Health Care Team (HCT)

A health care Risk Manager develops and enforces a risk management program plan and enacts the changes in clinical practice, policy and procedure, and employee and medical staff behavior necessary to fulfill that plan. The purpose of the plan is to preserve the assets, reputation, and quality of care of an organization through a process that identifies and reduces or eliminates the risk of loss.

Risk management is defined as the process of making and carrying out decisions that will assist in the prevention of adverse consequences and minimize the adverse effects of accidental losses upon an organization. The risk management program is designed to identify, assess, prevent, and control losses that can arise from employee work-related injury, liability, property, regulatory compliance, and other loss exposures.It also encompasses the evaluation and monitoring of clinical practice to recognize and prevent patient injury.

The roles and responsibilities of Risk Managers vary widely. The Risk Manager’s functional areas of responsibility include loss prevention and reduction (clinical and non-clinical), claims management, risk financing, patient safety, and regulatory and accreditation compliance. Risk Managers work in a variety of health care settings, including acute care medical centers, integrated delivery systems, academic medical centers, behavioral care (substance abuse, mental health), ambulatory care, long-term care, and the insurance industry. Risk Managers are responsible for coordinating risk management activities with the medical staff, managers, and employees at all levels of the organization. This includes fostering an awareness of risk management practices and techniques through education and communication among senior management and the governing body, medical staff members, and employees at all levels.

To be successful, Risk Managers must develop a variety of skills necessary for performing a difficult job in a complex environment. A Risk Manager is someone who can communicate effectively (verbally and in writing), negotiate, remain objective, maintain confidentiality, organize, and prioritize.

Education and training vary for Risk Managers, in part because of the way in which the profession has evolved. The professional and educational backgrounds of Risk Managers include nursing, law, administration, quality assurance, and insurance. Risk Managers may hold a bachelor’s degree, a master’s degree, or a juris doctor. They often have clinical training as a registered nurse. Other clinical training backgrounds include social work, medical technology, physician, physical or respiratory therapy, and pharmacy.

A Risk Manager may report to the chief executive officer, senior officer/vice president, director of risk management, or director of quality. The reporting relationship varies depending upon the Risk Manager’s position in the organizational hierarchy.

A Risk Manager must deal with sensitive and confidential information that directly affects the organization’s public image and financial status. These activities may include:

• managing claims against the organization
• communicating with defense legal counsel
• managing and analyzing risk management data
• conducting risk management educational programs
• triaging complaints and claims related to professional and general liability
• coordinating insurance coverage and risk financing
• complying with risk management standards established by The Joint Commission and other accrediting and regulatory agencies

The objective always is to enhance patient safety while promoting quality care.

Licensure requirements for Risk Managers vary by state. Risk Managers should be aware of and understand the state-specific statutes and regulations that govern their work environments. Professional designations held by a Risk Manager may include:

• Certified Professional in Healthcare Risk Management (CPHRM)
• Associate in Risk Management (ARM)
• Certified Professional in Healthcare Quality (CPHQ)

Though Risk Managers are not engaged in patient care, any type of patient who has experienced an adverse event or medical error may have this information disclosed by a Risk Manager. Disclosure is defined as the communication of information regarding the results of a diagnostic test, medical treatment, or surgical intervention.

Generally, Risk Managers are not directly engaged in patient care. A Risk Manager may provide support to a patient or family, as well as members of the health care team, after an adverse event or medical error. They may also provide support when there are concerns involving the quality of care rendered to a patient or general patient safety concerns. Such support may include facilitating effective communication between the patient/family and other members of the health care team relative to the disclosure of the event. Risk Managers may assist with making an apology, managing patient and family emotions, and dispute resolution.

Residents should contact a Risk Manager (and their attending physician) whenever there is an adverse patient care outcome as a result of an error in management, or even when the patient or family express concern that an error may have occurred.