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Risk Management Mentor Program

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Program Disclaimer

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Modules

1. Risk Management Fundamentals

2. Enterprise Risk Management

3. Applications

4. Healthcare Providers

5. Clinical and Patient Safety

6. Legal and Regulatory

7. Claims and Litigation

8. Risk Financing

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Topics

Web links

Primary sources

Templates

Questions

Responses

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Module 2: Part 1

Enterprise Risk Management

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Enterprise Risk Management

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Explain key points of enterprise risk management (ERM)

Define the inter-related ERM domains within healthcare organizations

Examine the goals in implementing ERM

Discuss internal aspects that influence the success of ERM implementation

Describe the ERM process tools

Identify ERM team members and their responsibilities

Analyze the application of ERM when contemplating adding a new service line

Objectives

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“Enterprise risk management in healthcare promotes a

comprehensive framework for making risk management

decisions which maximize value protection and creation

by making risk and uncertainty and their connections to

total value.”

ERM: ASHRM definition

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Vulnerabilities

• Potential losses

• Financial

• Reputation

Opportunities

• Return on investment

• New ventures

ERM overview

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Common goals between departments

Remove siloes

Share resources

and lessons learned

Practice risk-

mindedness

Engage in cohesive process building

ERM overview

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Risk domains in a healthcare organization

OperationalClinical/Patient safety

Financial

StrategicHuman capital

Legal/Regulatory

Technology Hazard

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Decision-making/Due diligence

Alignment

Corporate governance

Accountability

Risk management integration

Compliance

Exposure reduction

Standardization

Goals of ERM

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Leadership Culture

Decision-making

Engagement

Influences on ERM

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ERM process toolkit

Risk Identification

Risk Analysis

Risk Treatment

Risk Monitoring

Risk Evaluation

Self-

assessments

FMECA

RCA

SWOT

Risk Maps

Decision

Analysis

Trigger

Tools/

Audits

Source: Griffin, F. A., & Resar, R. K. (2009). IHI global trigger tool for measuring adverse events (2nd ed.). Retrieved from

http://www.ihi.org/resources/Pages/IHIWhitePapers/IHIGlobalTriggerToolWhitePaper.aspx

FMECA: failure mode effects and criticality analysis; RCA: root cause analysis;

SWOT: strengths, weaknesses, opportunities, and threats

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ERM teams

ERM Steering Committee

• Chief Executive Officer, CFO,

COO, CMO, CNO (C-suite)

• Legal counsel

• Senior human resources staff

• Chairman of the board of

directors

• Chairs of board committees

(audit, finance, and

compliance)

ERM Working Group

• Risk leader

• Compliance

• Patient safety

• Quality

• Internal audit

• Clinical unit leaders and staff

• Information technology

• Clinical ancillary services leaders

and staff

• Nonclinical services leaders and

staff

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ERM sample impact

• Operational

• Clinical/Patient safety

• Financial

• Strategic

• Human capital

• Legal/Regulatory

• Technology

• Hazard

New service line

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Operational

Patient acuity

Policies and procedures

Equipment

Transportation (ground and/or air)

Agreements

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Clinical/patient safety

Policies, procedures, and protocols

Medications (oxytocin, magnesium sulfate, betamethasone, etc.)

Obstetrical complications

• Shoulder dystocia

• Postpartum hemorrhage

• Emergency C-section

• Abruption

Infant abduction

Labor patient in emergency department

Newborn assessments

Visitation/rooming-in

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Malpractice insurance

Equipment

Addition or renovation

Transfer costs

Salaries

Financial

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Advertising

Community support

Public relations

Strategic

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Human capital

Providers and staff

Training

Retention and turnover

Absenteeism

Float staff

Compensation

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Professional guideline adherence

Centers for Medicare and

Medicaid (CMS)

The Joint Commission

(TJC)

State health department

Legal and regulatory

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Electronic health records

Infant abduction equipment

Surgical equipment

Electronic fetal

monitors

Technology

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Services during natural disasters

(snowstorms, floods, etc.)

EvacuationEmergency

transportation

Hazards

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Carroll, R. (2015). An Enterprise Risk Management Playbook: An

Implementation Guide for Healthcare Professionals. Washington, DC:

American Society for Healthcare Risk Management.

Resource

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In using an enterprise risk management approach, how

might your healthcare organization be affected by

another local hospital closing its emergency

department? Remember to consider the eight domains

of ERM.

Quiz question

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Consideration to organizational impact resulting from emergency department services being discontinued at another local hospital should include:

Operational – adequacy of policies and procedures, space and equipment, diversion protocols, and transportation services

Clinical/Patient safety – patient types and acuity levels, as well as patient volume

Financial – increased staffing and equipment

Strategic – community awareness, education, and outside resources

Human capital – increase staff and healthcare providers along with training needs

Legal/Regulatory – EMTALA, quality indicators affecting patient safety (i.e., readmissions, door to admission, staffing ratios, etc.)

Technology – existing capacity of electronic health records, clinical equipment for high acuity patients

Hazard – epidemic outbreaks, loss of utilities, weather-related conditions

Response

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Evidence-Based Practice

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Define evidence-based practice (EBP) and where to find it

Discuss the importance of bundles regarding patient outcomes

Examine the needs for and benefits of policies and procedures

Describe policy and procedure management

Explore the importance of guidelines, protocols, and checklists

Identify the role that processes play within the healthcare organization

Objectives

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Scientific research

Clinical expertise

Patient values

Potential liability when not followed

Evidence-based practice (EBP)

Source: Agency for Healthcare Research and Quality. (2018). Evidence-based Practice Centers (EPC) Program Overview. Retrieved from

https://www.ahrq.gov/research/findings/evidence-based-reports/overview/index.html

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Bundles

Policies and procedures

Guidelines

ProtocolsProcesses

Where to find EBP

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Evidence-based

research

Defined tasks

performed together

Improved patient

outcomes

Compliance versus non-compliance

Bundle examples

• Central line care

• Indwelling catheter care

• Ventilator care

• Elective induction

• Augmentation

• Vaginal-assisted delivery

Bundles

Source: Institute for Healthcare Improvement. (n.d.). Evidence-based bundles. Retrieved from

http://www.ihi.org/Topics/Bundles/Pages/default.aspx

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Standardization

Evidence-based practice

Quality indicators

Regulatory mandates

Compliance

Reimbursements

Legal liabilities

Policies and procedures

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Policy and procedure management

Development Access Reviews

Revisions Retention

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Adherence

Source: Griffin, F. A., & Resar, R. K. (2009). IHI Global Trigger Tool for Measuring Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge,

MA: Institute for Healthcare Improvement. Retrieved from http://www.ihi.org/resources/Pages/IHIWhitePapers/IHIGlobalTriggerToolWhitePaper.aspx

Monitoring

Trigger events (near misses and adverse events)

Audits

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General policies

Operational

• Disclosure of unexpected patient event

• Clinical chain of command

• Disruptive behavior providers, staff, patients, and family

• Informed consent and refusal

• Patient rights

• Documentation

• Critical test results notification

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General policies

Operational

• Event and near miss reporting

• Root cause analysis (RCA)

• Sequestering (patient records and equipment)

• Failure mode effects and criticality analysis (FMECA)

• Falls – patient and visitor

• Environment of care (EOC)

• Medical devices

• Admission, discharge, and transfer

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Standardized

• Guidelines

• Clinical decision algorithms

• Protocols

• Process management of care

• Checklists

• Mnemonics

• Step completion

Evidence-based

Guidelines, protocols, and checklists

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Wider scope

Performance methods

Contains policies and procedures

Examples: admission, discharge, medication administration, surgical checklist (preoperative, perioperative, and postoperative)

Process

Source: World Health Organization. (n.d.). Surgical safety checklist. Retrieved from

http://www.who.int/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf

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Resar, R., Griffin, F.A., Haraden, C., Nolan, T. W. (2012). Using care bundles to improve healthcare quality. IHI Innovation Series White Paper. Cambridge, MA: Institute for Healthcare Improvement: 2012. Retrieved from www.IHI.org

American College of Obstetricians and Gynecologists. (2015). Clinical guidelines and standardization of practice to improve outcomes. Retrieved from https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Patient-Safety-and-Quality-Improvement/Clinical-Guidelines-and-Standardization-of-Practice-to-Improve-Outcomes

Resources

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How often should policies and procedures be reviewed?

Quiz question

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A minimum of every two years and if any changes to

the policy and procedure are warranted in the interim.

Response

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How can policies and procedures not being followed

within an organization be a problem in litigation?

Quiz question

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Not following an organization’s policies and procedures

can quickly demonstrate a blatant disregard for the

rules in place dictating the standard of care and can

make the claims case indefensible.

Response

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Disclaimer

The information contained herein and presented by the speaker is based on sources believed to be accurate at the time they were referenced. The speaker has made a reasonable effort to ensure the accuracy of the information presented; however, no warranty or representation is made as to such accuracy. The speaker is not engaged in rendering legal or other professional services. If legal advice or other expert legal assistance is required, the services of an attorney or other competent legal professional should be sought.