Hospitals and Medical Malpractice--Risk Management Issues and Approaches
What Is Risk Management?
It goes without saying that health care is becoming an increasingly complicated field, which includes science, technology, and regulation. As its complexity has increased, so has its share of liabilities. Claims for medical errors are on the rise, as are the verdicts, settlements, and legal expenses that accompany claims. As the environment continues to heat up, there is no time to lose in implementing programs to turn the tide in your favor.
Risk management has three basic components: prevention of injury, financing for risks, and the management of claims. Risk financing is a necessary part of the equation that is usually accomplished by the acquisition of insurance of some sort. The management of claims is important, but having a claim signifies that some system may already have failed. These two processes are, by their very nature, reactive. You will never get ahead of the curve if you focus on insurance and claims. It is by preventing injury in the first place that your initiatives will truly yield the results that you seek. The only good claims are those that were prevented because there was no injury.
Risk management functions by focusing on failures. Injuries usually occur because some system has failed to prevent them. It is not possible to manage any process unless you know how it works and how it fails. We seek improvement by knowing what works and what does not; the ultimate goal is to make processes work safely, consistently, and reliably for long periods of time.
It is sometimes assumed that the demands for production run counter to the demands for a safe environment. This does not need to be the case. A safe hospital can be an effective and efficient hospital. For example, if a hospital can reduce its return to surgery rate, it can render care more safely, as well as reduce its operating costs and the charges paid by health plans. There is tremendous merit in seeking, above all, to do the right thing, for the right patient, in the right way, at the right time. This approach reduces total costs of care while enhancing patient safety. This is something upon which all providers, payers and patients can agree and can benefit.
Measurement Leads to Management
It is true that you cannot manage a process that you cant measure, because without measurement, you do not know what is working and what is not. If you implement a corrective action program without baseline data and a method for gathering data on the performance of the program, you will never know whether the program was effective. However, measurement in risk management is extremely difficult due to a number of variables, such as extremely small sample sizes, lack of benchmarks, the futility of benchmarks, long lag times, and the ambiguity of risk management data. These do not make measurement impossible, but they do make it challenging.
When we talk about the difficulties associated with small numbers, we mean that patient occurrences (especially those that lead to serious injury) are normally very rare. A hospital may have hundreds of thousands of adjusted patient days in a given year, and thousands of episodes of care, but they only have a handful of claims that arise out of that care. While it is good to have only a handful of claims, it is sometimes difficult to see trends because any variation may be random or it may not be meaningful.
Benchmarks can be useful tools in many settings, but they are of limited utility in risk management. There are statistics available on many aspects of patient care that can give rise to claims, such as birth injuries and surgical wound infections. There are not really many good sources of statistics on the numbers or rates of claims or lawsuits. However, any comparisons with national statistics are of limited value here. Is it acceptable to have a rate of birth injuries lower than the national average, when the real goal is to have none? It is preferable to have fewer lawsuits pending against your organization than the national average, but again, shouldnt your goal be to have none? Comparisons can lead to complacency, and complacency may be unacceptable.
Risk management data is often ambiguous. If in one month you receive 50 occurrence reports, and in the next month you receive 30, is your organizations performance improving? Do not confuse the rate of reporting of occurrences with the rate of occurrences. The latter is an unknowable number. The former is a surrogate for the latter, but it is an imperfect one because it depends upon a host of subjective variables, such as recognizing that an incident occurred, feeling empowered to report it, and remembering to report it. There is no known correlation between the number of incidents and the number of incidents reported, and it may vary from organization to organization.
If you really want to know whether your organization is functioning appropriately, pay attention to clinical indicators of patient care, such as unanticipated returns to the emergency department, unplanned returns to surgery, number of sentinel events, etc. These are the tried and true indicators of performance. The key to improving performance, however, is not to simply monitor it. If your data does not indicate where and how performance can be improved, you need to start monitoring other indicators of performance. If you are not seizing opportunities to improve performance, your performance will never improve.
Risk Management Needs to Start at the Top
Risk management is like safety: It needs to be practiced throughout the organization in order to be effective. Your risk manager performs many functions, including being a constant voice for patient safety and, on occasion, the conscience of the organization. The risk manager cannot be in all care locations at all times simultaneously monitoring the provision of patient care. Your risk manager is a cheerleader, not a provider of care. The risk management program will be more effective if it is fully integrated into the fabric of the organization.
All organizations have cultures. Cultures generally influence the attitudes of the workers toward the jobs that they perform on behalf of the organization. What is the culture of your organization? If it is like many health care entities, the culture may be focused on the bottom line for the organization. This is not a bad thing without a margin there may be no mission. However, focusing on the bottom line to the exclusion of patient safety will often lead to false economies. You may very well save money on one aspect of the organization, only to spend it in another. For example, as an organization saves money by using less staff, it may find its error rate (and hence its insurance premiums and liability losses) going up (and its reputation in the community going down). If organizations focus on doing the right thing, they will often find that their costs of doing business go down.
Cultures can be changed by leadership. Leadership is more than ensuring that the organization will survive. It involves setting the tone for all decision-making analyses. When the leaders of an organization start discussions on resolving problems with the question How will each of the available alternatives improve the quality of patient care? the organization will have made great strides toward becoming a safer and more reliable organization.
A culture of patient safety involves four basic components. It involves having systems in place that will:
- Reduce the potential for error to the minimum extent possible;
- Detect errors that do occur as quickly as possible;
- Provide corrective action to mitigate the consequences of the error as quickly as possible;
- Requires a system for feeding lessons learned and corrective actions back to the employees and members of the medical staff so that errors can be prevented in the future.
These components require a great deal of care in their implementation.
The provision of health care services is almost uniformly accomplished by humans, but it is always performed within systems. Humans are, by their very nature, prone to error. Humans working within systems that minimize the potential for error are inherently safer and more efficient. The problem with designing safe systems starts with our basic instincts regarding error. We tend to think that errors are caused when people are not paying attention, when they are poorly trained or uneducated, or when they are simply stupid. It is entirely true that some errors are caused by these factors. However, if you stop your analysis by blaming someone for being careless, you will never see that the problem lies with the process, not the people. If people work long enough in a process that allows for error, they will eventually make mistakes. If your analysis indicates that the processes are as safe as they can be, but errors are still being made, then, and only then, it may be appropriate to take corrective action through discipline or remedial training.
Discovering that an error has been made appears deceptively simple. Health care is not an exact science and it is frequently true that two people may have different outcomes from the same procedure in the absence of negligence. We frequently only know that an error has occurred when someone takes the initiative to report it. As noted above, rates of reporting are subject to numerous subjective variables that are often difficult to control. It can be safely stated, however, that an organization with a punitive approach to the occurrence of errors will have a lower rate of reporting than one that takes a blame-free approach to errors. If the organization stresses that it is most interested in building processes that enhance the safety of its patients, rather than looking for ways to fire people, and then lives by that rule, one obstacle to good reporting will have been removed.
Implementing a solution after an error has been made requires some degree of planning, as well as some degree of ingenuity. Clearly, the first task is to care for the patient. All necessary care must be provided as soon as possible in order to minimize the consequences of the event. Once the patients needs have been met, the real analytical work has to begin. Unless one continues to drill down and ask why something happened, it is likely that only superficial reasons for the event will be uncovered. How is the process supposed to work? How can it be made to function more reliably? Does it rely on weak cognitive functions, such as memory, or can reminders, such as checklists, be incorporated into the process? Blame is an easy trap to fall into; process improvement requires work.
Once you have determined the actual cause of the error, processes will need to change and people will need to be educated. The processes will need to be monitored to ensure that the fix was effective, or whether additional work needs to be done. If opportunities for improvement are neglected, or corrective action is taken injudiciously, the organization will be doomed to continue its mediocre performance.
Communications Are the Key to Teamwork
Almost by definition, the performance of an effective team will be greater than the sum of the performance of its parts.
Nowhere is this more evident, and often less appreciated, than in health care. The care given to each patient is provided by a team usually composed of physicians, nurses, pharmacists, therapists, and technicians. Each team member brings his or her own skills, talents, and abilities to the team. If the members of the team do not communicate with each other, for whatever reason, the team will stumble and possibly fail. Organizations that foster and encourage good communications will reap rewards in terms of efficiency, reliability, and safety. The JCAHO reports that the root cause of 85 percent of the sentinel event reports that it has received regarding delays in treatment were due to a failure of communication.
As in any process, there are a number of inhibitors to good communication. These can include a lack of respect for other team members, failure to consider, solicit, or receive input from other team members, disruptive activities, failure to effectively use good channels of communication, etc. While many of these are characteristics of individuals, organizations need to constantly monitor communication patterns to ensure that they are effective.
One channel of communication that may be either a blessing or a perennial problem is documentation. Documentation is a blessing when it supports the practitioners who have complied with the standard of care and provided care appropriately. It is also a blessing when it provides subsequent providers with the information that they need in order to provide care for the patient. It is a perennial problem when it is incomplete, inaccurate, incomprehensible, or inconsistent. Documenting care is a task that no health care provider enjoys, but it is essential to good patient care and to minimizing liability. As a general rule, all health care providers would be well-advised to follow the golden rule of documentation: document unto others as you would have them document unto you.
Activity disruptive to good communication is, unfortunately, a fact of life in many health care organizations. It is not a benign annoyance, and it does not go away if you ignore it. It can and often will have an adverse impact on communications between providers and hence the quality of patient care. To the extent it is tolerated, it will only get worse. Although dealing with it may be emotionally and financially unpleasant, it must be dealt with firmly and effectively.
Conclusion
The best risk management programs are those that prevent liability by preventing injuries in the first place. Organizations with effective risk management programs are safer environments for the provision of patient care. Unfortunately, risk management is not something that can be delegated to an individual or a small group of individuals. It must be a recurring theme in the fabric of the organization. To the extent that it is neglected, the entire organization will suffer.
