Enterprise Risk Management

Transcription

1 1 Are You Exposed? Building a Home Care Risk Management Program Click to edit Master title Pauline Barry, BSN, MPS, CPHRM, FASHRM Assistant Vice Click President Here Risk to add Management a subtitle Allied World Healthcare Debra Healey, RN, MSN, CPHRM Executive Director Middlesex Hospital Home Care Enterprise Risk Management Enterprise risk management is a discipline that engages professionals in the practice of identifying, managing, controlling, and monitoring all risks to the organization. Enterprise Risk Management Handbook for Healthcare Entities First Edition, American Health Lawyers Association

2 2 Enterprise Risk Management Enterprise risk management can best be described as an ongoing business decision making process instituted and supported by the healthcare organization s board of directors, executive administration and medical staff leadership. ERM recognizes the synergistic effect of risks across the continuum of care, and has as its goals to assist the organization reduce uncertainty and process variability, promote patient safety and maximize the return on investment e t through asset preservation, and the recognition of actionable risk opportunities. Enterprise Risk Management Handbook for Healthcare Entities First Edition, American Health Lawyers Association Domains of Risk Operational Financial Human Resources Legal/regulatory Technology Environmental Strategic

3 3 Operational Risks Documentation Performance Improvement Initiatives Adverse event management Patient assessment Communications with providers Operational Risks, cont d Medication and infusion therapy Transparency Chain of Command Patient safety Cultural l issues

4 4 Legal & Regulatory Risks CMS & DHHS Licensure & accreditation HIPAA Stark HITECH OSHA Environmental Hiring Practices Competency Supervision Codes of conduct Job descriptions Human Resources Risks

5 5 Human Resources Risks cont d. Policies and procedures Workers Compensation Sexual harassment Violence and personal safety Infection control Transportation Technology Risks Electronic medical record Telehealth Medical equipment/devices Laptops Security breaches

6 6 Environmental Risks Physical environment Fire Electrical Patient valuables Infectious and hazardous waste management Security Emergency preparedness Strategic Risks Managed care relationships Marketing/Advertising/Sales i /S Reputation Antitrust Contract administration Insurance coverage

7 7 Financial Risks Billing, collection and accounts receivable Corporate compliance Fraud & abuse Capital equipment Days of cash on hand Growth in programs and facilities Why Develop an ERM Program? Higher consumer expectations Increased use of internet t for health information Change in patient demographics Continuous need for and access to outcome data Competition Increased financial security Increased regulatory requirements Emphasis on patient safety and transparency

8 8 How to Get Started? Identify your risks -Review incident reports -Conduct FMEAs -Survey leadership -Ask staff Categorize risks by domains Current risk mitigation efforts Next Steps Risk Assessment & Evaluation Identify potential t likelihood and severitye Prioritize risks Develop organizational-wide solutions and strategies of handling the risks Implement solutions Monitor and evaluate

9 9 ERM Success Factors Leadership support Employee involvement Consistency in processes Benchmarking results Use of evidence based practices Internal & external monitoring & evaluation Professional liability General liability Directors & Officers Employment Practices liability Crime & Fiduciary Technology Auto Workers compensation Insurance Coverage

10 10 What do Underwriters Evaluate? The quality of an organization -Financial -Medical/performance improvement -Leadership -Risk management/patient safety Exposure Losses Selecting an Insurance Carrier Commercial v. self-insurance v. captive v. RRG Financial due diligence AM Best rating Occurrence v. claims made Tail, prior acts coverage Claims management philosophy Value added services Commitment to your industry

11 11 Homecare Specific Risks Employee Honesty Falls in the home with injury Emergent Wounds, pressure ulcers and skin integrity declines Failure to rescue a patient Failure to meet a treatment standard of care Structuring a Risk Management Plan for Homecare Components of the Plan List the Risks addressed by the plan List the Risks addressed by the plan Describe the action plan to prevent risks Present the plan to Professional Advisory Committee Review and adjust the plan as needed Educate Staff Report any potential events to the TPA or Insurance Company

12 12 Case Studies Case Study Number 1-Employee Dishonesty Case Study Number 1-Skin Integrity Employee Dishonesty The Patient - A 75 year old female patient who lived alone in an elderly housing apartment. Family support was a distant relationship with a daughter. The patient was seen under the State of Connecticut Homecare for Elders program and only had HHA services where the RN supervised the plan of care twice a month. The Employee - The HHA was hired using the standard protocol of background checks, references and a licensure search for any previous disciplinary reports or arrests. All the pre hire screening were clean.

13 13 The Situation Over the course of 4 months, the HHA was able to withdraw $25,000 from the patients checking account using her debit card. The withdrawals were discovered by the patient s daughter who immediately called the police. The Home Health Agency received notice of this dishonesty when a police officer called the HHA Supervisor asking her to cooperate with the alleged criminal act. The HHA was brought in by the Supervisor for questioning and initially denied all allegations. The Situation Continues Initially the patient was reluctant to discuss the situation with the HHA supervisor. Upon further investigation it was discovered that the HHA had been seeing the patient after hours, bringing her places in her vehicle and had offered to get the patient money, hence the possession of the debit card. The patient had no idea that this much money had been taken from the account until the daughter audited the account. The patient ended up hurt and angry as she had established a close relationship with the HHA and felt a loss of her friendship and a betrayal.

14 14 Homecare s Investigation The Executive Director of Homecare took charge of the Investigation. The HHA was notified of the allegations and that since it was criminal in nature, there would be complete cooperation with the police. The investigating Detective interviewed the HHA and produced evidence that were bank pictures showing the HHA making withdrawals from the account that were tracked back to the bank records and added up to the amount missing from the account. What Happened Next The Executive Director of Homecare kept in close touch with the patient, her daughter and a lawyer they had engaged. The hospital put the insurance company on notice that provides employee dishonesty coverage. At first the claim was denied as the insurance investigator cited that there was a chance that the patient contributed to the loss by providing the debit card and PIN number. Eventually the claim was paid by the insurance company. The funds paid back in full to the patient.

15 15 What Happened to the HHA The HHA was put on administrative leave as soon as the allegations were known. Once she confirmed her relationship with the patient, employment was terminated The Home Health Agency cooperated with the investigation and sent a statement to the court that they wanted to seek restitution for the funds. The HHA appeared in court and within one year she was sentenced to restore partial funds to the patient and she received a jail sentence and loss of her Certification as a Home Health Aide. The patient attended every hearing and felt satisfied with the result. Risks to the Homecare Department Reputational Risk - Several large articles appeared in the local newspaper that cited the names of the patient, employee and Homecare Agency. This sparked a large reaction from the community. Employee Satisfaction Risk - The Agency respected confidentiality and there was a large outcry from the remaining HHA s that all of their reputations were tarnished. Patient Reaction - Many patients questioned staff about the incident and wanted to know what measures the Homecare Agency would take to make sure this didn t happen again. Several other patients came forward with additional theft allegations.

16 16 Risk Management Plan Reviewed policy and procedure for employee handling of Patient s Money and re-educated staff with in- service education followed up by a memo. RNs reviewed policy with patients. Met in small HHA groups to educate and discuss the incident. Required all staff to notify supervisors if there is any request by a patient to handle money outside of the policy. Reviewed the case study with Executive Staff and Professional Advisory Committee. Ramifications to the Homecare Agency Department of Public Health Licensure During the routine licensure visit by the Department of Public Health, there was a request to review all information related to the incident and the medical record was reviewed for compliance.

17 17 Lessons Learned Ongoing education to employees and patients concerning relationship boundaries and handling patients money is essential. Providing a team of HHAs who see the patient vs. one HHA assists in decreasing the change that boundaries will be crossed. Providing in person unannounced HHA orients can assist with the monitoring of the care plan. Case Study # 2 Skin Integrity An 75 year old female patient came referred to Homecare by her surgeon after a successful hospital stay that involved a coronary bypass. She had moderate cardiac disease and was discharged 6 days after surgery with Homecare orders for an SN, PT, OT and HHA evaluation. The RN admitted her within 24 hours of her arrival home and completed the OASIS-C and requested a HHA 3 times per week with an OT and PT evaluation. The plan of care also included SN visits 3 times a week for 3 weeks then decreasing to 2 times a week for 3 weeks and finally 1 time a week for 3 weeks if needed. Telemonitoring services were also provided as part of the plan of care.

18 18 Skin Integrity Cont.. No skin integrity issues other than the surgical wound were noted on the OASIS C data set nor were any pressure or stasis ulcers or reddened areas identified. The PT and OT evaluation visits were completed with no mention of any skin integrity issues. On the third RN visit the RN noted new pedal edema bilaterally at +2. This edema continued for the next 2 RN visits with the patient reporting increased pain in the right great toe. On the last nursing visit there was no palpable pedal pulse. During the next two weeks the right great toe developed a red open area and the swelling continued. No PT or OT note mentioned this and there was no documentation of any telephone call to the MD to report the change in condition. Skin Integrity Cont. The RN documented extensive patient teaching on the need to keep the foot elevated and to continue to monitor for increased swelling. The cardiac condition improved and the patient began to resume usual activities of daily living including driving. During the 6th week of Homecare the patient was discharged as the PT and OT plan of care were complete, with no further need for a HHA and the patient able to follow up with her MD. The patient had a follow up appointment with her surgeon two weeks after discharge.

19 19 Skin Integrity Cont.. Two weeks later the patient followed up with her MD. At that time all of her toes were red with the small toe on the right foot black. The patient required an amputation of the toes. The patient brought a suit against the Homecare Agency for failure to properly assess skin integrity, failure to notify the MD of a change in medical condition and premature discharge from care. The patient also wrote a letter of complaint to the Homecare Agency with a copy to the Department of Public Health and CMS What Happened Next.. The suit was settled out of court with a confidentiality clause in place that would prevent disclosure of the settlement amount. The Department of Public Health investigated the complaint and required an action plan to be put in place that required re-education of all RNs on skin assessment and reporting changes in conditions to the MD. A licensure investigation was conducted with a reprimand to the RN for improper physical assessment, lack of follow up with the MD.

20 20 Changes in Professional Practice The Homecare Agency reviewed the skin assessment policies and developed an education plan for reminding staff to conduct and document complete and thorough skin assessment. A self audit tool was developed that was completed by RN staff on every patient with a wound. Data was tracked to monitor compliance with skin integrity documentation. All wound patients were discussed in IDT and case conferences with supervisors. A six month follow up prevalence study revealed increased compliance with documentation and follow up with MD. This data was submitted to DPH. Contact us! Questions? Pauline.Barry@alliedworld.com debra_healey@midhosp.org