Demystify risk management in nursing homes

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Paolo DiNatale
Paolo DiNatale

What if every staff member was asked to define risk management? It's likely that no two responses would match. It's even possible that some responses would be incorrect.

In all likelihood, however, everyone questioned would agree that risk management is essential given the increasingly litigious environment of long-term care. In this belief, they are correct. That's why it is important for every staff member to understand that risk management is the key to important benefits such as: fewer negative events, fewer survey deficiencies, improved reimbursement, lower costs for professional liability, and improved public relations. In addition to these benefits, controlling risk means more resources available for providing higherquality of care. This is why demystifying risk management deserves a second look.

What is risk management? 

Across any long-term care organization, the phrase "risk management" conjures up different images, even conflicting ideas. Perhaps it's better understood broken down. "Risk" is defined as the possibility of a loss or injury (i.e. the occurrence of a negative event) with the associated consequences. "Management" refers to the steps taken by an organization to prevent or mitigate any harm. Accordingly, risk management is the responsibility of every staff person from the top administrator to the front line caregivers and everyone in between. It is the sum of every step taken to minimize the risk of harm.

While this view may not seem revolutionary on the surface, the actual practice and implementation of effective risk management strategies does require a shift in mindset for many organizations, one that involves a change from a reactive response to a preemptive strike.

If the term preemptive strike sounds overly strong, just consider two recent lawsuits. In April 2009, a Franklin County jury in Columbus, OH, awarded a $6.5 million settlement in a wrongful death lawsuit against Whetstone Gardens & Care Center. The resident died from lack of water.

The nine-day trial heard testimony both doctors and nursing aides. The doctors informed the jurors that care fell below minimum standards while nursing aides claimed they were not fully apprised of the resident's critical need for water. (Source: The Columbus Dispatch, April 29, 2009).

Another recent jury trial, this time in Albany, GA, awarded a $3 million settlement. The patient was being treated with morphine after family members and caregivers determined death was imminent and ordered a DNR. However, once the patient slipped into a coma and died, family members blamed the death on too high a dose of morphine (Pruette v. Phoebe Memorial Hospital, No. 04CV628-2).

The fact is, once claims are taken before a jury, the result is unpredictable and a facility-wide preemptive approach to risk management is the only defense.

Don't discount the data

For starters, an effective risk management program should be based on data that are continuously analyzed. After all, data is used by insurers, plaintiff attorneys and regulatory agencies for the purpose of sizing up any long-term care provider. Furthermore, public data (such as quality measures) is the basis for which many future residents will be placed in your care, or not.

Accordingly, facilities should embrace this information and learn how to use it as the foundation for a proactive risk management approach. When carefully examined and processed properly, data can help facilities rapidly identify at risk residents and target risk management resources before an incident occurs. It's an approach that helps keep the small problems small.

Consider the potential of the Minimum Data Set alone. MDS represents a virtual treasure chest of information that has been painstakingly collected for 20 years by virtually every nursing home across the country. It's the source for Medicare reimbursement, publically documented quality measures, and the starting point for all surveyors. Why? Because MDS data is powerful. When analyzed from the perspective of risk management, and subjected to predictive modeling, it has the ability to forecast risk and give facilities a head start in managing that risk. Over time, scrutinizing MDS data will bring clarity and focus to any risk management program.

Plus, MDS data is the closest source of real-time data available on a large scale. Consider the advice of W. Edwards Deming, who revolutionized the manufacturing industry with Total Quality Management (TQM):  "Base decisions on accurate and timely data, not wishes, hunches or experiences.”

Long-term care is simply too dynamic an environment with constantly changing acuity and new risks emerging every day for reliance on retrospective data or periodic on-site visits.

Why Data? Look at the benefits

Comparatively, a data-driven risk management program is an inexpensive intervention as it leverages technology, existing resources and information already being collected. More specifically, a data-driven risk management program has demonstrated the ability to:

* Improve reimbursement accuracy

* Reduce survey deficiencies

* Obtain more accurate QI measures

* Reduce the occurrence of negative incidents

* Improve compliance with state and federal agencies

* Reduce professional liability premiums

* Improve public relations/marketing efforts

Sustained improvement depends on the ability to measure performance. By incorporating data into the foundation of a risk management approach, facilities gain the ability to benchmark, track, trend and continually monitor performance. Ideally, progress can be demonstrated in quantitative terms and communicated throughout the facility. In this way, the risk management program is viewed as every staff person's responsibility.

More importantly, everyone understands why certain changes are necessary. They see tangible benefits of those changes, and they are motivated to continue that progress. Yet another layer of mystery removed from the risk management program!

Policies and procedures impact protection initiatives

According to data reported by the Centers for Medicare & Medicaid Services, 90% of all nursing homes in the United States were charged with varying degrees of violations in 2007. No mystery here: Most violations result from deviations from established federal or state rules and regulations that should be incorporated into facility-wide policies and procedures. As one of the top regulated industries in the country, long-term care organizations need to identify high-risk areas and follow the very prescriptive guidance for managing such risks.

Bridging the gap

When implemented properly, an effective risk management program will bridge the widening gap between external challenges facing long-term care providers and the internal reality of providing quality care with limited resources. More importantly, a data-driven approach enables a facility to leverage available information to rapidly target resources, indentify actual risk and proactively manage these "pre-incidents" to avoid negative events.

Now is the time for facilities that are committed to optimizing their risk management program to discover the data's full potential and demystify their risk management initiatives.

Paola M. DiNatale MSN, RN, NHA, RAC-CT, is a national account manager, risk services, and Brad Granger, MBA, NHA, is a business account manager, risk management, at Lexington, MA-based PointRight Inc (www.pointright.com).


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