Risk managers have moved from reactive to proactive over decades
No longer just taking care of slip & fall, risk managers now play prominent role
Seasoned healthcare risk managers know that the job has changed significantly over the years, going from a relatively low-level position in hospital administration to a more high-profile leadership role. No longer responsible for just slip-and-fall cases or the occasional malpractice case, risk managers now promote patient safety and protect the organization from significant liability and regulatory threats.
The evolution of the risk manager has been steady since Healthcare Risk Management first published in 1979. We asked our editorial board members and others with experience in risk management to reflect on the changes they have seen, and all agreed that the role has changed dramatically.
One of the biggest changes has been a move toward more prevention efforts, says Grena Porto, RN, MS, ARM, CPHRM, healthcare practice leader with ESIS Health, Safety and Environmental in Philadelphia and former president of the American Society for Healthcare Risk Management (ASHRM) in Chicago. Rather than being primarily reactive by handling lawsuits filed against the healthcare provider, risk managers now are much more focused on ensuring safety and preventing injuries that can lead to liability, she says.
"Even when something does happen, we’re focused more now on doing the right thing for the patient. I think that has been a pretty significant achievement by the industry," Porto says. "I don’t know if everyone appreciates how big a change that is. When I started in this business 30 years ago, the attitude was we don’t say anything to the patients, we don’t tell them anything, and we don’t admit anything. It was pretty much a circle-the-wagons approach, and that has radically changed for the better."
The field will continue to evolve as risk managers address new and developing risks, such as safety issues involving robotic surgery and telemedicine, Porto notes. The shift to an accountable care model also will change risk management in the near future, and it will force a switch from focusing on inpatient care to more outpatient care, Porto says.
HRM’s 35 years corresponds almost exactly with the career of 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 ASHRM. When she looks back on her time in risk management, she realizes that one of the biggest changes is the availability of risk management education, guidance, and resources.
"When I first started in risk management, we didn’t have ASHRM, we didn’t have any textbooks, and we didn’t have any kind of media to rely on," Kicklighter says. "There was nobody to reach out to for help. If you were a risk manager, you felt like you were pretty much on your own, and nearly everybody learned on the job."
At that time the healthcare industry was lagging behind others in risk management, she says. The launch of HRM and ASHRM’s first meeting in 1980 helped advance the field, she says.
With help from new information sources, the risk manager’s role became more prominent in the organization, and key collaborations began to form. Unlike many in risk management at the time, Kicklighter did not have a background in insurance and found few resources to help her.
"I remember having to approve and sign an insurance policy before it could go to the board for approval, so I reached out to my broker, and they brushed me off. I had to go through the phone book until I found an agent that would take the time to help me understand it. At that time insurance brokers and risk managers were in different worlds," she says. "Now they’re meeting together with the underwriters and combining their skill sets to get the best contracts for the healthcare provider."
That kind of role expansion helped risk management move from more of a trade to a profession, says R. Stephen Trosty, JD, MHA, CPHRM, president of Risk Management Consulting in Haslett, MI, and a past president of ASHRM. Early risk managers often were people who had come from the insurance industry, and then as other concerns took hold, the field attracted more nurses and attorneys.
"We wound up with a broader sea of people because the responsibilities had significantly increased," Trosty says. "We were still protecting assets, but now the assets included the people, the patients, the physical structure, the finances. Our charge became maximizing quality and safety while reducing liability."
That increased responsibility usually led to increased visibility in the organization, Trosty says. Risk managers began reporting to chief financial officers or chief operating officers, a positive move for the field. (See the story below for more on how risk managers work with other departments. See the story on p. 4 for how risk managers are seen by others.)
Government regulation also has increased significantly over the years, with risk managers now obligated to oversee the reporting of far more data to the government and clearinghouses, Kicklighter notes. Compliance quickly became a primary concern for risk managers, says Jane McCaffrey, DFASHRM, MHSA, director of compliance and risk management at The Blood Connection in Greenville, SC, and a past president of ASHRM. At the same time, risk managers were trying to determine exactly where they stood in their organizations.
"I remember when risk management and quality were duking it out, with quality questioning if we should even be involved in their concerns," McCaffrey says. "It was a battle back and forth for a while, and then we threw patient safety into the mix, which raised more questions about who was responsible for what."
That battle has ended now, for the most part, with the risk management and quality departments finding ways to work cooperatively in most institutions, she says. Though she says the evolution of risk management has been dramatic, McCaffrey still frets that risk managers do not get the recognition they deserve. Executive level risk managers at large organizations might be recognized, she says, but there are many others who are not.
"The day-to-day folks who actually do the investigations, the evaluations, work with people on policy, training, prevention, I don’t think they get the attention that others get when they have the titles in patient safety and so forth," she says. "I think we’re still a bit of the stepchild in the world of healthcare. Part of the problem still is how to prove your financial worth."
John C. Metcalfe, JD, FASHRM, vice president of risk management services with MemorialCare Health System in Fountain Valley, CA, has been in healthcare risk management since 1972 and says he has been gratified to see the distinct shift away from traditional risk management essentials to a focus on patient and workplace safety and patient, employee, and physician satisfaction.
"You see the shift come to life in the attachment when you review the operational issues," he says. "There is also an expansion of issues noteworthy under the technology, strategic and human capital list of issues. It is evident the healthcare risk manager is involved in a more diverse setting of risk issues than ever before."
- Leilani Kicklighter, RN, ARM, MBA, CPHRM, LHRM, The Kicklighter Group, Tamarac, FL. Telephone: (954) 294-8821. Email: firstname.lastname@example.org.
- Jane McCaffrey, DFASHRM, MHSA, Director of Compliance and Risk Management, The Blood Connection, Greenville, SC. Telephone: (864) 751-3092. Email: email@example.com.
- John C. Metcalfe, JD, FASHRM, Vice President, Risk Management Services, MemorialCare Health System, Fountain Valley, CA. Telephone: (562) 933-2000. E-mail: firstname.lastname@example.org.
- Grena Porto, RN, MS, ARM, CPHRM, Healthcare Practice Leader, ESIS Health, Safety and Environmental, Philadelphia. Telephone: (610) 220-8500. Email: email@example.com.
- R. Stephen Trosty, JD, MHA, CPHRM, President, Risk Management Consulting, Haslett, MI. Telephone: (517) 339-4972. E-mail: firstname.lastname@example.org.