Evidence on Fall and Injurious Fall Prevention Interventions in Acute Care Hospitals.

Falls and injurious falls are a major safety concern for patient care in acute care hospitals. Inpatient falls and injurious falls can cause extra financial burden to patients, families, and healthcare facilities. This article provides clinical implications and recommendations for adult inpatient fall and injurious fall prevention through a brief review of factors associated with falls and injurious falls and current fall prevention practices in acute care hospitals.

[Simulation training as part of clinical risk management : A health economic view]. / Simulationstraining als Teil des klinischen Risikomanagements : Eine gesundheitsökonomische Betrachtung.

Working in anesthesiology is characterized by a complex environment in which effective teamwork with different disciplines as well as other professions (e. g. nursing staff and surgical assistants) is crucial. Clinical risk management includes all steps to prevent incidents and patient harm. An example for this is simulation training based on crisis resource management (CRM). This training course focuses on teaching non-medical skills using simulation manikins in order to enable employees to maintain patient safety under the adverse, ever-changing and unfamiliar conditions of a medical emergency. In detail, this involves skills, such as situation awareness, teamwork, decision making, task management and communication, whereby all elements must be taken equally into account to be effective in terms of CRM. A sustainable training aims to build up, promote and permanently establish a mindset within the team. Positive effects of these could be demonstrated for long-term training that addressed the entire patient care team and that was implemented along with various other patient safety measures. In addition, other positive aspects of simulation training, such as stronger employee retention or more effective task management in critical situations are described; however, hospitals are often found to have difficulties in financing these training sessions. This article shows possible health economic considerations in the discussion about financing CRM-based simulation training. Cost-benefit and cost-effectiveness analyses are difficult to perform. They require an individual planning. Regardless of this, simulation training enables participants to experience (simulation) and reflect their own actions in critical situations (debriefing). With the help of specially trained CRM instructors, deviations from expected behavior can be detected. This non-conformity can be used as a starting point for the establishment and further development of patient safety by a structural analysis of possible failures within the system. The decision to finance CRM-based simulation training remains a fundamental decision of the management of the respective hospital. In the near future, pressure from liability insurers to prevent incidents might increase. The inclusion of CRM-based simulation training as an integral component of clinical risk management could provide key benefits in contract negotiation.

Cost-effectiveness and comparative effectiveness of cancer risk management strategies in BRCA1/2 mutation carriers: a systematic review.

PURPOSE: To review the evidence for the effectiveness and cost-effectiveness of cancer risk management interventions for BRCA carriers. METHODS: Comparative effectiveness and cost-effectiveness analyses were identified by searching scientific and health economic databases. Eligible studies modeled the impact of a cancer risk management intervention in BRCA carriers on life expectancy (LE), cancer incidence, or quality-adjusted life years (QALYs), with or without costs. RESULTS: Twenty-six economic evaluations and eight comparative effectiveness analyses were included. Combined risk-reducing salpingo-oophorectomy and prophylactic mastectomy resulted in the greatest LE and was cost-effective in most analyses. Despite leading to increased LE and QALYs, combined mammography and breast magnetic resonance imaging (MRI) was less likely to be cost-effective than either mammography or MRI alone, particularly for women over 50 and BRCA2 carriers. Variation in patient compliance to risk management interventions was incorporated in 11/34 studies with the remaining analyses assuming 100% adherence. CONCLUSION: Prophylactic surgery and intensive breast screening are effective and cost-effective in models of BRCA carrier risk management. Findings were based predominantly on assuming perfect adherence to recommendations without assessment of the health-care resource use and costs related to engaging patients and maximizing compliance, meaning the real-world impact on clinical outcomes and resource use remains unclear.

Evaluating Partnerships to Enhance Disaster Risk Management using Multi-Criteria Analysis: An Application at the Pan-European Level.

Disaster risk is increasingly recognized as a major development challenge. Recent calls emphasize the need to proactively engage in disaster risk reduction, as well as to establish new partnerships between private and public sector entities in order to decrease current and future risks. Very often such potential partnerships have to meet different objectives reflecting on the priorities of stakeholders involved. Consequently, potential partnerships need to be assessed on multiple criteria to determine weakest links and greatest threats in collaboration. This paper takes a supranational multi-sector partnership perspective, and considers possible ways to enhance disaster risk management in the European Union by better coordination between the European Union Solidarity Fund, risk reduction efforts, and insurance mechanisms. Based on flood risk estimates we employ a risk-layer approach to determine set of options for new partnerships and test them in a high-level workshop via a novel cardinal ranking based multi-criteria approach. Whilst transformative changes receive good overall scores, we also find that the incorporation of risk into budget planning is an essential condition for successful partnerships.

[Incentive for Regional Risk Selection in the German Risk Structure Compensation Scheme]. / Anreize für regionale Risikoselektion unter dem Morbiditätsorientierten Risikostrukturausgleich.

The introduction of the new law GKV-FQWG strengthens the competition between statutory health insurance. If incentives for risk selection exist, they may force a battle for cheap customers. This study aims to document and discuss incentives for regional risk selection in the German risk structure compensation scheme. Identify regional autocorrelation with Moran's l on financial parameters of the risk structure compensation schema. Incentives for regional risk selection do indeed exist. The risk structure compensation schema reduces 91% of the effect and helps to reduce risk selection. Nevertheless, a connection between regional situation and competition could be shown (correlation: 69.5%). Only the integration of regional control variables into the risk compensation eliminates regional autocorrelation. The actual risk structure compensation is leading to regional inequalities and as a consequence to risk selection and distortion in competition.

[Impact assessment of inadequate hospital disaster management : Reflection based on a risk model]. / Folgen einer unzureichenden Krankenhaus-Katastrophenplanung : Betrachtung anhand eines Risikomodells.

BACKGROUND: According to legal regulations alarm and emergency plans have to be developed and kept current in hospitals. However, often neither the hospital administration, nor the medical employees and nursing staff pay the necessary attention to these alarm and evacuation plans. In particular, risks and consequences - including financial ones - due to insufficient planning, are not adequately considered. OBJECTIVES: Risks in hospitals are assessed based on a risk analysis. The risk assessment evaluates, whether the risk is acceptable, critical or unacceptable. Parameters for the risk analysis are the magnitude of damage and number of affected people. The intention of this paper is to evaluate whether there is a connection between estimated risk, quality of risk planning, and financial damage. MATERIALS AND METHODS: We visualized the risk analysis as a two-dimensional matrix. In addition, we introduced disaster planning quality as a third dimension and calculated the dependency between risk and planning quality and also between the resulting damage level and the planning quality. RESULTS: We showed that a poor disaster planning quality increases the unacceptable risk exponentially. Risk assessment can also draw conclusions about the extent of financial damage caused, for example fires, terrorist attacks or infrastructure failure. The amount of damage can be described as a function depending on the planning deficit of emergency planning. The worse the planning quality, the higher the amount of damages for non-tolerable risks can be. CONCLUSIONS: Risk management means recognizing risks, assessing risks and managing risks. In hospitals, this mostly means using a critical incident reporting system (CIRS), however risk management in the sense of disaster planning is largely unknown. With a three-dimensional risk matrix, we showed a clear correlation between the quality of disaster planning and relative risk or financial damage. To substantiate the presented theoretical considerations, however, further research must be designed and implemented.

[Quality Management for Surgeons: The Knowledge of Basic Contexts and Innovative Strategies Promotes the Competitiveness of Clinical Department]. / Qualitätsmanagement für Chirurgen ­ Kenntnis grundlegender Zusammenhänge und innovativer Strategien fördert die Wettbewerbsfähigkeit der Fachabteilung.

Efficient quality management aiming to achieve high quality in patient care is crucial to the success of a surgery department. This requires the knowledge of relevant terms und contexts of quality management. Implementation remains difficult in the light of demographic change and skills shortage. If a hospital has an efficient internal quality management in place, this should be used as a supplementary instrument. Otherwise it is the (sole) task of a specialist department to ensure quality for patients, employees, and cooperative partners. This paper provides basic knowledge on quality management, risk management, and quality assurance in the context of relevant medical terms. It demonstrates new ways for implementation on the level of a surgery department, and introduces a new model of quality.

[Quality Management in Medicine: What the Surgeon Needs to Know]. / Qualitätsmanagement in der Medizin. Was muss der Chirurg wissen?

Quality management (QM) is a method used in the field of economics that was adopted late by the medical sector. The coincidence of quality management and what is referred to as economisation in medicine frequently leads to QM being - incorrectly - perceived as part of the economisation problem rather than as part of its solution. Quality assurance defines and observes key performance indicators for the achievement of quality objectives. QM is a form of active management that intends to systematically exclude the effects of chance. It is supposed to enable those in charge of an institution to deal with complex processes, to influence them and achieve quality even under unfavourable circumstances. Clearly defined written standards are an important aspect of QM and allow for 80 % of patients to be treated faster and less labour-intensively and thus to create more capacity for the individual treatment of the 20 % of patients requiring other than routine care. Standards provide a framework to rely on for department heads and other staff alike. They reduce complexity, support processes in stress situations and prevent inconsistent decisions in the course of treatment. Document management ensures transparent and up-to-date in-house standards and creates continuity. Good documents are short, easy to use, and, at the same time, comply with requirements. Specifications describe in-house standards; validation documents provide a forensically sound documentation. Quality management has a broad impact on an institution. It helps staff reflect on their daily work, and it initiates a reporting and auditing system as well as the systematic management of responses to surveys and complaints. Risk management is another aspect of QM; it provides structures to identify, analyse, assess and modify risks and subject them to risk controlling. Quality management is not necessarily associated with certification. However, if certification is intended, it serves to define requirements, increase motivation for the implementation of measures to be taken, and provide long-term continuity in newly adopted processes. Specialist certificates issued by medical associations frequently emphasise an interdisciplinary treatment approach; however, their certification processes are often of poor quality. The effectiveness and efficiency is evident for individual QM instruments in medicine. It is very likely that quality management improves effectiveness in the whole field of medicine, but this has yet to be proved.

The great risk shift: a strategic road map for providers.

Healthcare providers that are assessing their readiness to assume financial risk for care delivery should understand the full range of risk options available to them. Available options fall into two broad categories: episode-based risk (e.g., the Medicare BPCI initiative and CJR model, commercial insurance models, and direct-to-employer models) and population-based risk (e.g., shared savings models and professional or institutional capitation models). Providers also require a deep understanding of both internal and market-based factors that are essential for success under any risk option being contemplated.

The Relationship between Resource Utilization, Clinical Risk and Hospital Costs for Emergency Medical Admissions.

There has been little study of the relationship between resource utilisation, clinical risks and hospital costs in acute medicine with the question remaining as to whether current funding models reflect patient acuity. We examined the relationship between resource use for investigations/allied professional and patient episode costs in all emergency medical admissions admitted to our institution during 2008-2013. Univariate estimates were compared with a multivariate model adjusted for major cost predictors. Interestingly, the model adjusted cost estimates changed considerably when compared with univariate analysis. We used both linear and non-linear (quantile regression) methods due to the highly skewed nature of hospital costs. The data suggested that hospital episode costs were predictable and driven by objective measures of clinical complexity. The use of expensive investigations and healthcare professional time was secondary to the clinical acuity. Thus, cost was heavily weighted towards higher complexity, and lower resource utilisation associated with lower risk patient groups. However, the non-linear nature of the costings would caution against simple predictor models and non-linear techniques such as quantile regression may, as we have demonstrated, prove superior in defining the underlying relationships.

An economic analysis of poliovirus risk management policy options for 2013-2052.

BACKGROUND: The Global Polio Eradication Initiative plans for coordinated cessation of oral poliovirus vaccine (OPV) after interrupting all wild poliovirus (WPV) transmission, but many questions remain related to long-term poliovirus risk management policies. METHODS: We used an integrated dynamic poliovirus transmission and stochastic risk model to simulate possible futures and estimate the health and economic outcomes of maintaining the 2013 status quo of continued OPV use in most developing countries compared with OPV cessation policies with various assumptions about global inactivated poliovirus vaccine (IPV) adoption. RESULTS: Continued OPV use after global WPV eradication leads to continued high costs and/or high cases. Global OPV cessation comes with a high probability of at least one outbreak, which aggressive outbreak response can successfully control in most instances. A low but non-zero probability exists of uncontrolled outbreaks following a poliovirus reintroduction long after OPV cessation in a population in which IPV-alone cannot prevent poliovirus transmission. We estimate global incremental net benefits during 2013-2052 of approximately $16 billion (US$2013) for OPV cessation with at least one IPV routine immunization dose in all countries until 2024 compared to continued OPV use, although significant uncertainty remains associated with the frequency of exportations between populations and the implementation of long term risk management policies. CONCLUSIONS: Global OPV cessation offers the possibility of large future health and economic benefits compared to continued OPV use. Long-term poliovirus risk management interventions matter (e.g., IPV use duration, outbreak response, containment, continued surveillance, stockpile size and contents, vaccine production site requirements, potential antiviral drugs, and potential safer vaccines) and require careful consideration. Risk management activities can help to ensure a low risk of uncontrolled outbreaks and preserve or further increase the positive net benefits of OPV cessation. Important uncertainties will require more research, including characterizing immunodeficient long-term poliovirus excretor risks, containment risks, and the kinetics of outbreaks and response in an unprecedented world without widespread live poliovirus exposure.

[Patient safety: a topic of the future, the future of the topic]. / Patientensicherheit : Ein Thema mit Zukunft, die Zukunft des Themas.

Almost 10 years ago, the German Coalition for Patient Safety (Aktionsbündnis Patientensicherheit) was founded as a cooperation covering most institutions of the German health care system. As in other countries facing the issue of patient safety, methods for the analysis of "never events" have been developed, instruments for the identification of the "unknown unknowns" have been established (e.g., CIRS), and the paradigm of individual blame has been replaced by organizational, team and management factors. After these first steps, further developments can only be achieved in so far as patient safety is understood as a system property, which leads to specific implications for the further evolution of the healthccare system. The "patient safety movement" has to participate in this discussion in order to avoid misuse of the patient safety concept as a defensive means, merely confined to overcome the adverse events of payment and structural incentives (e.g., diagnosis related groups in the inpatient sector). Because the dominant requirements for the future healthcare system consist of care for an elderly population with chronic and multiple diseases, the focus has to be shifted away from acute and surgical procedures and diseases, as given in the present quality assurance programs in Germany, to prevention and coordination of chronic care. Efforts to improve drug and medication safety of elderly people can be regarded as perfect examples, but other efforts are still missing. Second, the structural problems as the sector-associated optimization of care should be addressed, because typical safety issues are not limited to single sectors but represent problems of missing integration and suboptimal population care (e.g., MRSA). In the third line, the perspectives of society and institutions on safety (and quality of care) must urgently be enlarged to the perspectives of patients on the one hand and the benefit of treatments (e.g., overuse) on the other hand. All these issues are only to be implemented as far as the general societal attitude supportings further improvement of patient safety and is ready to regard it as a major aim for future developments. Cost arguments alone - costs of suboptimal safety can be estimated to around 1 billion in Germany per year - are considered as insufficient to guarantee further improvements because other issues in the healthcare system show similar magnitudes. As a consequence, ethical implications remain as major arguments for ongoing professional and public discussions.

controlling retained insurance costs through an allocation.

An insurance allocation may help a hospital or health system achieve the following goals for its professional liability and workers' compensation self-insurance or large-deductible programs: Loss-control incentive. Stability. Equity. Comprehension. Ease of administration.

Preparing for an At-Risk Era.

Transitioning to value-based health care is a daunting task, but boards can take steps today to help their hospitals thrive now and into the future.

Effect of a health system's medical error disclosure program on gastroenterology-related claims rates and costs.

OBJECTIVES: In 2001, the University of Michigan Health System (UMHS) implemented a novel medical error disclosure program. This study analyzes the effect of this program on gastroenterology (GI)-related claims and costs. METHODS: This was a review of claims in the UMHS Risk Management Database (1990-2010), naming a gastroenterologist. Claims were classified according to pre-determined categories. Claims data, including incident date, date of resolution, and total liability dollars, were reviewed. Mean total liability incurred per claim in the pre- and post-implementation eras was compared. Patient encounter data from the Division of Gastroenterology was also reviewed in order to benchmark claims data with changes in clinical volume. RESULTS: There were 238,911 GI encounters in the pre-implementation era and 411,944 in the post-implementation era. A total of 66 encounters resulted in claims: 38 in the pre-implementation era and 28 in the post-implementation era. Of the total number of claims, 15.2% alleged delay in diagnosis/misdiagnosis, 42.4% related to a procedure, and 42.4% involved improper management, treatment, or monitoring. The reduction in the proportion of encounters resulting in claims was statistically significant (P=0.001), as was the reduction in time to claim resolution (1,000 vs. 460 days) (P<0.0001). There was also a reduction in the mean total liability per claim ($167,309 pre vs. $81,107 post, 95% confidence interval: 33682.5-300936.2 pre vs. 1687.8-160526.7 post). CONCLUSIONS: Implementation of a novel medical error disclosure program, promoting transparency and quality improvement, not only decreased the number of GI-related claims per patient encounter, but also dramatically shortened the time to claim resolution.

Adaptive Flood Risk Management Under Climate Change Uncertainty Using Real Options and Optimization.

It is well recognized that adaptive and flexible flood risk strategies are required to account for future uncertainties. Development of such strategies is, however, a challenge. Climate change alone is a significant complication, but, in addition, complexities exist trying to identify the most appropriate set of mitigation measures, or interventions. There are a range of economic and environmental performance measures that require consideration, and the spatial and temporal aspects of evaluating the performance of these is complex. All these elements pose severe difficulties to decisionmakers. This article describes a decision support methodology that has the capability to assess the most appropriate set of interventions to make in a flood system and the opportune time to make these interventions, given the future uncertainties. The flood risk strategies have been explicitly designed to allow for flexible adaptive measures by capturing the concepts of real options and multiobjective optimization to evaluate potential flood risk management opportunities. A state-of-the-art flood risk analysis tool is employed to evaluate the risk associated to each strategy over future points in time and a multiobjective genetic algorithm is utilized to search for the optimal adaptive strategies. The modeling system has been applied to a reach on the Thames Estuary (London, England), and initial results show the inclusion of flexibility is advantageous, while the outputs provide decisionmakers with supplementary knowledge that previously has not been considered.

Beyond Value-at-Risk: GlueVaR Distortion Risk Measures.

We propose a new family of risk measures, called GlueVaR, within the class of distortion risk measures. Analytical closed-form expressions are shown for the most frequently used distribution functions in financial and insurance applications. The relationship between GlueVaR, value-at-risk, and tail value-at-risk is explained. Tail subadditivity is investigated and it is shown that some GlueVaR risk measures satisfy this property. An interpretation in terms of risk attitudes is provided and a discussion is given on the applicability in nonfinancial problems such as health, safety, environmental, or catastrophic risk management.

The young, the old, and the economists: rethinking how agencies account for age in cost-benefit analysis.

Federal agencies count all fatalities prevented by regulation as having the same value for the purposes of cost-benefit analysis, making no adjustment for the age of the person saved. This uniform valuation is guided by empirical studies that find that the young are not willing to pay more than the elderly for small risk reductions in private markets. This Note argues for a different approach. It proposes that agencies take account of a previously ignored body of "public choice" research that finds that most individuals think government should adopt lifesaving programs that benefit the young over those that benefit the old. These data illustrate a divergence between people's private and public preferences. While the economic theory that guides current agency practice prioritizes the former over the latter, this Note argues that it should be the other way around. The Note maintains that public choice data reflect a wider range of societal commitments than individual willingness-to-pay metrics, and therefore that the use of public choice data could help agencies satisfy their mandate under Executive Order 13,563 to engage in broader forms of analysis. The Note also posits that public choice data actually provide a better guide to the welfare consequences of prioritizing lifesaving regulations for different age groups than do individual willingness-to-pay data. It accordingly recommends a new system of age adjustment based on public choice results.