicians gave his views to HRMR on the route to zero patient harm.

For risk managers, the past year has been characterised by the struggle to fully grasp and implement the changes brought about by the Affordable Care Act, and to gain control of the risk issues that may result from these changes. That is the view of Lee McMullin, senior risk management & patient safety specialist for the Cooperative of American Physicians (CAP) and vice president/president elect of the Southern California Association for Healthcare Risk Management (SCAHRM). In particular, the formation of Accountable Care Organizations (ACOs) is creating hurdles for risk managers.

“Everyone’s still struggling to get their brains around exactly how the ACO structure is going to work, and how the reimbursement mechanisms are going to work within the ACO systems,” he says.

As hospitals in many states move towards employing multi-specialty physicians, often buying up multi-specialty physician medical groups and incorporating them into their hospital system as direct employees, hospital risk management staff face the challenge of having to deal with risk issues that are peculiar to physician private medical practices where previously they dealt only with hospital risk management issues.

“A classic example of the type of issue they are faced with is patient termination,” McMullin says. “Hospitals don’t terminate care of patients while they are within their walls. In contrast, a physician medical practice may choose to terminate a relationship with a patient. It’s a simple yet clear demarcation point where you can see the differences between hospital risk management and physician practice risk management, and now hospital risk managers need to broaden and become involved with dealing with physician-based foundation medical group-style risk management activities.”

In his role with CAP McMullin provides risk management counsel and support services for CAP’s physician member practices. The support, which is office-based rather than field-based, covers aspects such as how to interact with a patient’s family members, how to interact with other members of the healthcare team, and elements to capture in the records with respect to the non-disclosure and apology when something goes wrong.

As numbers of CAP’s physician members begin a closer integration into a hospital setting, such as hospitalists (physicians whose primary professional focus is the general medical care of hospitalized patients), McMullin’s team has a solid understanding of the risk management issues associated with a hospital setting, as opposed to a physician’s office practice, to help them be successful in their roles  .

New challenges

There are other emerging challenges, particularly the change of emphasis towards preventive care, reduced readmissions and shorter hospital stays.

“Where patients used to come in for a few days then go home, they are now being treated on an outpatient basis,” says McMullin.

“Certainly the technology has improved to a certain degree in order to make this possible, but I am convinced that the ability to identify complications from a surgical event on an outpatient basis may be reduced: by sending somebody home you may miss the opportunity to identify and respond to an emerging complication not present at time of discharge, whereas in a hospital you have the time and the staff there available to do that.

“There is a big push to manage inpatient hospital days from a utilization standpoint, but there is also a secondary factor, which is that when they are in the hospital you try to discharge them at exactly the right time so that they don’t boomerang back to you in 24 hours—which would indicate that your discharge was probably premature.”

Timing is also of the essence when problems do occur. “The biggest challenge for CAP is getting its members to remember to call us at the right time—neither too soon nor too late,” he says.

“We have members who will call us from the operating theatre to tell us about something that just happened—in which case, we advise them first to get their patient to the other side of the door. At the other end of the scale, we’ll have members who call a month or two after the event.

“The golden moments of risk management are within the hours of the event unfolding—like the golden 24 hours of search and rescue. It’s the dynamic clinical care phase of that event when providers are writing notes on the record, and you’re interacting with the patient or their family members. The biggest challenge is getting our members to remember we are here and to call us when they have those moments.”

Meanwhile, he says, one of the biggest challenges for SCAHRM members is addressing the requirements of the HIPAA omnibus final rule. Also top of mind is the ongoing need to strive for zero patient harm—a quest that McMullin believes can be aided by learning from organizations such as NASA.

“As with space flight, healthcare involves lots of tools, lots of equipment and highly trained people and they all have to interact with each other and with the equipment that they are using in a flawless manner, over and over again, with the objective of not causing the patient harm.”

Dissecting an event

He believes there is room to improve the way risk managers go about doing that, especially the quality of the analytics that they use in the root cause analysis, and the skillset that goes into being able to carry one out.

“There is no national standard, for example, that says someone is qualified to dissect and reverse-engineer how a problem occurred. People do try diligently to work these things out, but at the end of that process you have lukewarm corrective action plans because the skillset going into analyzing why it happened could be more robust.”

The key to improving the situation, he says, is training backed by information. Here, too, an analogy can be made with other highly technical industries.

“Aircrafts have black boxes so that you are able to reconstruct what happened to understand what went wrong. We don’t have black boxes in healthcare, and until it is possible to look back at a complex situation and have a uniform method of getting that ‘black box’ type information, we are going to continue to miss the objective of zero patient harm.”

He says that SCHARM’s members are hungry for tools of the trade to help with this process and bring them closer to zero patient harm. SCHARM has responded by bringing in representatives from an engineering firm that is skilled in analyzing everything from the Deepwater Horizon well failure to space shuttle crashes.

“They show how to do a causation analysis from an engineering perspective—how to take the problem apart and find out why it broke and from that, figure out a corrective action plan that matches what your analysis and your analytics actually show.

“These sessions have been very well attended for two years and some hospitals sent their entire risk management teams to attend. It teaches them the tools of the trade, and everyone walked out of that eight-hour workshop able to go back to their institutions and put what they had learned into practice.

“It wasn’t a matter of passively listening to somebody talk; we were up there grafting and taking things apart, figuring why something was broken and figuring out what we need to do to keep that part from breaking again.”

McMullin believes that in order to be equipped for the future, this is what healthcare risk managers need more of: practical steps that they can put into action when problems arise. With this in mind, the next thing on SCAHRM’s training agenda will be programs that address those needs with an equally practical focus.

“Risk managers look to new issues that are appearing on the horizon but in their day-to-day activities they are so busy running around and taking care of all the things in their facility that what they are really looking for are tools they can put in their tool belt and take out and put to work on that problem as is it arises in their facility. That’s what we strive to give them,” he says.