How will healthcare risk management develop in 2015 and which key initiatives are driving it forward? David Allison, president of Oregon Society for Healthcare Risk Management, gave HRMR a view from the coalface.
For David Allison, interim director for patient safety for Peace Health System, the biggest changes affecting his work come not from the Affordable Care Act but from legislation within Oregon, and from the creation of voluntary patient safety programs within the state.
These include the Patient Safety Reporting Program, which gathers information on adverse events that occur in Oregon healthcare facilities to help in understanding why and how adverse events occur and to share aggregate information state-wide to improve healthcare in Oregon; and the new Early Discussion and Resolution Program, a patient-centered approach to care after harm that gives healthcare facilities and providers a way to continue caring for patients and families, learn from undesired outcomes, and prevent harm to patients in the future.
Both are administered by the Oregon Patient Safety Commission, a semi-independent state agency charged by the Oregon legislature with reducing the risk of serious adverse events occurring in Oregon’s healthcare system and encouraging a culture of patient safety. The Early Discussion and Resolution Program—the first of its kind in the US—became effective on July 1, 2014.
“We are still seeing how that is going to unfold,” says Allison. “For a decade we have had a commitment as an organization to being transparent when errors have occurred; to not charging for the care that results from the errors; and to being open to talking with people about how to restore them and make them whole if that’s possible.
“Now the state is playing an active role in that process. It’s a significant change, one that everyone is watching with interest.”
Under the new Oregon program patients will be able to request early initiation of the discussion process. It remains to be seen how frequently this will occur. “All the more reason we in risk management and patient safety need to be prepared to support our caregivers, to ensure they are emotionally prepared and able to enter into a discussion,” says Allison.
A commitment to risk management
Peace Health is a 10-hospital health system operating in the Northwestern states of Oregon, Washington and Alaska. Sponsored by the Sisters of St Joseph of Peace, the system demonstrated an early commitment to risk management when one of the sisters decided it was necessary to professionalise the system’s risk management processes.
Risk management has remained a major function within Peace Health ever since—most recently with the creation of a dedicated patient safety department, which sets out to create a more coherent approach to risk and safety throughout the system.
“There has always been a great appreciation of the importance of risk management within the system, and over the last 10 years we’ve tried to be part of the patient safety movement, recognising the need to move more proactively in the direction of supporting patient safety,” says Allison.
“Previously the responsibilities for root cause analyses had been shared among the risk managers and quality improvement coordinators differently across the system, so the idea behind forming the new patient safety department was to create a department that would centralize the function of root cause analysis and investigations. The goals are very much in line with the risk management goals of reducing patient harm.”
Allison himself has been with Peace Health for many years, and came to risk management having previously worked in behavioral health and as a hospital chaplain. He has found the listening skills developed in those roles to be valuable in risk management.
“Also important are the ability to remain objective and gather information, the ability to calmly deal with people in very distressing situations and provide an offer of support to them, and the ability to conduct thorough and credible investigations.
“One thing I have learned along the way is that healthcare continues to be a very risky enterprise. Some of that is because healthcare organizations do not have hardwired highly reliable processes yet. In some ways healthcare lags behind other industries in that respect.
“Healthcare is very complex, which brings enormous challenges and opportunities for errors to occur. Our commitment to treating patients with respect has to translate into the way we deal with them when they have been harmed.”
As such, he is pleased to have seen risk management move towards greater transparency over the years, with disclosure now a major part of the role.
“During the time I’ve been in risk management, we have moved from a posture of denying everything to being aware of the degree of harm that happens to patients and being much more willing to being open and transparent about that. These days we to try to partner with them—and that adds up to a big change in the way we approach claims.”
The benefits of self-insurance
When it comes to paying claims, Peace Health System has been self-insured for hospital liability for close to 20 years, and it folded its professional liability coverage into this about 15 years ago.
“The reason for this was that with the insurance market as it was at the time, it made financial sense to self-insure. The benefit I’ve seen is that being self-insured gives us more of a say about the choices that are available to providers in situations of claims and litigation, in terms of supporting them in being a part of those conversations.
“We have more direct internal control over the process and we’ve tried to act in a way that means the interests of the hospitals and the interests of our licensed practitioners are really aligned. In the past it seemed there was a sense that our interests were in opposition, and that’s not productive.”
During his time in risk management, Allison has seen the process for disclosing and holding key conversations with patients, their families and representatives evolve significantly. A natural progression from this, he believes, is an awareness of how an adverse event affects not just patients and their families, but also the staff involved.
“I believe an emerging role and concern for risk management is the support for the ‘second victims’—the healthcare providers who have been involved in events where there was an error that resulted in harm or death, or where there is that perception on the part of the patient’s family, and so they make an allegation,” he says. “There is increasing recognition of the traumatic effect that has on the healthcare caregivers who are involved.”
Allison expects that this issue will gain more attention over the coming year, along with the need to increase patient safety by learning from claims data how to mitigate risk. Disclosure and early resolution will remain priorities, he says, with state rules around civil litigation determining how this is tackled from state to state.
“I’m hoping that there will be increasing recognition that one of the key roles for risk managers and patient safety professionals is to support people who have been traumatised along the way,” he adds.
As president of his local ASHRM chapter—the Oregon Society for Healthcare Risk Management—he aims to continue bringing active risk managers, safety professionals, defense attorneys and insurers together for mutual support and learning. A key concern for members this year is how to standardize a method of conducting root cause analyses that derives maximum reliable information for the whole organization to learn from.
“We are continuing to focus on refining the tools and the methodologies we use to do that,” he says. “Rather than a case-by-case review, we are trying to learn how to do more meta-analysis and gather greater amounts of data that will guide us going forward and show us where we need to focus process improvement.”
Allison is aware that the results of this work will have a direct impact on his role at Peace Health, and will help the system towards an ever more efficient and effective approach towards risk management and patient safety.
“I am always fascinated with the process of trying to understand how events occurred,” he says. “I get huge satisfaction from the sense that we may be preventing harm in the future. I enjoy the collaboration of all the professionals who are involved in helping to safeguard and be good stewards of our resources going forward.”
Risk Management, David Allison, Oregon Society for Healthcare Risk Management, US, Peace Health System, Affordable Care Act