Healthcare reform, patient safety, and the public's concern about potential medical errors are daily front page news. Never in my experience has there been so much focus on the need to improve quality, safety, and economies in healthcare, which everyone agrees are excellent "big picture" goals.
June 15-19, 2009 is Healthcare Risk Management Week, with the theme "Thinking Safety, Earning Trust" according to the American Society for Healthcare Risk Management. Slogans aside, it seems a good time to consider the function and goals of the Office of Risk Management in the heathcare setting. Since my experience in the field is limited to hospital risk management, I'll focus there.
Big picture goals have merit, but just like computer imagery, when we zoom in on the big picture we begin to see a multitude of individual, overlapping, multi-colored pixels; lots of little jagged-edged points that come together to create the whole. Making lasting changes to "the picture" requires an understanding of the issue from both overall and zoom-focus perspectives.
So how does Risk Management help effectively "realign" those pixels?
Although investigating unanticipated outcomes and determining root causes is often a primary responsibility of Risk Management, focusing narrowly on those elements alone tends to be like looking only at the zoomed-in pixillated image of the problem. Rearranging the specific elements that caused a problem has value, but rarely will it change the big picture.
In my experience, the first order of business must be proactive risk education for people at every level of the organization, starting with the most vulnerable - the patients. Joint Commission launched the "Speak Up" campaign several years ago to educate and empower patients about their role in improving safety and mitigating risk, and supporting the concept of an empowered patient is a start. As part of my risk management role I worked extensively with an excellent web-based patient education program. An educated patient provides the first layer of defense against error.
But risk-avoidance education must go beyond the patient. For example, are the housekeepers in your hospital educated as to how vital their role is in protecting those in our care from potentially life-threatening infections? A housekeeper's work may not be brain surgery, but without it, brain surgery may not save the patient. Do your housekeepers understand the value of their role in safe patient care and protecting the organization?
How much time is spent educating your nurses and other front-line care givers about ways to minimize risk? Nurses often manage the most significant risk/reward ratio as they are often the "face" of the hospital in the patient's mind. Caring for multiple critically ill patients, documenting that care in a way that would hold up in a court of law, interacting with concerned family members, and dealing with numerous physicians are all in a day's work. A skilled, compassionate nurse is a tremendous asset to the organization and its patients. Nursing care may not be brain surgery (although in today's world of high-tech medicine it's getting close) but without it brain surgery may not save the patient. Do your nurses understand the value of their role in safe patient care and protecting the organization?
On to perhaps the most challenging group, your physicians. Challenging not necessarily because they aren't interested in learning how to better mitigate risk, but because it can be so difficult to gain their attention for any length of time. Does your organization support transparency and apology when care goes awry? Hopefully so, and if that's the case, how educated are your physicians in handling those most difficult of conversations? Do your physicians know where to go for assistance when facing a conversation with a distraught patient or family member? Often that support comes from the Office of Risk Management.
Is effective risk management on the minds of your C-Suite executives? It is if they are educated as to its value; a value that includes protecting patients, protecting the organization's good name and reputation, and protecting the financial assets that enable the organization to continue its mission.
Education is a challenging, ongoing, and multi-faceted role of Risk Management. The only way to effectively manage risk in an organization is with everyone's help. Risk education supports improved quality, safety and economy in the heathcare setting. It's a big-picture, zoomed-focus kind of role.
Happy Healthcare Risk Management week!
Editors Note: Simple Data Solutions is working on an affordable, Microsoft Access based, healthcare risk managment event tracking database, stop over for a sneak peek.
It is true that healthcare reform, patient safety, and potential medical errors are fast becoming major concerns for people in general. This is a very informative posting on the Health-care Risk Management Week.
Posted by: Nurse Line | June 29, 2009 at 02:17 PM
I'm glad to see that patient education, housekeeping, nurses, physicians and executives all have a stake in risk management, a term which as a layperson, I haven't been able to define. I hope it has something to do with better health, not just the bottom line. However, sometimes we just need common sense. About a year ago I was hospitalized after international travel with severe diarrhea. Everyone (after I made it out of ER) was wonderful, attentive and thoughtful, from housekeeping to dietary to nurses to hospitalists. But no one EVER cleaned the bathroom, which was where I was spending a lot of time. I finally took towels and cleaned it myself, then threw the towels away in the trash bin, not knowing if what I had would disappear in the wash. Really, how much education do you need to know this?
Posted by: Norma | July 28, 2009 at 07:16 AM