Risk Management for Physiotherapy Offices

Risk Management for Physiotherapy Offices
Introduction to the Issue
Risk management is needed in any health care setting due to the rising costs of liability and a need to guarantee value for money to clientele. Subsequently, health care practitioners, administrators, and the directors of the facility may also take a major hit when mishaps occur, such as client falls, malfunctioning equipment, and improper medication distribution. Health care organizations, such as physiotherapists’ offices, are beginning to become characterized by how they conduct business and manage their workforces in addition to what they do to help clients recover from illness. The overall effect of not performing a risk management evaluation and interventions increases the need for additional medical resources in addition to litigation costs. In order for this to happen, health care organizations need to incorporate tenets of the philosophy of creating a quality work environment that involves both professional ethics and careful, best-practice-based planning processes.
Theoretical foundation. In this review of risk management best practices for a health care organization such as a physiotherapy office, the underlying theoretical foundation is that of quality work environment theory. The concept of a quality work environment, according to Maxfield, Grenny, Patterson et al. (2005) is specifically linked to developing a culture of coordinated client safety and care so that risks are mitigated. This is because, when team members’ skills come under pressure, there could be a higher chance of cutting corners or making mistakes, all of which can lead to a lack of safety for not only clients, but also for staff members in a health care environment. A lack of safety could lead to client injury or death, staff injury, medication problems, or even lawsuits and malpractice considerations. In their conception of quality, Maxfield et al. (2005) argue that it is necessary to build up a constant stream of open communication in order to ensure that the highest standards of safety and care are provided for each client. As they note, without this type of communication, clients are at risk, because of the fact that “The most alarming finding of the study was that only one in ten healthcare professionals today actually speak up when facing these kinds of concerns” (Maxfield et al., 2005, p. 2). For these reasons, a quality environment that is aligned with a high level of risk management is one that supports dissent and discussion (McGillis Hall, 2005).
Practical foundation. This risk management plan will employ a Six Sigma framework. Under Six Sigma, the quality of process outputs is improved via identifying and removing the causes of errors via minimizing the variability in service that arises in a health care practice (Chassin, 2013; Martens, Goode, Wold et al., 2014). This entails the creation of a special internal infrastructure within the organization that incorporates quality leaders who are there to ensure that quality control methods are used consistently (Chassin, 2013; Martens et al., 2014). Each and every Six Sigma project in an organization will have a defined sequence of risk management and quality control steps as well as quantified financial targets that must be met (Harry & Schroeder, 2006).
Risk Management Best Practices
Planning. Before any risk management plan is put into action, the Six Sigma process demands that a quality audit takes place. This process would allow the organization to dig deeper into what makes employees successful at mitigating risks, both internally, through an analysis of social networks and knowledge centers where client care practices can face barriers and gaps, and externally, through client or client surveys and focus groups (Janakiraman & Gopal, 2006). After this process is complete, allow the organization then needs to conduct a gap analysis on training on any identified risks, and also determine what types of risk management information are needed to fulfill client needs prior to implementing any changes in coordination of care. In addition, according to Janakiraman and Gopal (2006), to show true leadership in Sig Sigma processes at a health care organization, the organization will likely need to evaluate these findings, and undergo a values audit to re-imagine and re-create its mission for risk management. A new system of risk management must be consistent with evidence-based and safe practices appropriate for the physiotherapy setting, and in particular, to communication issues serving as a barrier to current delivery of quality client care.
Needed controls of people, process and technology. Risk management needs to begin at the top of the organization, with an assessment of how risk protocols and quality criteria are communicated by leaders. This is because the origins of poor work environments are often linked to leadership. McGillis Hall (2005) describes three major functions that all health care leaders must perform to achieve quality for their organizations: image management, relationship development, and resource deployment. Image management refers to the sense of legitimacy and credibility that a leader projects to followers. Although specific behaviors associated with credibility vary across social and organizational domains and cultures within health care, one commonality is that all leaders must be viewed as competent, honest, and loyal to group norms and values. Poor work environments arise when these behaviors are not valued. Relationship development refers to how a member of the health care team interacts with clients and communicates their intentions, and the choices that the client has with respect to their own care. Resource deployment refers to learning how and when to use different people, tools, and processes that can mitigate risk when it takes place. A health care organization that creates a foundation of trust between its colleagues is one that allows for quality to build on both the client level and the professional level, according to McGillis Hall (2005). This means that there is a need to recognize that processes come second to the people who work for the health care organization, because clinical environments are those in which there is a significant propensity for quick decision making. If the right health care team and processes are in place, and trust is made a priority, then there is a good chance that the health care organization will be able to adapt to whatever they face in terms of risk. Bringing leadership into the ranks of the organization, rather than only at the top, allows health care organization to create the means by which each team member has the confidence to make choices that benefit clients.
One of the major challenges in medicine today is quality improvement and identifying just what evidence-based mechanisms, guidelines and implementation methods can prove effective at improving client care (Institute of Medicine, 2001). To this end, best practice risk management practices are linked to the use of an ongoing gap analysis, in which a current organizational need is recognized, an end goal is identified, and a strategy is created in order to abate risks in a loop (Vincent, Burnett, & Carthey, 2014). What this means is that instead of being focused on quality alone, risk management is focused on the process which can lead to ongoing development of best practices and a constant review of quality frameworks. This reflects the findings of Harry and Schroeder (2006), who state that in organizing change, companies do not have to focus on whether or not they succeed or fail, but instead on the level of quality at which they are trying to aim. All organizational leaders at a physiotherapy office need to buy into this organizational mandate of continuous improvement. Specifically, structuring a new system of physiotherapy care consistent with evidence-based and safe practices is appropriate for the setting, and in particular, to process-oriented issues serving as a barrier to current delivery of quality client care.
As well, the organization needs to implement medical information systems through technology which allows health care professionals to access integrated data about clients, their previous care, and their medication (Stange, Etz, Gullett et al., 2014). This is because, as noted by O’Grady (2008), “as data systems evolve and payers insist on “paying for performance,” a level of accountability and transparency will be required regardless of provider type or health care setting” (p. 11). Internal coding that promptly identifies some clients as having specific complex problems can, from the outset, ensure that the proper health care team members and support staff are available to assist the individual in question. If there is a typology at the front desk that makes diagnosing a problem easier, and if the coding in place is fast and easy to use, then the front office staff – in the absence of any documentation from the client – can make a quick determination and the right team members on duty can be notified immediately so that risks can be abated.
Communication processes also need to be codified. Decision makers at a health care organization need to implement a tight risk management feedback loop that is typified by defining the client need, measuring the problem, analyzing the protocols that are necessary, proactively stepping forward to tackle the problem, and controlling the outcome that results. If the communication process is too lax or the measurements are imprecisely shared between team members, even if they are collected correctly, then a problem that seems insignificant at one point can grow into something very challenging over the course of a client’s care, specifically if accidents occur. The medical staff will have to learn new methodologies for using client information within the new information technology system, sharing it among different internal units, and making decisions regarding client care. The health care organization needs to utilize collected data to create a new and more efficient structure that has a direct impact on saving clients’ lives. As well, to achieve this goal, it is recommended that the physiotherapy office use a declarative strategy in which team leaders communicates the change and its chosen methods to the entire health care staff through not only training on these systems, but also linked to the way in which team members are evaluated and provided incentives for key goals. By building more structured bridges between employees at different levels, the organization can link its challenges with solutions, and better codify organizational and employee informational and training gaps which will lead to continuous quality improvement and lower risk (Janakiraman & Gopal, 2006).
Training and testing processes for compliance. Risk management protocols involve direct training and ongoing testing. This includes training on communication between health care professionals and to clients, client and staff safety including reduction of errors, improvement in technological resources, and the consistent monitoring of all quality assurance protocols and practices (Chetter, 2009). Nonetheless, this process is not always as simple as it seems, even with a focus on safety as a focal point of training. A culture of safety is one in which health care professionals know how and when to communicate their needs and the needs of the client, which is critical to the process of mitigating risk. In an evidence-based study, Wagner, Capezuti, and Rice (2009) found that there was often a disconnect between health care managers’ perceptions of safety, and the perceptions of nurses on the floor as well as student nurses in practicum. As they write, there is a need for interventions which are designed to improve a culture of safety in the average health care organization, and these “should be focused on the concerns of licensed staff nurses and the improvement of communication between these nurses and their managers” (p. 184). Without clear communication and a commitment to creating this kind of culture, there will be disconnects between what is expected of nurses and what actually takes place with clients. For example, as noted by Reid-Searl, Moxham, Walker, and Happell (2010), health care team members often feel that it is necessary to conform to a hospital culture for the benefit of others, which suggests that cultural norms become quickly accepted and replicated in a clinical environment. While in a culture of safety, health care team members would be likely to base their decisions on professional expertise and pride, namely the ability to demonstrate their knowledge and concern for client safety, in cultures that did not focus on these goals, health care team members would absorb a different approach to care (Reid-Searl et al., 2010).
There is a need to look at multiple layers of education and support when creating an education program for safety and risk management that has the desired effects on the skills of health care team members. Looking at a process instituted at a nursing program that was devised to cull unsafe clinical practices, Brown, Neudorf, Poitras, and Rodger (2007) found that there was a difficulty in clinical teachers’ actions in both identifying risks that were associated with student practices, as well as ways in which these risks could be addressed. This research team found that it was necessary to implement a more systematized approach to delivering competent care that involved multiple levels of safety and risk management engagement that included mentorships, clear expectations, and additional support for team members in need of assistance. In a similar vein, Lewallen and DeBrew (2012) looked at positive and negative aspects of clinical performance in terms of safety through the point of view of nurse educators and discovered that attitude, preparation, and commitment to the process of learning were key factors that led to positive safety practices. Likewise, Killam, Montgomery, Raymond et al. (2012) point out that there is a need to come to terms with the context of culture, social support systems, critical inquiry, and team member attitude in planning for a more comprehensive training program that would result in better safety and risk management. The Killam, Mossey, Montgomery, and Timmermans (2013) research found that health care team members were affected by their own internal negativity about their skill sets, as well as a lack of professionalism and ethics in completing their clinical duties, as causes for unsafe practices, and concluded that clinical instructors must be aware of these challenges in order to develop appropriate teaching processes. To this end, Steven et al. (2014) have recommended a simplification of the safety training process in health care contexts so that students were better equipped to deal with issues. In this way, to avoid unsafe clinical practices, evaluating and supporting team members’ needs to take place within a multilayered approach to student training and evaluation.
Finally, there is a need to look at practical processes that may help health care team members with the development of critical thinking skills as well as client safety skills in the health care classroom. For example, Henneman, Roche, Fisher, et al. (2010) measured how unsafe clinical learning situations could be avoided through the use of simulation techniques and their research found that health care team members were better prepared when exposed to high-fidelity simulation processes at least at the senior level. Given these findings, Henneman et al. (2010) recommended that high-fidelity simulation practices be implemented when and if possible in order to avoid risk. It is important to examine what simulation practices are helpful in order to ensure that physiotherapy office health care team members learn how to provide care which is safe, feasible, and compassionate at the same time, but at the same time underling the fact that safety is a paramount consideration in developing critical clinical skills.
Ongoing documentation and review. Annual evaluations must be conducted to see if the types of changes that are being implemented are actually working. Those protocols that are working will be continued and those that are not working will require more attention in the following calendar year. Structure, process, and outcomes are what are typically monitored to ensure quality assurance protocols and practices are taking place in the physiotherapy office. Structure refers to elements such as training of staff, proper mix of skills, diagnostic and therapeutic resources and client care. Process includes the distribution and utilization of resources, both diagnostic and therapeutic, for client care and for all treatments rendered. Outcomes are the consequences of treatments and include injuries, errors, and mortality rates and so on (Ward, Daniels, Walker & Duckett, 2007). External entities will be consulted for the educational training and possibly annual audits. Accrediting bodies and professional interest groups can play a critical role in helping the physiotherapy organization objectively evaluate where they are and where they need to be.
Conclusions
Developing a culture of coordinated client safety and care so that risks are mitigated requires any physiotherapy office to create a quality work environment based on Six Sigma principles of practice. This process begins with a quality audit, new controls of people, process and technology, an increased focus on communication and records maintenance, as well as an ongoing gap analysis that results in frequent training and testing processes for compliance to risk management protocols and practices. As well, multiple layers of education and support must be delivered when creating an education program for safety and risk management that has the desired effects on the skills of health care team members. Annual evaluations need to be conducted to see if the types of risk management protocol changes that are being implemented are actually working.
In addition, in order to support risk management and client safety protocols on the job, there are often very specific organizational cultural issues that affect the ability of health care team members to deliver safe care at all times. To this end, positive communication needs to be a priority for all clinical health care workers, and there needs to be support for divergent points of view especially in high risk client situations. Leadership attributes need to be developed in order to create evidence-based practices to develop appropriate care decisions for clients and lower risk. Fostering and implementing new ideas to create physiotherapy office environments that support the development of a culture of safety may be challenging, but if organizational leaders can help shift the way that health care team members think about safety and risk management and build efficiencies into current protocols and systems, it will ultimately lead to better client care. This kind of focus on the development of clear solutions can only lead to augment the level of professional standards in the physiotherapy clinic and the clinic’s ability to meet client needs over the long term.


References
Brown, Y., Neudorf, K., Poitras, C., & Rodger, K. (2007). Unsafe student clinical performance calls for a systematic approach. The Canadian Nurse, 103(3), 29-32.
Chassin, M. R. (2013). Improving the quality of health care: What’s taking so long? Health Affairs, 32(10), 1761-1765.
Chetter, T. G. (2009). Statistical process control part 2: Using statistical process control to measure process improvement in client flow. Australian Health Review, 33(3), 412-422.
Harry, M. & Schroeder, R. (2006). Six Sigma: The Breakthrough Management Strategy Revolutionizing The World's Top Corporations. New York: Random House.
Henneman, E. A., Roche, J. P., Fisher, D. L., Cunningham, H., Reilly, C. A., Nathanson, B. H., & Henneman, P. L. (2010). Error identification and recovery by student nurses using human client simulation: Opportunity to improve client safety. Applied Nursing Research, 23(1), 11-21.
Institute of Medicine. (2001). Crossing The Quality Chasm: A New Health Care System For The 21st Century. Washington, DC: National Academy Press.
Janakiraman, B., & Gopal, R. K. (2006). Total Quality Management: Text And Cases. Delhi: PHI Learning.
Killam, L. A., Montgomery, P., Raymond, J. M., Mossey, S., Timmermans, K. E., & Binette, J. (2012). Unsafe clinical practices as perceived by final year baccalaureate nursing students: Q methodology. BMC Nursing, 11(1), 26-42.
Killam, L. A., Mossey, S., Montgomery, P., & Timmermans, K. E. (2013). First year nursing students' viewpoints about compromised clinical safety. Nurse Education Today, 33(5), 475-480.
Lewallen, L. P., & DeBrew, J. K. (2012). Successful and unsuccessful clinical nursing students. The Journal of Nursing Education, 51(7), 389-395.
Martens, L., Goode, G., Wold, J. F., Beck, L., Martin, G., Perings, C., ... & Baggerman, L. (2014). Structured syncope care pathways based on lean Six Sigma methodology optimises resource use with shorter time to diagnosis and increased diagnostic yield. PLoS ONE, 9(6).
Maxfield, D., Grenny, J., Patterson, K., McMillan, R. & Switzler, A. (2005). Dialogue Heals. New York: VitalSmarts.
McGillis Hall, L. (2005). Quality Work Environments For Nurse And Client Safety. New York: Jones & Bartlett Learning.
O’Grady, E. T. (2008). Advanced practice registered nurses: The impact on client safety and quality. In R. G Hughes (Ed.), Client Safety And Quality: An Evidence-Based Handbook For Nurses. Retrieved from http://www.ahrq.gov/qual/nurseshdbk/docs/O%27GradyE_APRN.pdf.
Reid-Searl, K., Moxham, L., Walker, S. & Happell, B. (2010). “Whatever It Takes”: Nursing students' experiences of administering medication in the clinical setting. Qualitative Health Research, 20, 952-966.
Stange, K. C., Etz, R. S., Gullett, H., Sweeney, S. A., Miller, W. L., Jaén, C. R., ... & Glasgow, R. E. (2014). Metrics for assessing improvements in primary health care. Annual Review Of Public Health, 35, 423-442.
Vincent, C., Burnett, S., & Carthey, J. (2014). Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety. BMJ Quality & Safety, 23(8), 670-677.
Ward, M., Daniels, S. A., Walker, G. J., & Duckett, S. (2007). Connecting funds with quality outcomes in health care: A blueprint for a Clinical Practice Improvement Payment. Australian Health Review, 31(5), 54-58.
Wagner, L. M., Capezuti, E., & Rice, J. C. (2009). Nurses' perceptions of safety culture in long‐term care settings. Journal of Nursing Scholarship, 41(2), 184-192.