DorlandHealth

Richard Scott

One thing the depressed economy is teaching health care workers is how to stretch every inch of the talent and personnel of a workforce in the face of dwindling resources. Similarly, this situation looms like a giant specter across the diverse folds of health care as sweeping reform inches closer to fruition. While still a great unknown, the consequences of reform could further stress the work and resources of in-the-trench case managers and their colleagues.

These two areas—the economy and impending health care reform—stand as two of the most influential factors governing the challenges ahead in the field of risk management, according to an informal survey conducted by ECRI Institute’s Healthcare Risk Control (HRC) System as reported in the December issue of the Risk Management Reporter. Designated an Evidence-Based Practice Center by the Agency for Healthcare Research and Quality. ECRI Institute is a nonprofit organization dedicated to applied scientific research.

Polling approximately 75 of its members, HRC asked respondents to select up to 10 of the most pressing challenges risk managers face in 2010 and beyond. HRC members, choosing from a list of 25 challenges, identified several fronts that hold a crossover appeal to case managers and the difficulties they face in their respective line of work.

“It’s interesting to look at how these top 10 issues relate to the risk managers and case managers,” says Cynthia Wallace, senior risk management analyst with ECRI’s risk management services, who wrote an adjoining editorial in the newsletter.

The top five concerns, which can be viewed through a case management lens as well, are as follows, with the percentage of risk managers identifying the area as a top challenge in parentheses:

1. Nonpayment for hospital-acquired conditions (56%).
2. Integration of risk management, quality and patient safety (49%).
3. Healthcare reform (47%).
4. Demonstration of risk management value (44%).
5. Decline in risk management resources (44%).

“Items like nonpayment for hospital-acquired conditions definitely relates to the economy,” says Wallace. [It] is also a health care reform issue. This is the first time the Medicare program is looking at not paying for certain hospital-acquired conditions, and there will be more hospital-acquired conditions added to the list.”

The report notes that there is “a lot of anxiety” surrounding this area. One hospital in Illinois engaged in process improvement efforts to address nonpayment provisions has ushered in a more collaborative, quality environment involving case managers. “The hospital’s case management department is partnering with its physicians to improve the completeness of their documentation,” reads the report. In this case, prevention by way of proper documentation of present-on-admission cases proves an important safeguard. “It’s so key to have that information on the front end so it’s not seen as a condition acquired in the hospital,” says Wallace.

The second concern—integration of risk management, quality and patient safety—speaks to the silos that exist within some facilities or organizations. While it applies predominantly to risk managers and practitioners involved in quality and safety issues, it provides an example of a collaborative process. At one health system with an integrated model, “the risk management department’s patient safety coordinator is also involved in the quality department’s activities. When an event occurs, risk management helps with the disclosure process, provides counseling to staff, and leads the debriefing following the event. The quality department conducts the root-cause analysis…and oversees implementation of an action plan for process improvement.”

While health care reform, the third concern, is demanding an anxious wait-and-see from many fields of care, the demonstration of value is something that both risk managers and case managers can take steps to bolster today. According to Wallace, individual departments must focus on three areas to evince value:

1. Make yourself visible within the organization.
2. Be the person that is sought-after. The person recognized for his or her expertise.
3. Third and most important is to make a business case for what you do. “Data is key,” says Wallace. (For instance, if the case management department has an impact on reducing readmissions or repeat testing or minimizing the potential for infections, making that well-known is essential.)

The fifth concern is a decline in resources. This item bears a mark on the other items surrounding it. Not only is it essential to show value, but a drop-off in resources makes it important to work together as a unit. “One of the strategies is the need to set priorities and move out of silos to team up with others,” says Wallace, who heard from one risk manager who has teamed up with the organization’s case management department to identify “trends that signal the need for further evaluation” within a patient’s medical record—to prevent an infection or readmission, for instance. “Risk managers and case managers can work together to improve patient care,” Wallace says.

As frontline risk managers—and colleagues who share the same goal of improving patient care—may be interested to know, the following are the remaining challenges looming ahead in 2010 and beyond:

6. Event investigation and disclosure.
7. Physician involvement in safety and quality.
8. Electronic health record implementation.
9. Effective event reporting systems.
10. Medicare secondary-payer mandatory reporting.

For more information about the report and the Healthcare Risk Control System, visit ECRI Institute online.