What will be the major issues for healthcare risk managers in the US in 2016? HRMR asked seven industry experts for their view of the future.
Ann Gaffey, president of the American Society of Healthcare Risk Management
The American Society of Healthcare Risk Management (ASHRM) has identified several areas of focus for 2016. Enterprise risk management (ERM) continues to be a critical issue for healthcare systems and risk managers. Organizations are delving deeper into the shift to an enterprise-wide approach to risk management. We have data from ASHRM members that has directed our work in the ERM field. Building on that feedback, ASHRM has developed education and support for risk managers and healthcare leaders to shape ERM implementation.
ASHRM has developed detailed guidance on developing ERM strategies, identifying risks and opportunities, and various methodologies for assessing risk across an organization. An important key is understanding ERM concepts and details on the infrastructure necessary for an optimal ERM program. The Enterprise Risk Management Playbook was developed to meet these needs.
Additionally, ASHRM members have identified patient safety and the use of value-driven metrics as areas of focus. Risk managers have identified their role in these areas of opportunity, and they are key to moving these tools, strategies and metrics forward in their organizations. ASHRM has developed training, education and tools in patient safety, including the recently developed Root Cause Analysis Playbook.
Finally, ASHRM continues to focus on key collaborative partnerships with other organizations in the field that align with or advance ASHRM’s mission. These important relationships support ASHRM by expanding our reach and joining with us to achieve safe and trusted healthcare for the patients and families our members serve across the healthcare continuum.
I’m looking forward to 2016 as resources for ERM, patient safety and root cause analysis are used to shape healthcare systems’ practices. Risk managers are leaders in their organizations, and I’m looking forward to the positive impact this profession will have in 2016 and beyond.
Josi Wergin, risk management analyst at ECRI Institute, an independent nonprofit organization that researches approaches to improving patient care
In the US, major challenges in healthcare risk management in 2016 will include issues of emerging importance as well as long-standing concerns that need sustained risk management attention.
In the early days of electronic health records, many organizations focused their attention on selecting and implementing these systems. Recent years have seen more examination of the patient safety issues related to health information technology (IT). For example, the Partnership for Health IT Patient Safety, a multistakeholder collaborative that ECRI Institute convened in 2013, has analyzed issues such as processes for identifying health IT hazards, copy and paste, and patient identification, and the partnership continues to investigate other patient safety issues related to health IT.
Another important matter is meeting people’s behavioral health needs. Access is one issue. How can we get people the behavioral health services they need when they need them? And how can we better manage behavioral health issues in hospitals, long-term care, and other such settings? We have seen that in these settings, unmet behavioral health needs may pose risks to the patient, other patients and visitors, and staff members.
Opioids are an area of focus for medication safety. Key questions include whether we are prescribing safely and appropriately in ambulatory settings and whether we are effectively monitoring patients on opioids for respiratory depression in acute and surgical settings. Opioid-related issues have appeared on ECRI Institute’s lists of top 10 health technology hazards and top 10 patient safety concerns.
Another medication-related issue of increasing priority is antimicrobial stewardship. As the World Health Organization’s 2014 report emphasized, antimicrobial resistance is a global concern.
Some persistent challenges continue to need sustained risk management attention. We still need to do more to address hospital readmissions, not just for reimbursement reasons but also to improve quality and safety. Long-standing clinical issues such as alarms management, falls, pressure ulcers, and surgical events—particularly unintentionally retained objects and wrong-site surgery—also need sustained energy and focus.
Michelle Foster Earle, president of risk management consulting and solutions provider OmniSure Consulting Group
An article in HRMR in 2015 revealed that 100 percent of risk management professionals surveyed considered the behavioral healthcare crisis an issue for their organizations. Opioid abuse, alcoholism, and drug addiction are growing at alarming rates. The Mental Health Parity and Addiction Equity Act (MHPAEA) requires health plans to cover the same level of benefits for mental and/or substance use treatment and services that they do for medical/surgical care. However, access to inpatient treatment and mental health counseling is very limited.
"Opioid-related issues have appeared on ECRI Institute’s lists of top 10 health technology hazards and top 10 patient safety concerns." Josi Wergin, ECRI Institute.
Our client emergency departments and correctional healthcare providers are presented with the challenge of managing these patients, who are often suicidal or violent, without the manpower and expertise to do so. Expect to see more integration of care with mental health counselors in physician offices, clinics, and emergency departments.
Another hot topic is cyber security. This threat is not going away. We’ve only seen the tip of the iceberg. It’s estimated that at least one in eight people have already had their medical record compromised in some way. As we complete the move to electronic health records, digitize everything and send it around the global medical community for consults or post it on the web for access through patient portals, add telehealth and telemonitoring, mixed with smartphones and remotely controlled devices, we are creating more and more opportunities for hackers and accidental breaches.
Expect more healthcare organizations to perform data security assessments and purchase cyber liability insurance with risk management and response services included.
Violence is another issue for 2016. 2015 has seen a sharp increase in murder rates in many cities. Add to that the recent terrorism trends, and the polarizing political/racial/religious tensions our nation is grappling with, along with disagreement around gun laws, immigration, and reported increases in alcohol and drug abuse. Now top it off with the fact that according to the Bureau of Labor Statistics, healthcare workers are five times more likely to be victims of assault or violence than the average worker in all other occupations.
We have seen an uptick in the number of client hospitals, senior living facilities, and home health organizations who have consulted us about issues such as patient aggression, guns in the independent living section of a continuing care retirement community, sexual assaults, murder/suicides, and belligerent family members and even riots. Expect healthcare risk managers to get even more serious about bringing these issues to the forefront in 2016.
Kristian Poitier, president of the North Texas Society for Healthcare Risk Management and director of patient safety and clinical risk management at Tenet Health System
The main themes and challenges for the coming year for healthcare systems will likely encompass one if not all of the following domains: people, processes and exposure.
People aspects relate to accountability, focusing on a Just and Safe Culture. This will include a heavy focus on competence and ethics.
The processes domain relates to standardization as much as possible as we continue to focus on high reliability in the care and services we provide, looking at the processes we have in place in determining the failure modes and weak links in more of a proactive way to eliminate the ‘never’ events and other preventable errors.
Lastly there will be a focus on a positive public image and limiting negative exposure within the community in response to public reporting.
A fourth area might be staying relevant by reviewing the services provided and opportunities for growth as we continue to think about keeping patients out of hospital beds. How do we continue to look for opportunities to provide needed services in the communities we serve?
Kevin Junod, Northeast healthcare practice leader for insurance brokerage firm and risk management specialist, Lockton
The past year has been characterized by both horizontal and vertical growth in the healthcare arena, with service lines broadening and a rise in M&A activity.
These themes have brought a host of new challenges for risk managers, which they continue to grapple with. Many of our discussions with clients have been focused around the structure of the risk management department, the processes that they employ within these new, larger organizations and how they measure and track patient outcomes so they can measure success.
I expect that to continue into 2016. These are ongoing processes as organizations continue to evolve.
I expect risk managers to face challenges around risk management integration and new operating models as organizations evolve in 2016. Another theme will be the financial risks presented by new payment contracts, as an influx of new capitation and bundled payment programs begin.
There will be a shift from risk managers looking at patient health and safety, to focusing on population health and safety, where the organization is responsible for individuals’ health and well-being whether they come into the facility or stay at home in their community. Risk management will develop in this area from a communication, risk evaluation, intervention and risk financing standpoint.
With the shift to population health and the revenue model moving away from fee-for-service, healthcare is now about how we serve the population in the appropriate manner, at the appropriate time, with a very high standard of care and still maintain an acceptable margin.
Other areas of focus for 2016 will include workplace violence, evolving cyber/privacy/technology risks, and ongoing operational challenges associated with the implementation of electronic medical records.
Dan Cohen, chief medical officer of patient safety and risk management software company Datix
Diagnostic errors are a major cause of patient harm and even death. The processes of diagnosis are complex and frequently impaired by failures in cognition related to a variety of patterns of behavior, intellectual and pragmatic biases, commonly employed by physicians especially when working under pressure. Increasing attention to the causes of diagnostic error, in particular the known and unknown or generally not-acknowledged human factors affecting clinical reasoning, hopefully will lead to identification of mechanisms to modulate these errors.
"The challenge of recognizing complacent behavior and modulating that begins with leadership and extends through the culture of an institution." Dan Cohen, Datix
Another theme for 2016 is failures in leadership. Leadership begets culture and culture begets performance. Highly performing institutions are those in which leaders are seen to be authentic, genuine, in their concerns regarding processes and outcomes and who value the contributions of front-line staff. When authenticity is lacking then subordinate staff can sense this and may not experience the joy and meaning so important to providing highest quality safe healthcare. Authentic leadership is key to achieving higher reliability.
Healthcare is complicated and is provided in complex environments fraught with hazards. Even though progress has been made in some important areas, the fact remains that thousands of patients die every year because of healthcare-related incidents and millions more are harmed. Where complacency is pernicious or even malignant, deviations from appropriate quality standards run the risk of becoming normalized, thus increasing the structural, process and human factor-related hazards even more. The challenge of recognizing complacent behavior and modulating that begins with leadership and extends through the culture of an institution.
Many have argued that big data holds the keys to quality improvements and reductions in risk, but the realization of these dreams remains elusive. The fact is that for an analysis of big data to be useful then the data elements that contribute to big data must be well-defined and evidence-based and should be generally consensus-adopted.
At present big data is probably most useful for identifying trends and patterns worthy of closer focused examination, but should not be used for drawing definite conclusions. Unfortunately that is often not the case and many are rushing down the road waving the big data flag without appreciating the challenges.
In the past decade the proliferation of small primary care clinics located inside commercial settings that include pharmacies has proliferated in response to demands by patients for rapid convenient access to acute care services apart from emergency rooms. Although these clinics are subject to regulatory oversight they operate in settings where conflicts of interest are inherent. The fact that prescriptions can be filled by pharmacies co-located with these clinics raises the specter of over-prescribing of unnecessary medications.
This potential problem has not been systematically studied, although over-prescription may well lead to harmful events and contributes to spiraling healthcare expenditures. In addition, for healthcare clinics to be co-located in stores that sell tobacco and alcohol products and nutritional or homeopathic supplements of dubious value seems at best to represent a moral conflict of interest. Patients often confuse what they want with what their health and healthcare needs may really be.
Kevin Gabhart, managing director of insurance brokerage and risk management firm Beecher Carlson
Challenges for the healthcare industry extend from the traditional focus on patient care and management of the provider workforce to new evolving issues relating to patients, providers and payers. While the list is extensive, some of the most worrying risks can be aggregated in a few major categories.
"Healthcare is now about how we serve the population in the appropriate manner, at the appropriate time, with a very high standard of care and still maintain an acceptable margin." Kevin Junod, Lockton,
One of these is patient care: there are increased concerns for misdiagnosis as there is a high demand for, or expectation of, medical perfection which is complicated by the lack of coordinated care across a patient’s universe of providers.
Another theme is technological risk. This includes risk from expanding resources for data and communication including hand-held devices that lead to privacy concerns, as well as the expanding developments in medical devices and potential product liability claims.
Environmental or societal risk is also an issue: the protection of patients and employees in an escalating environment of violence. Additionally, there are concerns with an aging workforce where young, less experienced providers are replacing aging professionals.
Finally, there is the issue of financial risk: increased documentation and process compliance while focusing on maximum reimbursement and seeking optimal patient outcomes.
Judy Klein, president of the Ohio Society for Healthcare Risk Management and risk management manager for medical professional liability insurance company Coverys
On September 22, 2015, the Institute of Medicine (IOM) released a report that emphasized the magnitude of misdiagnosis. According to the report, diagnostic errors result in 40,000 to 80,000 deaths annually and the associated costs are staggering, but little has been invested to improve diagnostic accuracy. According to the IOM, nearly every person will experience a diagnostic error in their lifetime.
The risk of misdiagnosis can be reduced by providing resources to clinicians such as clinical decision support tools. Such tools are known to interface with a number of electronic medical record (EMR) systems, can be used on any mobile device, and aid in formulating differential diagnoses and treatment plan options.
Coverys is taking on the issue of diagnostic error in 2016, making it a key focus of risk management service delivery. This effort will include policyholder access to VisualDx, a clinical decision support software. Coverys is also working with the Institute for Healthcare Improvement, a leading innovator of health and healthcare improvement worldwide, to educate insureds on diagnostic error.
Issues associated with EMR systems should continue to be a focus for risk managers. When these systems don’t function properly, patient records can be inaccurate and incomplete, leading to incorrect treatment decisions and harm. I encourage risk managers to continue to monitor EMRs to identify opportunities for improvement through the use of formalized chart reviews. It is critical to bring any areas identified for improvement to the forefront of organizational leadership.
Another important theme is patient engagement. Patient engagement may seem like old news, but studies show that better informed patients are more compliant, have better clinical outcomes and their care tends to be less costly. Engaged patients are more satisfied with their care and less likely to pursue litigation.
One such opportunity to keep patients engaged may be to provide discharge information on videos that patients and their family members can watch at home to reinforce important discharge instructions in an effort to improve patient outcomes.
I also encourage risk managers to continue to focus on cyber risks and conduct cyber response drills and assessments to identify vulnerabilities. Healthcare organizations continue to be a prime target for data theft, as medical records are viewed as a permanent source of identification.
Last, it is worth remembering that under the Affordable Care Act, becoming part of a Patient Safety Organization (PSO) is likely to become mandatory for some on January 1, 2017. Those who have not yet joined a PSO will need to consider doing so in 2016.
Ann Gaffey, ASHRM, Josi Wergin, ECRI Institute, Michelle Foster Earle, OmniSure Consulting Group, Kristian Poitier, Kevin Junod, Dan Cohen, US, Crisis