Learning the hard way


Learning the hard way

Tatum O’Sullivan, left a career in staff nursing for risk management and is now ambulatory risk and patient safety manager for North Shore Physicians Group. She tells HRMR how her experiences in healthcare have shaped her approach.

Early in her career Tatum O’Sullivan, RN, BSN, MHSA, CPHRM, president of Northern New England Society for Healthcare Risk Management, had an experience that would shape her future approach to risk management. She had been working in her local community hospital as a staff nurse when she was named as a defendant in a malpractice case.

“Although I had never cared for this patient physically my name was all over her record because of my role as an MDS (minimum data set) coordinator on the unit,” she says.

Her role involved documenting assessments on patients’ records that would help determine reimbursement. These assessments were completed by reviewing the patient’s medical record and speaking with the interdisciplinary team. But despite the fact that O’Sullivan had not been involved directly in treating the patient, she was pulled into the malpractice case.

“Being named in the suit was very traumatic for me,” she says. “You place doubt on your value as a professional and worry about the implications for your career and the organization you are working for. I remember meeting with the hospital risk manager, who did not discuss the case with me. She introduced me to the hospital’s claim representative and left the room.”

The legal process unfolded slowly, and two years later she attended her deposition. “I met my attorney that morning after driving to Boston alone. Although the attorney was kind I did not feel I had anyone to support me. After a three-hour deposition where I was questioned on my credentials, training, standards of care, and documentation I was released when the plaintiff’s attorney realized I had never physically cared for the patient.

“It took another year for me to be dropped officially from the case, but I remember wondering why no-one advocated for having me removed sooner. I had mentioned many times to the claims representative and attorney that I never cared for the patient, but that did not matter until I said it to the plaintiff’s attorney myself in my deposition.”

O’Sullivan continued with her career, and by 2005 she had become a quality and safety specialist at the same hospital.

“I developed a passion for risk management and patient safety,” she says. “I believe that I am drawn to risk management and patient safety activities because of my early experiences as a nurse. Working on the short term rehab unit I developed an appreciation for providing safe quality care.”

Other than a brief stint in management in a home health agency she has worked in risk management ever since, moving on to take a risk management role at a small hospital in Derry, New Hampshire, before becoming director of risk management there and eventually moving to her current role as ambulatory risk and patient safety manager at North Shore Physicians Group (NSPG) in Peabody, Massachusetts, in 2012.

NSPG comprises more than 400 physicians, nurse practitioners and other healthcare professionals in 17 locations throughout the North Shore.

O’Sullivan’s position is the first of its kind at the organization and was developed through a grant funded by medical professional liability insurer CRICO.

Experience counts

Years after the early ordeal of being named in a malpractice case, O’Sullivan still draws on that earned knowledge to assist her work.

“Being involved in a malpractice claim has shaped how I interact with physicians, nurses, and healthcare workers when approaching a serious safety event or claim,” she says. “It’s important to me that no-one feels alone, that they know they have someone they can call with any question at any time.

“The entire process is very anxiety-provoking and it’s important to provide encouragement and support throughout. Healthcare professionals do not enter this field to hurt people so when someone accuses them of being negligent and causing harm it certainly has an impact on them emotionally.”

She says the biggest challenge of her role is the amount of change that is currently occurring in healthcare—and finding the best way to communicate those changes to staff on the front lines. Whether it be policy changes, updates on technique, clarification of information, or safety alerts, it is difficult to reach every employee.

“I send out many email broadcasts, I have created a quarterly patient safety newsletter, attend staff meetings at the offices, and interface with staff at different times but I often feel there are changes and updates that have been made that did not get communicated in a timely or effective manner,” she says. “There is constant change in healthcare and at times I think that becomes a burden for caregivers.”

At NSPG O’Sullivan manages the risk management concerns and many of the patient safety initiatives, and works with her supervisor, the medical director of quality, safety, and population health, on day-to-day events. When a trend or organization-wide concern is addressed they work closely with the director of clinical services and innovation, and have adopted many of the tools and methodologies that the Virginia Mason Institute and Toyota Production Systems utilize.

This approach places an emphasis on quality and safety. The attitude that the patient comes first is the driver of all their processes, and in many cases patients are included in the improvement team. 

“The organization engages all staff in continuous process improvement,” she says. “Throughout the year different offices will participate in improvement activities that may require them to be pulled offline for anything from a day to a week.

“Staff are made to feel safe and encouraged to engage in improvement activities. They are tasked to be innovative and think outside the box. Having front line staff in different positions working on the same process allows for the development of standard work that will eventually be implemented by all offices.”

The ‘standard work’ refers to algorithms that staff use to reduce variation and ensure all the elements of a process are completed in an efficient manner.

“As risk manager, I have participated in improvement activities related to specimen labeling and medication administration using this approach to improvement,” she says. “Although the process may be time-consuming due to the amount of data collection and observations that are performed before and after the improvement event, it is worth it when you witness less variation and defects and provide safer care to patients.”

Kinds of risk

Moving from a hospital setting to a physicians group, O’Sullivan initially thought that she would face fewer types of risk.

“I remember thinking, ‘no operating room, no emergency department, no intensive care unit, and no labor and delivery ... there must not be a lot of risk’,” she says. “I soon learned that approximately 50 percent of all claims take place in the ambulatory setting.”

The majority of these claims are diagnosis-related. Missed and delayed cancer diagnoses make up more than half of the outpatient claims, including breast, colorectal, prostate and lung cancers.

“Developing strong systems which prompt for routine screening and follow-up studies is a challenge many in the ambulatory setting are tackling,” she says.

Test and referral tracking is a hot topic in her field of risk management. Closing the loops to ensure that patients have completed studies that have been ordered, that results have been reviewed and communicated, and that patients receive timely follow-up continues to be a challenge.

“As we rely more and more on electronic systems we learn that we still have a long way to go in making care safer,” she says.

A plus side of the job is how engaged physicians now are with patient safety and risk management activities. “I have been in healthcare for almost 24 years, 18 of those as a nurse, and I have seen such a dramatic change in the culture,” she says.

“Physicians are leaders and activists in their office to promote change, improvement activities, and put patient safety on the forefront. Physicians will communicate adverse events on a regular basis and are very interested in the follow-up and what has been done to prevent future events.”

O’Sullivan has long been a member of Northern New England Society for Healthcare Risk Management (NNESHRM), having initially joined when she took on her risk management role in Derry, NH. The society has more than 100 members from New Hampshire, Vermont and Maine, with a broad range of experience in risk management.

Members meet twice a year for educational sessions and there is an annual regional conference hosted by NNESHRM along with the Connecticut and Massachusetts chapters.

“The opportunity to network provides great resources when questions arise and you want to ‘bounce an idea off someone’ or share policies,” she says. “Often there is only one risk manager at each organization so it is nice to have a group of trusted professionals to discuss ideas with.”

Two years ago O’Sullivan joined the board of NNESHRM as secretary; this year she is president. This year the society continues to place great emphasis on its educational opportunities and development of the risk management professional. The society also has programs to offer reimbursement for testing for the Certified Professional in Healthcare Risk Management (CPHRM) and scholarships to attend the annual regional or ASHRM conference.

“NNESHRM enjoys our relationship with ASHRM and we often share information and ideas from those meetings and conferences with our membership,” she adds.

During the course of her career, the biggest change O’Sullivan has faced is the push for transparency. “I remember years ago believing that if you apologized to a patient you were setting yourself up to be sued. These were the days when we did not explain medical errors to patients unless we needed to.

Being transparent is good for everyone involved. Although providing a disclosure and apology means having a difficult conversation that is uncomfortable, it is the right thing to do. Often when you walk away from these conversations you feel better about the team you are working with and it helps the healing process for all involved.”

A just culture

As part of the continued drive for openness and improved quality, O’Sullivan is working to build a just culture within NSPG. This is a challenging task that brings wide-reaching benefits.

“Building a just culture is something that everybody still struggles with—it’s a matter of striving for the perfect balance between trying to hold people accountable but making them also feel safe coming forward and reporting things. No matter how much people think that they’ve embraced a just culture you still find out that there are events people are not telling you about, or things that are being addressed in the offices or on the units rather than moving into risk management.”

The one thing that would make her work easier, she says, is an event-reporting system developed with the front line users in mind. While risk managers promote reporting, staff members still tell them the biggest obstacle is the amount of time it takes.

“If we could develop a system that is interfaced with the medical record that allows for date, time, narrative, and location to get reported initially we would see much more reporting. When I’m doing my rounds I hear about events that happened weeks ago that did not get reported. Often time is the biggest barrier.”

Communicating with staff is a key part of O’Sullivan’s role, and one that she relishes. She makes it a priority to develop relationships so that her co-workers understand what she does and appreciate her goal.

“I get pleasure from many aspects of my job but what I enjoy most is developing relationships with so many people across the organization,” she says. “As a risk manager, it is your goal to have everyone in the organization appreciate patient safety and risk reduction as a priority.

“I enjoy it when physicians, nurses, and medical assistants think to contact me rather than getting anxious when they see me appear and ask ‘what went wrong?’. I try to have my first interaction with employees be something positive or routine rather than meeting for the first time over a safety event.”

When faced with a safety event, she has learned that the best approach is to listen before speaking, not to draw conclusions, and to listen, without interrupting, whenever anyone is telling you a story. These are lessons that hark back to that first, unpleasant, experience of risk management at the beginning of her career.

“Let them get out everything they need to say, because otherwise it comes across that you’re judging before they even finish what they have to say, or that you might not even be listening completely,” she says.

“Any time I’m talking to somebody about something risk-related I try to really hear what they’re saying, and any solutions or recommendations they’re asking you for, and to try to make it collaborative rather than jumping in with my opinion as to what they should be doing.”

Tatum O’Sullivan, NNESHRM, NPSG, US