Looking back: Much has changed, but goals and basic strategies hold steady

Healthcare Risk Management celebrates 30 years

As Healthcare Risk Management enters 2009, we celebrate 30 years of serving health care risk managers across the country. It has been an eventful three decades, with many changes in technology, philosophy, and strategies.

But the song remains the same. From the very first issue and continuing on year after year, HRM has highlighted the need for sound risk management principles, diligently applied no matter what current crisis had risk managers in a panic or what new technology offered a better solution. The first issue of HRM covered such topics as the need for good incident reports, the hidden costs of injuries, and how sloppy records could affect a jury's verdict - all topics that still should be of concern to any health care risk manager.

Leilani Kicklighter, RN, ARM, MBA, CPHRM, LHRM, a patient safety and risk management consultant with The Kicklighter Group in Tamarac, FL, and a past president of the American Society for Healthcare Risk Management (ASHRM) in Chicago, says HRM was one of the first risk management-focused publications available to those in the health care field.

"As such, it has been invaluable to me as a risk manager over the years," she says. "This publication brought to us timely information and education about issues of national importance and other notable information along with commentary from and by our peers in a day before we had all the various textbooks and other publications now available."

These are some of the other headlines from the early years:

• "Computer system streamlines variance reporting for Iowa hospitals" - January 1980

• "Early physician intervention saves hospital's resources" - May 1980

• "Malpractice crisis similar to 1976 not possible, Mills says" - January 1981

• "Hospitals 'can't lose' with self-insurance, RM attorney says" - January 1982

• "Prevent patient suicides with early- identification strategy" - December 1982

• "Court-ordered guidelines regulate psychotropic drugs" - May 1983

• "Multiple explosions pinpoint hospital's disaster needs" - November 1983

• "Increased liability comes with reusing medical devices" - June 1984

• "Experts: Consider AIDS a handicap in employment matters" - April 1986

• "Temper ad claims to avoid suits from dissatisfied patients" - April 1987

• "Tougher COBRA fines may increase documentation" - April 1988

• "Will doctors declare war with RMs over National Data Bank?" - March 1989

• "The perennial challenge: Overcoming physician resistance" - September 1990

• "How can risk managers prove their effectiveness?" - December 1990

• "Court rulings yield new warnings against patient dumping" - October 1991

• "Separate anesthesia consent form can strengthen defense" - June 1992

• "Violence often enters a hospital through the ED" - May 1993

• "Hospitals share physician liability for misdiagnosed cancer claims" - August 1994

• "Unexpected avenues of sex harassment mean hospitals must be on alert" - December 1996

• "Telemedicine poses new, huge risks: Know what your docs are doing?" - November 1997

In recent years, HRM has covered those topics and more, including new and more complex regulatory requirements and the ever-changing legal rulings that affect malpractice prevention and defense. Patient safety has become a much bigger focus in recent years, and the technological innovations have greatly changed how risk managers do their jobs.

HRM has won a number awards over the years, including the prestigious Sigma Delta Chi Award for Excellence in Journalism, awarded by the Society of Professional Journalists, in both 2001 and 2005. The most recent Sigma Delta Chi award was for a groundbreaking report on how security experts believed that terrorists were behind a string of suspicious incidents in which people tried to gain access to secure areas of hospitals and asked questions about emergency response capabilities. Experts in hospital security and terrorism said the most likely explanation for those impostors' attempts to gain access is that they were collecting information for future attacks on health care facilities.

Some change undeniable

As we look back on 30 years in health care risk management, Kicklighter says the field has changed significantly while staying much the same in many ways.

"Thirty years ago, there were no textbooks on risk management written by health care risk managers or by anyone else except those texts for the Associate in Risk Management (ARM) or the Charter Property and Casualty Underwriter [CPCU] designations," she says. "In those days, few - if any of us - knew what those designations were. There was no ASHRM and therefore no networking or knowing your peers to bounce ideas or issues or to benchmark against. It was only when ASHRM came on the scene did we as risk managers find out that we weren't alone and that significant and untoward events were not just happening in our facilities, but in our colleagues' facilities as well."

While many of the pioneering risk managers in the health care field were not responsible for the risk financing aspect of the management of risks, the insurance world, for the most part, did not have the partnership relationships with the facilities, much less with the risk managers in those days, Kicklighter says. Calling out to a broker for assistance was not always returned with a willingness to support and assist as there is today.

"However, the focus on risk management activities was, and still is today, on the prevention of injuries or situations that could lead to injuries to patients or visitors, for other assets, including employees," she says. "Data collection and analysis, for the most part, was done by hand and trusty secretaries. Risk managers who were on call 24 hours for early identification and to report a significant event carried a beeper, and we had to find a pay phone if we got a page while in the car or weren't in the office or at home."

Kicklighter recalls that working with those in senior administrative positions in many ways was easier and in some ways more difficult.

"In those early days, we were still getting reimbursed based on the percentage of Medicare patients who had incidents and claims, so there was an interest in our maximizing the accuracy and completeness of our capturing that data that seemed to give a different collaborative relationship in many ways," she says. "Today, there are organizations where the risk manager is recognized as a part of senior management and is a part of the C-Suite meetings and deliberations; while in others, risk management is a part of another division and reports up the chain through one or more levels and only focuses on incident reports and clinical risk management."

Having been in the field for 30 years, Jane McCaffrey, MHSA, DFASHRM, director of safety and risk management at Self Regional Healthcare in Greenwood, SC, and a past president of ASHRM, says the job looks quite different now. But at the same time, she says, it seems little has changed. It just depends on where you look.

"Risk management has more of a patient focus, with prevention being key," McCaffrey says. "But there are still those who focus on the financing and claims only. Now the C-Suite knows there is something called "patient safety" and, in some cases, they associate it with risk management activities."

She offers these other examples of how health care risk management has changed over the years:

• Patients have finally realized that they have rights. "For most risk managers, this has been used to the benefit of patient safety, but there are still those who wish it weren't so," McCaffrey says.

• "We used to get paid even for the care after a patient was harmed while under our care. Now, we won't be and could be considered negligent."

• Paternalistic medical care is fading away and patients now are part of the team.

• Paper has given way to the electronic versions of documents.

• Protocols, guidelines, and best practices are now a fact of life and have contributed to improved and safer care.

• "Nonpunitive" approaches have become far too popular at the expense of accountability.

• There is more focus on process design and less on individuals.

• "We still lose dentures, have slips on wet floors or out of bed, give medication to the wrong patient or give them too much, nick organs, perform incorrect procedures, fail to respond to a deteriorating condition, and so on," McCaffrey says. "But you know what? I believe we are having fewer incidents, know about a higher percentage of those that are happening, and are making a difference in preventing it from happening again."

First issue focused on incident reports, common mistakes

The October 1979 issue of Healthcare Risk Management, Vol. 1, No. 1, focused on a topic that would recur many times and continues to be a concern for risk managers. The first headline was "Incident reports: Five common failures and how to correct them."

"No matter what your hospital's bed size or budget, a comprehensive incident reporting system is essential to the success of a cost-cutting risk management program," the story began. "How do you avoid five common pitfalls that plague risk management professionals in the health field?

"Four nationally known experts with hospital experience agreed that accurate incident reporting can be realized in any hospital if certain guidelines are followed. Their advice focuses on specific ways to avoid the common failures to file reports, complete them correctly, route them to proper authorities, activate immediate correction, and plan long-range prevention strategies."

The story went on to explain that educating employees about the importance of incident reporting was one of the biggest hurdles.

"Getting hospital employees to fill out incident reports can be a stumbling block to a successful program in terms both of spotting the individual occurrence that can result in litigation and identifying trends that lead to prevention of similar events.

"Why are incident reports not filed? Some employees may fear the report will be used as a disciplinary tool on them or will be a mark against them in their record. Other employees - and some administrators - simply may not understand the importance of the incident report and the necessity for filing one on each incident."

Technology has had a significant influence on risk management in health care, including the flow of information, the advent of a computer on everyone's desk (and in a lot of pockets), the ability to analyze data faster and with more parameters, and the ease of maintaining or establishing contact through cell phones, Kicklighter says.

"The instant gratification, instant need satisfaction through the use of scanning, faxes, and e-mail can be stress-provoking, necessitating faster response and turnaround than in the past, but that often depends on which end of the request you are on," she says. "The job responsibilities have changed during the last 30 years as the risks and regulations have changed. The biomedical and medical technology aspects of patient care have changed significantly over these years changing the face of health care, and with that the risks have changed. The immediacy of the flow of information has changed our society and, as our society has changed, so has risk management."

Kicklighter also notes that risk managers work much more cooperatively with patients and their families than they used to.

"It used to be that if a patient or family was keeping a diary, we were on alert of a potential claim," she says. "Nowadays, we encourage our patients to keep notes, to have advocates, and to ask questions to be a partner in their care. Many patients consult their computers before seeing their physician for care and question their care more closely than in the past."

It seems as though the regulatory changes have grown significantly over these 30 years, Kicklighter says. She attributes part of that to the information explosion.

"The media can flash a significant court verdict or untoward outcome almost immediately worldwide within a very short time. It is more difficult to hide such negative stories; in turn, regulatory response is also almost immediate," Kicklighter explains. "Over these years, the issues have arisen that have been the bases for the laws and regulations that have created the need for compliance programs, reporting of untoward events and sentinel events with root-cause analyses along with the current focus and emphasis on patient safety and prevention of never events and errors in general."

Kicklighter also notes that risk financing and handling of claims has changed in many ways, with more self-insured organizations, creation of captives, and the roller-coasting hard-to-soft-to-hard markets. What once was a runaway verdict or significant settlement at $500,000 or $1 million is, while still a big hit, not so astounding in a day when we see payouts of more than $10 million in some parts of the country. Enterprise risk management, while new on the horizon, is beginning to see more attention, and more organizations are beginning to undertake the process to develop and implement this risk management program structure, she notes.

Despite all the changes, the basic concept of health care risk management has not changed so much over the decades, Kicklighter says.

"The basic philosophy or concept of risk management, protecting patients through prevention of errors, has always been the first goal of risk management," she says. "How we go about identifying, analyzing and treating/preventing those risks has changed due to the changes in the health care setting, regulations, advances in science and technology that have all influenced society in general. However, the theory of risk management is still the same: Prevention and, if that fails, early identification and early resolution."


For more information on the 30-year retrospective of HRM, contact:

• Leilani Kicklighter, RN, ARM, MBA, CPHRM, LHRM, The Kicklighter Group, Tamarac, FL. Telephone: (954) 294-8821. E-mail: imlani@comcast.net.

• Jane McCaffrey, MHSA, DFASHRM, Director of Safety and Risk Management, Self Regional Healthcare, Greenwood, SC. Telephone: (864) 725-4111. E-mail: jmccaffrey@selfregional.org.