The many layers of risk management in healthcare

Risk management in healthcare has especially high stakes. In addition to risks related to operations, finances, and reputation, healthcare organizations must consider those that can be a matter of life or death. Hospitals and health systems work tirelessly to ensure the health and safety of their patients. The right healthcare risk management software will help them achieve that goal.

No matter what an organization hopes to improve—from claims management to incident reporting to clinical rounding—an integrated healthcare risk management information system (RMIS) offers the right solutions for improving patient well-being and finding organization-wide success. Read more about the many aspects of risk management in healthcare.

  • Patient Safety & Quality
  • Claims & Insurance
  • Healthcare Enterprise Risk Management (ERM)

Patient Safety & Quality

Medical error is the third-leading cause of death in the United States. This includes process errors, planning errors, and failures to act. With the right reporting and workflow tools, integrated healthcare risk management software eliminates human error and allows clinicians to work in lockstep to provide better patient care.

Incident Reporting

To effectively address adverse events and near misses, hospital risk managers need an informed understanding of what constitutes such incidents. This starts with having the technology to efficiently report them. Integrated data tools—such as data surveillance, patient safety event reporting, and enterprise-wide near miss/unsafe condition reporting—that contain simplified forms with clear instructions make data collection efficient and straightforward.

Healthcare risk management software with built-in workflow tools and automation can also alleviate some of the administrative burden of patient safety event reporting. Offloading administrative tasks to a risk management system not only helps reduce human error that can lead to medical error, but also allows employees from across the organization to return their focus to their most important priority: patient care.

Finally, flexible reporting from any location and any device—a web browser, secure portal on an organization’s intranet, or mobile phone—further improves reporting. And as an incident report progresses, the employee who initially reported an event can receive automated updates, thus making them feel more involved in organizational change.

Patient Experience

Understanding the reasons for and causes of patient complaints helps hospitals and health systems respond in a meaningful and timely manner. Patient experience professionals can enter, track, and aggregate complaint and grievance data through easy-to-use tools that save time, ensure accuracy, streamline communication, and trigger actions that leads to lasting change. Further, using data to spot trends and patterns, patient experience professionals can take action that proactively addresses the issues driving complaints.

Peer Review

Risk management in healthcare requires physician involvement. The peer review process, when properly carried out, protects patients, clinicians, and the organization as a whole. The right healthcare risk management software will streamline the centralization and analysis of data from disparate systems; aid in confidential, secure communication; and tailor workflows to match an organization’s internal processes. Once a workflow is established, the system can be used to automatically generate peer review cases, based on incidents, patient experience, or claims records and thresholds.

To improve accountability, specific tasks can be automatically created and assigned to team members. Equally important, the right tool can track and organize performance improvement plans, corrective actions, and recommendations for a peer review case. Utilizing external data sets and aggregation tools, the right system can also simplify the peer review process while providing deeper insights into provider performance.

Internal Audit and Surveys

Auditing and survey technology can be a powerful tool in the overall risk management plans of hospitals and health systems. By conducting periodic assessments, organizations can gauge whether they’re meeting internal standards for quality of care. By administering regular audits or surveys, organizations can collect data for internal benchmarking and for use in determining year-over-year improvements or deficiencies. Anonymous surveys with open-ended questions can also reveal valuable insights from the ground-level, and guide changes to patient care processes, policies, and procedures.

Medical Record Reviews

Medical record reviews, or case studies, provide an additional level of data collection that is often missed through voluntary incident reporting alone. By providing specific templates based on patient type, care setting, or procedures and treatments performed, users can provide data that can bring to the fore adverse events, near misses, or unsafe conditions that may be otherwise missed. Using a healthcare risk management system to schedule and automatically create these studies saves time and reduces costs associated with the administration of this process.

Safety Huddles

Safety huddles are an important tool for fostering better communication and raising awareness of issues, concerns, and trends. However, creating meeting agendas, capturing meeting details, and assigning follow-up tasks can be burdensome and reduce participation. Healthcare risk management technology that includes a proper safety huddle tool can help reduce the level of effort required by making it easier to track meeting outcomes and assign tasks, auto-generate meeting agendas, and facilitate the collection of meeting items and concerns.

Root Cause Analysis

By handling administrative tasks associated with costly root cause analysis (RCA) and delivering data-based insights, healthcare risk management software can make a big difference in the lives of hospital risk managers. The following root cause methodologies inform strategic decisions and enhance quality programs:

  • Fishbone: a visual display of contributing factors, broken down by category
  • RCA2: the Root Cause Analysis and Action method aims to uncover what happened, why it happened, and the corrective actions needed. From corrective actions/action plan creation to timeline development to contributing factors to the assignment of the RCA team, healthcare organizations can pick and choose what tools work best for their process and workflow.
  • 5 Whys: an exploration of the cause-and-effect relationships underlying a particular problem

Healthcare Failure Mode and Effects Analysis

Healthcare Failure Mode and Effects Analysis (HFMEA) is an insightful way to identify where a process breaks down and, as a result, has the greatest potential to cause harm. Unfortunately, because of the time it takes to identify, organize, and conduct a proper HFMEA, organizations often bypass the process or conduct “mini” HFMEAs instead. A healthcare risk management system with automation tools can simplify the process and shorten the HFMEA lifecycle, thus allowing users to focus on the real impact of each step in the process and generate more accurate scores to understand where a process failed. Further, the right solution can help users identify corrective actions and process improvements that prevent the recurrence of process breakdowns.

Healthcare Claims and Insurance

Healthcare claims cause patient stress and cost hospitals and healthcare systems time and money. Efficient and accurate claims administration and insurance management technology can benefit all involved in the claims process.

Healthcare Claims Administration and Management

Healthcare risk management software serves as a consolidated repository for all claims data—involved parties, financials, notes, tasks, files, related parties (i.e. physicians, attorneys, etc.), insurance information, and more. Further, integrating claims administration data with patient safety data can help in correctly identifying the causes of claims. With greater access to this critical claims data, healthcare claims managers can more easily and efficiently manage the entire claim life cycle and streamline all claim-related activities for all lines of coverage. Rules-based automation reduces clerical work for adjusters and keeps the process moving for faster approval.

Insurance Policy and Program Management

Successful risk management in healthcare involves managing all facets of the healthcare industry’s complex insurance requirements. The right software will have comprehensive policy and program functionality designed to automate renewal and policy management activities throughout the year. With the right tools, hospital risk managers can chart programs, model prospective programs, project cash-flow impact of retention options, benchmark coverage, and more.

Physician Administration and Underwriting

Physician administration can be overwhelming, with redundant processes, volumes of data, and tight deadlines. An integrated, streamlined risk management platform can help reduce the time and effort involved. Through an online application and renewal portal, providers can easily supply the required data for coverage. Using proper workflow tools, administrators can provide information, quotes, and documents in a more timely and complete manner. Integration with physician administration tools simplifies the tracking of credentials, trainings, and certifications administration, and when linked with claims and safety data, provides deeper levels of insight. Finally, maintaining all provider data in one system simplifies the verification and historical reporting process, thus saving time, effort, and money.

Policy Renewal

A fully automated policy renewal process saves time and reduces error. Using healthcare risk management technology, insurance policy information can be entered into the system (either through electronic data import or manual entry) and renewed with a click of a button. The system can also be configured to generate alerts for upcoming policy expiration dates so designated users can get in front of them. When a new policy starts, previous policy info remains attached to claims and named insureds (such as physicians) for easy access.

Policy Modeling

The right healthcare risk management software will allow hospital risk managers to model policy programs from within the platform. Users can build a policy program from existing policies, with the system constructing a graphical illustration of what that program looks like using full-color charts, multiple lines/layers, deductibles and SIRs, and more. This type of visualization allows users to easily identify coverage gaps or add an existing policy to a program.

Workers’ Compensation

Risk management in healthcare involves monitoring employee health and safety while they are on the job. The right healthcare risk management software will streamline the collection and standardization of employee injury, claim, return-to-work, and loss time data to provide insight and swift action. Interactive, customized dashboards can also simplify the management of workers’ comp claims. Claims adjusters can set up multiple dashboards based on location or specific area of focus (cause of injury, injury type, injury severity, etc.). Using exception-based reporting, these dashboards can then be used to ensure claimants with the most severe or complex cases receive the attention and action they require. Report lag analysis makes it simpler to spot outlying claims, as well, through the use of time-based parameters (3, 7, 14, 30, and 90 days, for example) and automatically generated alerts for outstanding claims.

An integration with the Official Disability Guidelines (ODG) provides access to evidence-based medicine (EBM) data against which claims adjusters can a hospital or health system’s workers’ comp claims. Data such as primary and secondary diagnoses, a target return-to-work date, and a Risk Assessment Score (RAS), allows adjusters to monitor the highest-risk claims and intervene early. The integration can trigger alerts so adjusters know when to act. These alerts keep all stakeholders aware of changes and guideline updates, preventing miscommunication and unnecessary delays.

OSHA Compliance and Reporting

With the right healthcare risk management software, hospitals can improve the quality of workplace injury and illness data, reduce the amount of time spent on compliance-related activities, fulfill the latest OSHA reporting requirements, and implement processes that help ensure compliance and audit clearance. These efforts also go a long way toward contributing to an organization-wide culture of safety.

Healthcare Enterprise Risk Management (ERM)

Healthcare ERM establishes a standardized framework for identifying risk across a healthcare organization and for helping hospitals move from a reactive clinical risk program to a proactive holistic risk management program.

Risk Assessments

Risk assessments provide the structured, organized data needed to identify tolerance gaps. Through healthcare ERM software, hospitals can customize risk records to fit their unique structure or process. This includes creating dashboards and reports highlighting the risk factors most critical to strategic goals. With risk assessments in one centralized location, hospitals can standardize risk and exposure data for better analysis and reporting, as well as provide easier tracking of high-risk exposure across multiple years.

Compliance Management

Risk management in healthcare involves keeping up with the industry’s complex web of compliance standards and laws. The American Society for Healthcare Risk Management’s (ASHRM) eight risk domains help inform and guide an organization’s ERM program. The right healthcare ERM software will take these guidelines into account.

Healthcare Analytics

When copious data is viewed in isolation, it only tells part of the story. When data comes together through the use of healthcare analytics, however, it paints a more meaningful picture. Understanding causes, trends, and exceptions can help hospital risk managers and leadership alike make informed decisions and develop effective strategies for developing a culture of safety. For example, an individual metric like an erroneous dose of medication cannot, by itself, lead to improvement. But further analysis could uncover that the medication was labeled incorrectly in the system, which can lead to immediate correction and preventative measures.

The right healthcare risk management solution will leverage tools like exception-based reporting, leading indicators, benchmarking, and root cause analysis to cut through the noise and reveal underlying causes and broader trends. Customizable dashboards can help tell these stories in an organized fashion, delivering insight to all stakeholders to push for strategic change.

Origami Risk’s end-to-end integrated healthcare risk management software

In an increasingly complex healthcare industry, Origami Risk’s integrated risk management software makes incident reporting, claims administration, healthcare analytics, and other facets of risk management in healthcare a seamless and simplified endeavor. Origami Risk understands the vital importance of patient safety and quality care, and our industry-leading service and support team understands the vital role a robust risk management program plays in accomplishing that goal.

Contact our healthcare team today.