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The voices of change: building a better field through collaboration and innovation
Upper Lobby
The voices of change: building a better field through collaboration and innovation
The Risk Authority
The Risk Authority Stanford’s book, Inside Looking Up, is a scholarly, practice-based work for leaders in health care, and those invested in transformation, to begin reconsidering, reassessing, and enhancing... Read more

Description

The Risk Authority Stanford’s book, Inside Looking Up, is a scholarly, practice-based work for leaders in health care, and those invested in transformation, to begin reconsidering, reassessing, and enhancing traditional risk management practices.
The following case study on a communication and resolution program (CRP) introduces one example of the innovative methodologies explored throughout the book. 

A Case of Medical Error 
A critically ill child was being monitored on the telemetry unit. The frequency of the sounding alarms prevented the child and his mother from getting any sleep. In a compassionate effort to reduce the noise in the room, the nurse silenced the monitor next to the bed. But, in giving some quiet to the child and his mother, the nurse inadvertently silenced more than the monitor next to the bed, she silenced the alarms on her pager and at the central unit station. When the child experienced a cardiac event, there was no alarm to notify the nurse or any member of the unit care team. The child died.

The Role of CRPs 
The organization thoroughly reviewed the circumstances and discovered a safety issue with the monitoring system that could have an impact on other patients. Rather than focusing on the liability risk to the organization, the focus remained on patient safety. The organization alerted all other hospitals using the same monitors of the event in an effort to prevent harm to other patients. Additionally, the organization continued to share information with the child’s family in an effort to express sincere apology and commitment to ensuring such a tragedy did not happen again. 

CRPs act on multiple dimensions to improve health systems, address the needs of patients after unexpected outcomes and enhance the claims management process. The Risk Authority Stanford’s CRP is called PEARL (Process for Early Assessment, Resolution, and Learning) and it is used in Inside Looking Up to demonstrate how CRPs can further innovate and thrive via patient liaisons, peer support programs, and a limited liability model CRP. 

PEARL reveals a promising future, conveying improved satisfaction among patients, caregivers, and physicians after unexpected outcomes, as well as improving patient safety to prevent future adverse events. PEARL has been shown to reduce costs without increasing litigation, as demonstrated by the results of a study by an independent actuary. A pre/post analysis of 2003-2008 vs. 2009-2014 shows that after PEARL was implemented, the frequency of lawsuits was 50% lower, indemnity costs in paid cases were 40% lower, and defense costs were 30% lower for cases handled through PEARL. 

CRPs like PEARL are one example of emerging risk management strategies explored in Inside Looking Up. It is the intention of this text to offer similar insights on how, through buy-in, collaboration, and dedicated resources, a commitment to innovation can assist managers of risk in building a better playing field that benefits all. 

From lawyers to clinicians, to finance strategists, safety engineers, and patient communication specialists, The Risk Authority Stanford team is comprised of individuals that are committed to improving the effectiveness and efficiency of care delivery systems through innovation – and we know that we are not alone. 

It’s time to charge forward, together.

Jeff has more than 25 years of experience as a risk management professional and has managed the enterprise risk in community, tertiary and academic medical centers. A frequent speaker and author on risk management issues, Jeff has expertise in incorporating and managing subsidiary insurance companies, and assuring organization corporate compliance, as well as in claims and litigation management, patient safety and loss control, employment practices consulting, and the development, reorganization and implementation of alternate risk financing programs.   

Jeff serves as the chief executive officer of The Risk Authority Stanford and as the chief risk officer of Stanford Health Care and Stanford Children’s Health. Before joining Stanford, he was chief risk officer and director of regulatory advocacy at the Beth Israel Deaconess Medical Center in Boston. He is a past president of ASHRM (2004), served on its board of directors and was steering committee chair of its JCAHO Liaison, Advocacy and Legislative & Regulatory Affairs task forces. He has also served as faculty to ASHRM’s Barton Certificate in Healthcare Risk Management Program and to the Harvard Medical School.  Jeff is a member of the State Bar of California and has been designated as a Distinguished Fellow by the American Society for Healthcare Risk Management (ASHRM) and an Associate in Risk Management by the Insurance Institute of America. In 2008, he was awarded membership to the Risk Management Honor Roll by Business Insurance Magazine.  Jeff holds a JD from Thomas Jefferson School of Law in San Diego, an MBA from Cleveland State University, a BS in Allied Health Clinical Professions from Ohio State University and is an AHA Patient Safety Fellow.

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