Owning the risk, real time

For president of the Illinois Society for Healthcare Risk Management Kelly Van Fleet, risk management is all about making a difference. She told HRMR about the highs—and lows—of her job.

Kelly Van Fleet’s career as a risk manager followed naturally from a long career in nursing. But an opportunity to move into risk management suited her and she has taken the opportunity with both hands.

“I was a nurse for 32 years, I always did nursing around whatever town we happened to live in and around my husband’s career and kids’ schools,” she says. By 2008 she was a manager of an intensive care unit with 147 people reporting to her. Her hospital was one of a big group of Chicagoland hospitals that pooled all their insurance risk together but in 2008 the process of dissolving that group began.

Where the member hospitals had previously shared nurse experts who helped them come up with risk reduction strategies, they now had to create their own on-site teams to manage their risk. This presented an opportunity for Van Fleet.

“I’d always worked on quality improvement and I always liked the legal regulatory stuff so I decided to join the risk world and jump in feet first,” she says. “I got my certifications and discovered that all those years of doing a little bit of everything became very helpful because I can visit and talk with anybody in the business and have a clue, at least, of what they’re talking about.”

MAKING A DIFFERENCE
Van Fleet’s reasons for pursuing a career in risk management were simple: she wanted to prevent harm, keep patients safe and make a difference.

She had been dismayed to encounter a lack of urgency surrounding quality and safety, accompanied by an attitude that ‘doing ok’ is good enough, so she is pleased by recent moves to turn healthcare providers into High Reliability Organizations. Regarding the accreditation required by the Centers for Medicare and Medicaid Services (CMS), she believes that the new, modern accreditation process now available from DNV Healthcare is another step in the right direction.

Having recently merged with Chicago healthcare group Advocate Health Care, her hospital, Advocate Sherman, now has two years to transition from Joint Commission accreditation to DNV accreditation and she is optimistic about the switch.

“It’ll help standardise processes. The Joint Commission has done a lot of work but I think the new move from a lot of hospitals to use DNV to do their accreditation has really helped move organizations towards being more highly reliable.”

This is just one of several positive changes stemming from the hospital’s recent merger.
“The biggest thing is that the Sherman Hospital hasn’t ever had an
on-site attorney and our new health system has a whole bunch of attorneys,” she says. “It’s going to be a reality shock—our administration team here is used to doing things without having to get permission so having to learn to live in the corporate world has been challenging for them. It’s been interesting and I’m very relieved to have the backup of the corporate attorneys so that it’s not just me telling everybody ‘no’ all the time—I feel like the mother hen nagging them!”

Van Fleet loves the fact that every day in her job is different. Whenever anything goes wrong she is the person the staff turn to, and she actively encourages them to call her even if they have just a small query.
“I’d rather handle it then than try and make it up after the fact,” she says. The hospital is currently working to achieve a goal set for all Advocate hospitals, which is that by 2020 they will have zero serious safety events. This target has led to the instigation of safety huddles at 8:30am every day.

“The whole leadership team meets in person and we go around and talk about what’s happened on their specific units,” she says. “We then look forward to any issues that are coming up with staffing or machines being down or perhaps road constructions or delays for patients getting in on time for appointments. It’s made a huge difference.”

The hospital also has an online event reporting system, designed to ensure that staff know any issue they raise is being listened to and dealt with by senior team members.

“We’re averaging about 700 events a month and it’s going up and up, so it’s been very good because staff are engaged in making process improvements and we’re starting to see more things reported prior to them impacting on the patient. Instead of saying, ‘I’m sorry that we hurt you,’ we’re seeing more process improvements.

“The biggest challenge now is having enough manpower and bodies, not only to manage the data coming in but then to do the process improvements we need to make. We have to prioritise what’s a hot topic and what can wait—that’s been a challenge.”

MUTUAL HELP
Since becoming a risk manager Van Fleet has, she says, benefited enormously from the help and support of the Illinois Society for Healthcare Risk Management (ISHRM)—a group that has just celebrated its 25th year. She has enjoyed its educational and networking opportunities and has quickly made her way from being a board member to being president of the society.

Its activities include a program of webinars covering hot topics selected by the members; collaborations with neighbouring risk management societies; and real-time posting of questions and sharing of policies and procedures on the society’s website. The society also has a new group that focuses on active mentorship, so that if members have a specific issue they need help with, they can be matched with a member who is an expert in that field.

“ISHRM is a really engaged group of risk managers who are there to do the right thing,” she says. “They focus on education and mentoring and helping each other and I just can’t say enough good about the group and about how active the membership is in helping to improve things for the right reasons.”

A major concern for ISHRM’s members is the switch towards ‘owning the risk real time’—that is, maintaining an honest and open attitude when something goes wrong. “In the past you didn’t admit anything, you waited for them to come after you, but it’s too big a business now, really it’s about doing things right, and preventing harm wherever possible,” she says.

By having a good response team for bad events Advocate Sherman Hospital has been able to cut down its number of lawsuits.

“We handle events in real time, we own what we’ve done wrong and we’re able to help families make things right, right up front,” she says. “Besides the reactive and proactive part of it we start seeing the near misses, and we can then work on process improvement so that the safety net’s there for them.”

Recent healthcare reforms linking quality outcomes (and, more specifically, patient harm) to reimbursements have of course increased the pressure to get everything right and placed risk managers under the spotlight.
“We are working more closely than ever with the quality world,” Van Fleet says. “Now you can go on any website and Google your physician, your hospital, and find out who’s providing the best services and what their outcomes are, so it’s really driving business for those patients who have private insurance and are able to pick and choose their provider. With the public funded patients we’re just trying to make sure that the numbers are good so that we’re getting a full reimbursement.”

Asked how she thinks her profession will develop over the coming years, Van Fleet predicts that there will be a continuing shift towards prevention, determining causes and helping to keep patients, physicians and staff educated.

“I think that’s going to keep going and going especially with Obamacare, because of the emphasis on prevention. They’re not going to pay for hospital-acquired conditions, they’re not going to pay for poor quality. Instead of the traditional way where if something was wrong we’d diagnose it to death, scan it a hundred different ways and then repair it after it was broken, the whole shift is towards keeping it from ever being broken in the first place.

“It’s been hard for some of the older physicians to embrace that but it’s really trying to get the shift back to preventive medicine.”

EVERYONE’S A RISK MANAGER
Part of this shift is the move towards recognising that everyone in a hospital is a risk manager: everybody needs to be able to spot potential harm and take action to prevent it. Advocate Sherman Hospital has an anonymous reporting system that makes it easy for staff to take action when they spot a problem.

“It’s important that they see that something’s been done with it,” Van Fleet adds. “Staff can see that there are actions behind the reports and that’s helped to skyrocket it—and we have the front line staff involved in the process improvement.” She believes that this has helped the hospital to achieve Magnet recognition for nursing excellence. “Our front line nurses are involved in making things happen, identifying our needs and helping to make improvements,” she says.

Asked what she has learnt in her time as a risk manager, Van Fleet says that good communication is central to her role.

“You can never learn enough and you can never stop trying to figure out what the true story is. It’s horrible when you all see is the bad every day, but you have to take it one step at a time and recognise that you can’t fix it all. Bad things happen, but it’s one of those jobs where every day you can make a difference, so it’s very rewarding. 

“It’s frustrating because sometimes you see the same things going
on over and over again and what you thought was fixed turns out not
to be. It’s the most rewarding job that I’ve ever loved and hated at the same time!” 