For some human-service provider organizations, risk management is simply a by-product of the insurance-buying process. Others consider risk management to be an inherent part of their organizations’ cultures. As providers strive to reach the highest levels of service quality, they must keep in mind their risk-management processes, which in many cases are defined by a mission to support individuals with disabilities in achieving their full potential for independence in the community.
Traditional risk management is a structured process for controlling losses and reducing the uncertainty of risk. It consists of five steps: risk identification, risk evaluation, risk treatment, implementation, and monitoring and revision. However, as a provider agency reaches the level of meeting all quality standards, it needs to look beyond traditional risk management. Agency officials should not fall into the trap of thinking that by meeting the minimum standards set in state and federal regulations, the agency has achieved its ultimate goal.
A quality-driven agency should understand that quality constitutes a continuous learning process. A major part of that process involves developing an in-depth risk-management program—one that is open to revision and input from all levels, but most importantly from senior management. Risk management should become a systematic approach to minimizing loss potential that is driven by the organization's mission, with a strategic focus intended to ensure quality.
Allegations against a human-service agency can include negligent hiring, negligent supervision, sexual assault, violation of professional boundaries, and wrongful death. In working with hundreds of provider agencies across the country and examining claims against them, the Irwin Siegel Agency has identified five distinct areas as key contributors to the claims. The agency's Risk Management Support Continuum targets these five areas that are partly responsible for poor-quality outcomes: culture, treatment plans, policies and procedures, frontline staff (direct-care professionals), and the standard of care. A closer look at the five areas illustrates the diversity of risk-management challenges that provider agencies face.
The quality of an agency's management team reflects the quality of the agency. Leadership holds the key to creating an organizational culture that follows its mission, focuses on the consumer, and consistently looks to improve its services and supports. Key components of a quality culture include a formal risk-management committee, parent/consumer review committees, a human-rights committee, administrative site visits, and zero-tolerance policies for abuse. Organizational leadership assumes a critical role in developing a learning organization, as well as ensuring that a viable risk-management system is in place so that the organization may stay true to its mission.
Based on a review of incidents and claims, it becomes clear that most of those involving consumers can be directly linked to staff not following an individual's treatment plan. Investigations often find that staff, especially new staff, are not trained in the consumer's plan. A well-prepared plan includes input from the consumer, staff, family members, and everyone else who is part of the consumer's circle of support. The plan articulates the person's health needs and goals, and outlines steps on how to achieve them. Staff members need to be aware of any changes to the plan, especially when they affect service delivery. When a change is made (e.g., in staffing ratios for a consumer presenting behavioral challenges) and staff members are not informed, this can affect the standard of care and equate to poor service quality, leading to negative outcomes and serious incidents.
Policies and Procedures
Policies and procedures are generally designed to ensure the effective delivery of the services and supports that are critical to an agency fulfilling its mission. Many policies are developed and revised based on experiences—usually bad ones. Many providers have great written policies and procedures, but staff often are not aware of their content. In other cases, they aren't revised for several years. Sometimes key policies and procedures are not well defined or are missing completely in areas such as sexual behavior, suicide prevention, medication administration, behavior modification/restraints, and incident investigation. When revisions are made or new policies and procedures are written, all staff should be trained on them (including third-shift and weekend staff).
Direct-care professionals have one of the toughest—yet most rewarding—jobs in the human-services industry. At the heart of quality care is the person providing the direct support to the consumer. Also involved at this level is the supervisor/middle manager. Proper staff selection, training, and supervision are critical. If the agency has a program in place to screen incoming staff appropriately, and provides proper and sufficient staff supports, achieving high-quality outcomes becomes likely.
Consultant and quality guru W. Edwards Deming generally attributed quality failure to system failure, not worker failure. An agency can write good policies and procedures, conduct person-centered planning, support self-determination, and be recovery-focused, but if the staff member is not encouraged to continue to learn and improve job performance, then sooner or later he/she will feel unvalued and lose interest in the job. When this occurs, the potential for the agency to incur professional losses increases.
Standard of Care
If an incident becomes a claim and a claim becomes a court case, it's likely that the plaintiff's attorney will bring in a “field expert” to evaluate and testify against the agency. An all-inclusive risk-management program, one open to consistent review, will invite such an expert in before an incident occurs in order to evaluate services.
Meeting a standard of care involves exhibiting the amount of skill and training ordinarily possessed and exercised by professionals providing similar services. For example, if an agency provides services for people with suicidal ideation, do staff members know the right questions to ask? Are they formally and properly trained in suicide prevention? Do they understand the supports and safeguards needed? A lack of these supports adversely affects care and potentially increases the frequency of incidents and their severity.
Services and supports provided by agencies are designed to enable each person served to guide his/her own personal growth and to make decisions about services received. While respecting each individual's wishes, the service system must ensure that the proper safeguards are in place to protect the health, safety, and rights of anyone receiving services and supports. As stated earlier, the agency's primary goal is to support the individuals it serves so that they may reach their fullest potential for independence.
Risk management is a process for achieving a better understanding of potential loss areas related to the health and safety of consumers and staff, and the integrity of the organization. The risk-management process further ensures that service quality continuously improves. Like recovery, risk management is a journey, not a destination. When agency officials think they have reached their ultimate goals in quality, it is at that point that they need to reevaluate and aim higher, in the hope that the steps taken will help the organization move closer to managing liability.Sean Gerow is Assistant Vice-President of Risk Management for the Irwin Siegel Agency, a national company insuring human-service provider agencies. He is a former director of residential services for a long-term care facility, where he implemented a mental health and aging program. Gerow serves as board chairman of the Suicide Prevention Action Network USA.