OPERATIONS MANAGEMENT SECTION
Risk Management in the ED Kraftin E. Schreyer, MD MBA FAAEM
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isk is inherent to emergency medicine (EM). Emergency departments (EDs) are full of undifferentiated patients, many of whom present acutely ill and without additional clinical context or information. Management must be done expeditiously in a constrained time frame in a chaotic environment. Furthermore, the threat of malpractice is always looming. In addition to the inherent risk within our field, additional risks can develop from variation in care delivery. The lack of standardized processes, equipment, transitions of care, and interactions with consultant or ancillary services can all contribute to increased risk within EM. As such, every ED would benefit from recognition of risk and consideration of a risk management strategy. Risk management, in and of itself, is a well-established process often undertaken within a silo of a hospital’s risk management department. Many times, decisions regarding risk, while well-intended to improve patient care, are made by administration, without frontline physician input. As operational leaders, it behooves us to be a part of risk management on behalf of our departments. To be a full participant in risk mitigation efforts, though, one must understand the process behind risk management. Risk must first be identified, then quantified and prioritized. Key risk events, including sentinel events, should be further investigated. Steps should be taken to learn from risk events, and ultimately, risk control measures should be enacted. When risks are identified, they are often categorized for further stratification. Risks are often looked at in terms of the chance of loss or gain, diversifiability, subjectivity, and responsiveness to external factors. Key risk
indicators can also be used to identify risks and can be defined before or after a risk event. Within EM, risks can be categorized in other ways, such as situational, conditional or personnel related risks. Situational risks might include transitions of care, interactions with consultants or ancillary services, procedures, equipment, documentation, or disposition. Conditional risks might include high risk or time-sensitive diagnoses, or those diagnoses requiring transfer for a higher level of care. Personnel risks might include insufficient familiarity with a system (e.g., for new hires), or insufficient fund of knowledge (e.g., for trainees). Risk quantification and prioritization is often reflected in an organization’s risk attitude, which translates to a degree of risk tolerance. Policies and goals are established in accordance with an organization’s appetite for, or aversion to, risk. Risks can further be quantified and prioritized using a framework known an enterprise risk management (ERM). Within ERM, risks are categorized into hazard risks, operational risks, financial risks, and strategic risks. Hazard risks are threats to either property (damage/ theft) or personnel (employee injury). Operational risks can be external or internal to the organization. External operational risks might include problems with supply chain, whereas internal risks include technology, security, quality control, and training of employees. For EM, financial risks might include the billing and revenue cycle, insurance audits, malpractice, and litigation. The investigation and reporting of risks events if often done by the risk management team, centralized throughout a hospital or health system. Individual people and departments should be encouraged to report risks through established internal reporting systems, so that they may be escalated by the risk management department if needed.
Many times, decisions regarding risk, while well-intended to improve patient care, are made by administration, without frontline physician input
Risk management strategies may be instituted system wide but may also be employed on a local level. Generally, there are four strategic approaches to risk management. Risks can be retained, that is, accepted as an essential piece of departmental operations. Conversely, risks can be avoided and removed entirely from the departmental milieu. The transfer of risk to a third party, such as an insurance company, is another strategy. Finally, risk reduction or mitigation involves taking actions to limit the occurrence, impact, or both, of a risk. A key tool for risk management is a risk map (Figure 1). Risk maps plot risks based on the likelihood of occurrence of the risk and the severity of the risk. As such, the maps are sectored into four quadrants—one low risk, one high risk, and two medium risk quadrants. >>
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COMMON SENSE MARCH/APRIL 2024