Critical Risks Facing the Healthcare Industry

Diane Doherty and Renee Carino

BusinessMedical Risk Descriptor Critical Risks Facing the Healthcare Industry

As part of a Hospitals and healthcare organizations strengthening their ability to deliver face enormous challenges on a daily quality patient care. comprehensive basis as they seek to provide quality care to patients. Over the last few years, the risk management healthcare industry has come under 1. Preparedness for Pandemics pressure to respond to new regulatory strategy, healthcare requirements under the Affordable Care Growing concern about Ebola in the Act. While those demands continue, new has forced healthcare organizations challenges are emerging that have the facilities to review their current practices potential to disrupt facility operations and and consider the impact that a potential should work with put employee and patient safety at risk. nationwide pandemic would have on their organizations and the communities insurers that have From pandemics to violence in hospitals, they serve. alarm fatigue to healthcare-acquired proven expertise infections and contamination from The ability to deliver care with minimum pollutants, healthcare organizations will disruption and safeguard the health of in working with be put to the test in the coming months workers and patients will depend on and years. Failure to adequately address planning and preparation measures that the healthcare these issues could not only put patient facilities undertake today. Organizations and employee safety at risk, it also could should consider a number of critical steps sector and that lead to heightened liabilities, an increase as they prepare for the possibility of a in workers’ compensation claims, potential pandemic, whether as a result of understand the fines and penalties and damage to an Ebola or any other infectious disease. organization’s reputation. unique challenges To minimize their exposures, hospitals Top Critical Issues Facing facing the industry. should have a comprehensive risk Hospital Leadership: management program that addresses each of these issues. Hospital risk 1. Preparedness for Pandemics management teams should be familiar 2. Violent Incidents in Hospitals with these challenges and should be 3. Healthcare Reform/ empowered to take action to mitigate Physician Integration the risks. Because of the potential 4. Disruptive Staff Behavior adverse consequences, risk management 5. Telemedicine teams should report directly to the top 6. Cyber Risk leadership, including the chief executive 7. Environmental Pollutants as well as the hospital board. 8. Emergency Preparedness 9. Alarm Fatigue As part of a comprehensive risk 10. Obesity Epidemic management strategy, healthcare 11. Healthcare-Associated Infections organizations should work with insurers that have proven expertise in working A Pandemic Action Committee with the healthcare sector and that Healthcare facilities should form a understand the unique challenges facing pandemic action committee to help the industry. While hospitals are under identify, respond to and recover from a constant pressure to do more with less, broad range of potential business and those that have the foresight to prepare clinical interruptions. The committee for these emerging risks can reduce should include representation from: the chances of debilitating losses while senior administration, risk management,

2 the emergency department, occupational health, human resources, nursing administration, medical staff, hospital disaster services, infection control, engineering and institutional safety, and laboratory and therapeutic services. The committee should designate a response coordinator who is well versed in federal, state and local government planning for pandemic conditions as well as being knowledgeable of private sector efforts.

Education and Training A healthcare organization’s infection control practitioner should provide mandatory in-service training for all shifts to review measures for the prevention and control of a virus. Suggested topics should prohibit staff members who work 2. Violent Incidents in Hospitals include: selection and proper use in close contact with quarantined patients (including proper removal and disposal from rotating to other units until the Hospitals may be places of healing, but of ) of personal protective equipment, local health department has determined they also have become the scene of an hand hygiene, cleaning and disinfection the outbreak is under control. increasing number of violent incidents. of environmental surfaces, handling Remember to include contracted agency Such incidents not only put patients of laboratory specimens, safe work workers, housekeeping, volunteers at risk but also medical professionals, practices, and post-mortem care. and administrative staff in any policy who are often the targets of attacks, statement that restricts work assignment. harassment, intimidation and other Triage and Containment disruptive behavior. One measure proven to have a Electronic and other documentation temporizing effect on pandemic formats utilized during the triage process The incidence rate for violence and transmission is to quarantine patients to must allow for shared access across other injuries in the healthcare and a single treatment area or unit or floor. established nursing and physician social assistance sector in 2012 was over Facilities should establish a separate workflow processes. Critical data, three times greater than the rate for all entry and waiting room for patients including a history of travel to affected private industries.1 The Joint Commission, with suspicious symptoms and erect a regions and/or prior contact with infected meanwhile, reports increasing rates of temporary structure near the emergency persons must be prominently noted in the assault, rape and homicide in healthcare department to treat infectious patients, patient care record when members of the facilities.2 Perpetrators can include and reserve the emergency department treatment team access the electronic or patients, family members, visitors and for regular patients. They should screen paper record. vendors as well as current and former all patients according to a standardized healthcare employees. protocol for the presence of Ebola A multitude of other issues should be associated symptoms or of the particular addressed as well. These include: disease The costs to hospitals and healthcare disease and should move suspected surveillance, facility access and security, organizations can include increases emergency department patients from hospital communication, vaccine and in malpractice litigation and workers’ triage into isolation units until diagnostic antiviral use, occupational health compensation claims, federal and state tests are negative for the applicable virus. policies, surge capacity planning, supply fines, damage to the organization’s All infected patients should be admitted chain and resources, waste management reputation, as well as difficulties with staff to a floor that is designated for the and mortuary needs. retention, morale and absenteeism. inpatient care of those who are afflicted with the virus. Organizational policy also

3 Critical Risks Facing the Healthcare Industry

As part of a To address the problem, hospitals and own liability risk. As the employer, healthcare organizations should: for instance, hospitals could be held comprehensive vicariously liable for their physicians’ • Enact a zero-tolerance policy. The negligent acts or omissions. risk management policy should state that no form of violence — physical, verbal or In spite of this risk, the hospital risk strategy, healthcare psychological — will be tolerated, management team has often been and that all offenders will be subject left out of contract talks with doctors organizations to disciplinary action, including and physician practices, resulting in termination. The policy should be employment arrangements that may be should work with communicated to management, less than ideal from a risk management employees, volunteers, contracted perspective. insurers that have workers and patients. • Conduct an assessment of risk factors. Before reaching any agreements, proven expertise Assess current practices and attitudes hospitals should consult with their risk toward workplace violence and develop management team and include the team in working with a violence prevention program. in the development of contracts with Healthcare organizations may wish to doctors and their practices. Hospitals the healthcare consult with their insurer for guidance. should rely on the risk management • Educate and train all personnel. team to help integrate the physicians and sector and that Institute policies and procedures on their practices into the hospital’s system, how to spot danger, how to defuse including its reporting of incidents and understand the conflict and how to respond to violent managing risks. Hospitals also should incidents, and personal safety training. consider using a self-assessment tool to unique challenges determine whether a physician’s office policies and practices may fall short of the facing the industry. 3. Healthcare Reform/ organization’s standards. Physician Integration

As hospitals move ahead with the 4. Disruptive Staff Behavior implementation of the Affordable Care Act, they have been hiring physicians at a Disruptive behavior by physicians and rapid rate; but the integration of doctors medical staff is a serious problem that and their practices opens hospitals up to can lead to medical mistakes and put increased liability risk. patient safety at risk by promoting an environment of hostility and distrust. If The changes in the employment left unaddressed, disruptive behavior can relationship between hospitals and create significant liabilities for healthcare physician practices have been dramatic. organizations. In 2014, about 64 percent of newly hired physicians were employed by hospitals, up Behavior such as verbal outbursts, from just 11 percent in 2004.3 Fewer than bullying, condescending language and one percent were going into solo practice refusal to answer questions also comes in 2014, down from 20 percent in 2004. with other risks. Individuals with a These changes are expected to continue. history of disruptive behavior pose the highest litigation risk for hospitals. This While hospitals pursue the strategy of also contributes to poor teamwork, low hiring more physicians, they should staff morale, poor patient satisfaction; be mindful of the impact on their impedes operational efficiency and

4 Hospitals should causes difficulties with staff recruiting email to communicate with patients and and retention.4 they are gathering information remotely rely on the risk through the transmission of diagnostic In 2009, the Joint Commission began images and test results. Many of today’s management team requiring hospitals to establish formal monitoring devices also allow doctors codes of conduct as well as processes for to remotely collect information about to help integrate managing disruptive and inappropriate patients who are in the intensive care unit behavior by medical staff5; however the or at home. the physicians and existence of a written policy can only go so far. Healthcare organizations need While this can provide patients with better their practices to develop an effective intervention access to healthcare and offer physicians process to address each complaint and more detailed information in less time into the hospital’s make appropriate recommendations. A than ever, healthcare professionals should formal conflict management committee keep in mind the risks. system, including that reports directly to the governing board should be established and charged Telemedicine could result in allegations its reporting of with the development of policies and of negligence if healthcare providers do procedures as well as the education and not have the proper training, experience incidents and training of medical and clinical staff. and credentials. Currently, there is no The committee should be accountable federal standard of clinical guidelines for managing risks. for responding to reports of disruptive telemedicine. The practice is regulated behavior, investigating incidents and by varying state laws, and Centers for overseeing the negotiation process to the Medicare and Medicaid Services (CMS) point of resolution. guidelines. Hospitals and physicians may find it difficult to manage telemedicine Confronting the problem of disruptive risks because there is often a lack behavior ahead of time will help of clarity about legal, licensing and administrators, physicians and nurses to regulatory requirements, as well as which recognize and respond to incidents before jurisdictions take precedence. Strategies they become a liability. to mitigate telemedicine risks include:

• The credentialing and privileging 5. Telemedicine process at the facility should be evaluated to ensure CMS guidelines are Advances in technology, the current met. physician shortage and the dramatic • Medical staff bylaws, rules and increase in the number of patients regulations should reflect the full seeking care under the Affordable integration of CMS telemedicine Care Act have led a growing number of standards with other lines of clinical healthcare facilities to expand their use practice in the organization. Any state of telemedicine to deliver services to specific licensure requirements should patients in hospitals as well as in remote be incorporated. locations. Over half of all U.S. hospitals • Written agreements, service contracts now use some form of telemedicine to and risk-transfer plans should be treat patients.6 carefully reviewed by the board of directors to minimize potential lapses Healthcare professionals are using in the standard of care as well as technology such as interactive video and disputes with telemedical partners.

5 Critical Risks Facing the Healthcare Industry

• Physicians should be educated about and worth 10 times more than credit card essential informed consent elements information on the black market.8 and audit documentation for inclusion of telemedicine consent in the patient Data breaches cost healthcare record. Explanations should include organizations millions of dollars how the technology is used and every year, with the average cost for any limitations. organizations represented in the • The credentialing committee should Ponemon study estimated at $2 million have the authority to grant membership over a two-year period. The potential to telemedical providers. cost to the healthcare industry could be • A new medical staff membership as much as $5.6 billion annually based category should be created for on the experience of the healthcare telemedicine practitioners and should organizations in the study.9 adhere to the American Medical Association’s model bylaw language. The healthcare system’s move to • A board-approved list of authorized electronic healthcare records has created telemedical procedures and services new exposures as records are now more should be established. easily accessed by consultants, vendors • Compliance with all aspects of the CMS and other third parties for efficient Final Rule regarding credentialing of operation. Additionally, healthcare telemedicine practitioners should be organizations face exposure to cyber risks documented. Insist on mutual hold that could have significant impacts on harmless and indemnification clauses their operations, including shutting down in all business contracts between critical, health-related systems. telemedicine partners. Data breaches and network disruptions can jeopardize an organization’s financial 6. Cyber Risk stability, security, and reputation. Standard general liability policies As the healthcare industry adopts often do not adequately cover perils electronic healthcare records and associated with cyber and technology increasingly relies on technology, related exposures. Cyber liability hospitals face new challenges and can address coverage gaps evolving regulations in their efforts to and the underwriting process increases protect patient information and minimize awareness of exposures while also their exposure to cyber risk. In its Fourth enabling companies to transfer risks Annual Benchmark Study on Patient associated with cyber, such as patient Privacy & Data Security, the Ponemon notification, crisis management, and Institute said that while the total number forensic analysis expenses as well as of data breaches declined slightly over certain regulatory fines, indemnity previous years, almost every healthcare payments, legal costs in addition organization represented in the research to business interruption exposures experienced a data breach.7 In addition, associated with the technology supply security experts have been cautioning chain. Healthcare organizations should that cyber criminals are increasingly look to their insurance carrier for targeting the U.S. healthcare industry solutions to help manage and mitigate as medical information contained in these types of risks. healthcare records is extremely valuable

6 7. Environmental Pollutants

Rapid advances in medical technology, combined with industry consolidation driven by economic and regulatory challenges, are leading many healthcare organizations to build new facilities or expand and remodel existing ones. Construction and maintenance work, however, may lead to a wide variety of environmental exposures involving indoor air quality, water systems and other areas. These risks are of particular concern when projects take place in a facility that is still in use. Fugitive dust, fumes and mold spores spread by construction work can cause life- threatening reactions for patients with Given a healthcare organization’s badly wounded patients under weakened immune systems. Renovation obligation to protect patient health, crisis conditions. and expansion projects may spread mold, governing boards should remain abreast bacteria or viruses through heating, of applicable environmental laws While events such as these come as a cooling, ventilation and water systems. regarding infection control measures shock to local communities, they happen The risks also include exposures that arise and standards of care as established frequently enough to underscore the from the transportation and disposal of by professional entities that govern urgent need for additional emergency construction materials and debris off site. construction. Boards should recognize preparedness planning for all hospitals. that many pollution and environmental Mass casualty incidents happen, not Besides the potential for bodily injury exposures are specifically excluded from only in large cities like Boston and among patients and staff, major general liability policies. San Francisco where emergency considerations include the potentially planning may be routine, but in smaller significant remediation costs should Environmental insurance policies communities as well. a pollution problem occur and the especially designed for the healthcare possibility that all or part of a facility industry provide coverage against a Hospitals should be prepared to provide may have to be shut down during broad range of pollution exposures, while emergency medical care to the victims environmental remediation. reducing potential coverage gaps found who may have injuries more commonly in general liability policies. The coverage seen on a battlefield and who may Reputational damage should not be should include the costs of remediation as overwhelm the capacity of a local overlooked. Pollution problems at a well as business interruption. emergency department. In many cases, healthcare facility may attract negative the injuries can strain the capabilities news coverage. In that case, the facility of the medical staff. In the case of the may want to work with public relations 8. Emergency Preparedness Asiana plane crash, for instance, many of experts to help limit the potential damage the victims were children, who required to their reputations. Disasters can strike anywhere at any specialized care, which presented time. In just the last few years, events additional challenges to an already To address these risks, healthcare such as the Boston Marathon bombing, overwhelmed medical staff. organizations should make sure that the explosion at a fertilizer plant in building projects are conducted West Texas and the Asiana Airlines In addition to being prepared to by qualified contractors in an crash in San Francisco have resulted in provide medical care, healthcare environmentally sound manner that mass casualties, forcing hospitals and organizations should also be ready for mitigates the potential exposures. healthcare workers to deliver care to the other pressures they may face in

7 Critical Risks Facing the Healthcare Industry

Environmental a mass casualty situation. The media, Emergency preparedness planning has government organizations and family become a necessity in today’s world and insurance policies members will all require attention at a no hospital should consider itself immune time when the healthcare organization’s to the threat of a mass casualty incident especially designed leadership will already be under pressure. or a catastrophe that could disrupt operations. for the healthcare The healthcare organization itself may be directly impacted as well. Superstorm industry provide Sandy, for instance, caused flooding and 9. Alarm Fatigue power outages in certain states, forcing coverage against some healthcare organizations to rely Hospital nurses hear them constantly — on backup generators and consider the beeps and chirps of alarms on medical a broad range questions such as whether to evacuate devices, such as ventilators, cardiac patients. Leadership and communication monitors and pulse oximetry devices. of pollution are critically important in ensuring that While alarms are designed to draw a healthcare organization is prepared attention to a potential problem, they exposures, while to deliver care to victims, while, to the can easily be tuned out by overwhelmed extent possible, protecting staff and medical professionals, who may then fail reducing potential patients from being exposed to any to respond as they should. further risk. coverage gaps Alarm fatigue is a growing problem for Organizations should designate an hospitals and the consequences can be found in general incident response team to take charge fatal. The Joint Commission’s Sentinel in any disaster. It is vitally important Event database includes reports of 98 liability policies. that healthcare organizations review alarm-related events between January and update their emergency disaster 2009 and June 2012. Of the 98 events, The coverage plans on an ongoing basis. Without 80 resulted in death, 13 in permanent proper planning, the organization loss of function and five in unexpected should include may be unable to provide care as it additional care or extended stay.10 Alarm should, while simultaneously dealing fatigue was rated a top concern by 19 out the costs of with the media, family members and of every 20 hospitals in the United States, disaster management organizations. according to a national survey presented remediation as The disaster management plan should at the annual meeting of the Society for be fully integrated with those of other Technology in Anesthesia in 2014.11 well as business organizations and agencies at the local, state, regional and national levels. Alarm hazards were also at the top of the interruption. ECRI Institute’s Top 10 List of Technology Communication becomes critical during Hazards in 2014.12 In recognition of the a disaster, and staff should be designated problem, the Joint Commission made to provide accurate information to alarm system safety a National Patient employees, patients and their families, Safety Goal in 2014, requiring hospitals and to work with local, state and federal to improve their systems. To reduce the agencies. Employee training is an risk of patient harm from alarm fatigue, important component of emergency The Joint Commission, along with preparation. Hospitals should implement the Association for the Advancement and practice drills of different disaster of Medical Instrumentation and the scenarios across all shifts. ECRI Institute offer the following recommendations:13

8 • Ensure that there is a process for safe alarm management and response in high-risk areas. • Prepare an inventory of alarm- equipped medical devices used in high-risk areas and for high-risk clinical condition, and identify the default alarm settings and the limits appropriate for each care area. • Establish guidelines for alarm settings; including identification of situations when alarm signals are not clinically necessary. • Establish guidelines for tailoring alarm settings and limits for individual patients. The guidelines should address situations when limits can be modified to minimize alarm signals. Check and hospitals should investigate specialized The American Society for Healthcare Risk maintain alarm-equipped devices to exam tables, wheelchairs, toilets, blood Management recommends healthcare provide for accurate and appropriate pressure cuffs, hospital gowns and scales. organizations:15 alarm settings, proper operation A lack of appropriate equipment or failure and detectability. to treat obese patients with respect and • Establish a multidisciplinary committee dignity could lead to liability claims. responsible for analyzing and responding to obese-related 10. Obesity Epidemic The safety of medical professionals care issues. working with obese patients is • Ensure that patient care is preceded Obesity is one of the country’s most another concern. Lifting, handling by a frank discussion of all known and serious health problems. Adults with a and transferring obese patients has possible complications associated body mass index (BMI) of 30 or higher always been a challenge for healthcare with obesity and is documented in the are considered obese and in the United professionals and healthcare patient’s medical record. States, more than one-third of adults, professionals may be injured when • Assess facility layout and design and about 1 in 5 children, are considered trying to care for or move an obese accommodations for patients who obese.14 With the increase in obesity in patient, leading to workers compensation are obese. the overall population, there has been claims, lost time claims, increased staff • Assess staff training and education a noticeable increase in the number turnover and new employee training in areas such as patient handling and of bariatric admissions to healthcare costs. Hospital staff, meanwhile, may transport, special care needs and facilities and ambulatory care facilities as require enhanced training or additional staff sensitivity. well. This trend presents a challenge to assistance in order to prevent injuring • Evaluate supplies including: beds; healthcare organizations and providers themselves and to ensure appropriate exam tables; wheel chairs; gowns; striving to deliver dignified care that is care, transport and patient satisfaction. blankets; ID bracelets; blood pressure effective and safe both for the patient and Today’s healthcare leaders should cuffs; compression stockings; needles the providers. recognize the challenges of caring for and catheters; chairs in waiting rooms; obese patients, and develop policies patient lifts; bariatric commodes; Obese patients often require specific to address the issue. They also should scales; stretchers; and tracheal tubes. attention, and healthcare professionals ensure that they have appropriate • Adopt a zero-tolerance policy toward should be sure that they have the equipment to meet the needs of these discriminatory attitudes and behaviors appropriate equipment to accommodate patients, and should educate staff so as to that are directed at obese patients and this high-risk population. To provide for promote patient and staff safety. which specify disciplinary measures for the safety and dignity of obese patients, non-compliance.

9 Critical Risks Facing the Healthcare Industry

11. Healthcare-Associated Infections government evaluates.23 Hospitals Hospitals and healthcare organizations can lose as much as three percent of should begin to take action now by Healthcare-acquired infections (HAIs) their Medicare payments under the making sure they are familiar with cost the U.S. healthcare system billions of program.24, 25 each of these issues and that they have dollars each year and lead to the loss of a comprehensive risk management tens of thousands of lives.16 At any given In 2013, nearly 18 percent of Medicare program in place to address them. time, about 1 in 25 hospital patients has patients who had been hospitalized Hospital risk management teams should at least one such infection, according were readmitted within a month for report directly to the chief executives to the Centers for Disease Control and additional treatment. While that is lower and hospital boards and should have the Prevention. These infections can have than in past years, roughly 2 million authority to take action to manage the severe consequences for patients. In 2011, patients return a year, costing Medicare hospital’s risks and develop solutions. there were an estimated 722,000 HAIs $26 billion. Officials estimate that in U.S. acute care hospitals, and about $17 billion of that comes from potentially As part of this effort, hospitals should 75,000 hospital patients with HAIs died avoidable readmissions.26 work with an insurer that understands during their hospitalizations.17 the risks facing the healthcare sector Healthcare organizations should ensure and that can offer solutions to help Healthcare-acquired infections also come all sanitation systems are up to date and mitigate those risks. In addition to loss with a financial price, costing $9.8 billion operational and that staff know how to control, insurance is a critical element a year, according to research published properly use the systems to keep in any risk management program. in 2013 in JAMA Internal Medicine.18 The patients safe. Hospitals and healthcare organizations U.S. Department of Health and Human should have comprehensive coverage Services, which has made the reduction They also should continue to remind staff including property and general liability, of these infections one of its top priorities, and visitors about basic infection control environmental and cyber coverages. has put the added financial burden due to techniques. Medical personnel should When selecting an insurer, hospitals HAIs at $28 billion to $33 billion a year.19 take extra care to wash their hands with should consider the breadth of the antiseptic soap and water before treating carrier’s underwriting experience, years Reducing the risk of HAIs is one of patients. A new study shows only of experience, product offerings and The Joint Commission’s National Patient 13 percent of emergency medical dedication to the healthcare sector. Safety Goals and the goal specifically providers reported cleaning their requires adherence to hand hygiene hands before patient contact.27 Simple The healthcare industry is changing practices and considers death or steps such as installing alcoholbased rapidly, and hospitals are coming under serious disability due to an HAI to be hand sanitizers also can help to reduce intense pressure to meet existing and a sentinel event.20 infection rates. emerging challenges and still provide quality care. With a comprehensive risk Hospitals now face reductions in management strategy and appropriate reimbursements associated with such A Comprehensive Risk insurance coverages, healthcare infections. Since 2008, hospitals have Management Program organizations can better fulfill their not been reimbursed by Medicare and primary mission and deliver the best care Medicaid for the cost of care associated As hospitals and healthcare organizations to their patients. with certain HAIs.21 In addition, Medicare adapt to the changing regulatory, has been docking hospitals since technological and demographic trends, 2012 for excess readmissions.22 While these critical issues will demand attention readmissions can take place for a number in the coming months and years. Some of reasons, healthcare-acquired infections of these issues may already be making are a frequent cause. In October 2014, the headlines in some communities, but third year of the Hospital Readmissions sooner or later they will affect nearly all Reductions Program, Medicare increased hospitals, from busy big city institutions the maximum penalty for hospitals and to those in small towns. expanded the number of conditions the

10 With a About the Authors: Endnotes:

Diane Doherty, M.S., CPHRM is Vice 1. “Nonfatal Occupational Injuries and comprehensive Illnesses Requiring Days Away from Work, President, USA operations at Chubb 2012,” Bureau of La-bor Statistics, U.S. risk management Medical Risk based in New York City. Ms. Department of Labor, Nov. 26, 2013. See: Doherty is responsible for providing a http://www.bls.gov/news.release/pdf/osh2. pdf strategy and broad range of risk consulting services to 2. “Preventing Violence in the Health Care clients that are designed and customized Setting,” The Joint Commission, June 3, to help meet the evolving healthcare 2010. See: http://www.jointcommission. appropriate org/assets/1/18/SEA_45.PDF industry challenges and proactively 3. “Merritt Hawkins 2014 Review of Physician insurance address unique risk management needs. and Advanced Practitioner Recruiting Ms. Doherty has more than 25 years of Incentives,” Merritt Hawkins, June 30, 2014. See: http://www.merritthawkins. coverages, healthcare risk management experience. com/uploadedFiles/MerrittHawkings/ Her areas of specialization include Surveys/2014_Merritt_Hawkins_Physician_ clinical risk management, hospital Recruiting_Report_Infographic.pdf healthcare 4. “Revisiting Disruptive and Inappropriate administration, quality management, Behavior: Five Years after Standards organizations can patient safety, claims management, and Introduced,” JC Physi-cian Blog, Oct. 2, patient relations. Ms. Doherty is an active 2013. See: http://www.jointcommission. org/jc_physician_blog/revisiting_disruptive_ better fulfill their member of ASHRM and several regional and_inappropriate_behavior/ ASHRM chapters, including GHSHRM, 5. “Behaviors that undermine a culture of SCAHRM, GASHRM, and CASHRM. She safety,” The Joint Commission, July 9, 2008. primary mission See: http://www.jointcommission.org/ received and maintains her CPHRM assets/1/18/SEA_40.PDF and deliver the designation since December 2001. 6. “Telemedicine Frequently Asked Questions,” American Telemedicine Association. See: http://www. best care to Renee Carino is Vice President and Chief americantelemed.org/about-telemedicine/ Underwriting Officer of Chubb’s Medical faqs#.U8Rb117Xn8t Risk division. Based in New York, Ms. 7. “Fourth Annual Benchmark Study on their patients. Patient Privacy & Data Security,” Ponemon Carino is responsible for overseeing Institute, March 2014. Chubb Medical Risk’s underwriting 8. 8 “Your Medical Record is Worth More to operations including the development Hackers than Your Credit Card,” Reuters, Sept. 24, 2014. See: http://www.reuters. of Medical Risk and Life Sciences com/article/2014/09/24/us-cybersecurity- products and underwriting strategy and hospitals-idUSKCN0HJ21I20140924 training. Ms. Carino has over 16 years of 9. “Fourth Annual Benchmark Study.” 10. “Medical Device Alarm Safety in Hospitals,” insurance industry experience including The Joint Commission Sentinel Event 10 years in healthcare professional Alert, The Joint Commission, April 8, 2013. liability insurance. Her diverse insurance See: http://www.jointcommission.org/ assets/1/18/SEA_50_alarms_4_5_13_FINAL1. background includes roles in claims, legal PDF and underwriting. She has been with 11. “’Alarm fatigue’ a top-of-mind concern Chubb for over 12 years. for U.S. hospitals, finds national survey presented at Society for Technology in Anesthesia Annual Meeting,” The Physician- Patient Alliance for Health & Safety, Jan. 22, 2014. See:http://www.prnewswire.com/ news-releases/alarm-fatigue-a-top-of-mind- concern-for-us-hospitals-findsnational- survey-presented-at-society-for-technology- in-anesthesia-annual-meeting-241468331. html

11 Endnotes: (continued)

12. “ECRI Institute Releases Top 10 Health 20. “Health Care-Associated Infections,” Technology Hazards Report for 2014,” Agency for Healthcare Research and ECRI Institute, Nov. 4, 2013. See: http:// Quality. See: http://psnet.ahrq.gov/primer. www.prnewswire.com/news-releases/ecri- aspx?primerID=7 institute-releases-top-10-health-technology- 21. Ibid. hazardsreport-for-2014-230500731.html 22. “Hospital Readmissions Reduction 13. “Medical Device Alarm Safety in Hospitals,” Program,” medicare.gov. See: http:// The Joint Commission Sentinel Event Alert. www.medicare.gov/hospitalcompare/ 14. “Adult Obesity Facts,” Centers for Disease readmission-reduction-program. Control and Prevention. See: http://www. html?AspxAutoDetectCookieSupport=1 cdc.gov/obesity/data/adult.html 23. “A Guide to Medicare’s Readmissions 15. “ASHRM Webinar: Patient Safety and the Penalties and Data,” Kaiser Health Obesity Epidemic. How to Tackle the News, Oct. 2, 2014. See: http://www. Risks of an Expanded Patient Population,” kaiserhealthnews.org/Stories/2014/ American Society for Healthcare Risk October/02/A-Guide-To-Medicare- Management, March 13, 2014. Readmissions-Penalties-And-Data.aspx?utm_ 16. “Health Care-Associated Infections (HAIs),” source=khn&utm_medium=internal&utm_ Office of Disease Prevention and Health campaign=related-content Promotion. See: http://www.health.gov/hai/ 24. Ibid. prevent_hai.asp#hai 25. “Medicare Fines 2,610 Hospitals in the Third 17. “Healthcare-Associated Infections (HAIs),” Round of Readmission Penalties,” Kaiser Office of Disease Control and Prevention. Health News, Oct. 2, 2014. See: http:// See: http://www.cdc.gov/HAI/surveillance/ www.kaiserhealthnews.org/Stories/2014/ index.html October/02/Medicare-readmissions- 18. “Hospital-Acquired Infections Rack up penalties-2015. aspx?utm_source=khn&utm_ $9.8B a Year,” FierceHealthcare, Sept. 3, medium=internal&utm_campaign=viewed 2013. See: http://www.fiercehealthcare. 26. Ibid. com/story/hospital-acquired-infections- 27. “Hand-washing rates low among emergency rack-98b-each-year/2013-09-03 See also: medical personnel, study finds,” CBS News, http://archinte.jamanetwork.com/article. Nov. 13, 2013. See: http://www.cbsnews. aspx?articleid=1733452 com/news/hand-washing-rates-low-among- 19. “AHRQ’s Efforts to Prevent and Reduce emergency-medical-personnel/ Health Care-Associated Infections,” Agency for Healthcare Research and Quality. See: http://www.ahrq.gov/research/findings/ factsheets/errors-safety/haiflyer/index.html

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Chubb 436 Walnut Street Philadelphia, PA 19106 O +215.640.1000 www.chubb.com

Diane Doherty Senior Vice President Chubb Healthcare O +212.703.7120 E [email protected]

Renee Carino Senior Vice President, Chief Underwriting Officer Chubb Healthcare O +212.827.3823 E [email protected]

Chubb Group is one of the world’s largest multiline property and casualty insurers. With operations in 54 countries, Chubb provides commercial and personal property and casualty insurance, personal accident and supplemental , and to a diverse group of clients. , the parent company of Chubb Group, is listed on the New York Stock Exchange (NYSE: Chubb) and is a component of the S&P 500 index. Additional information can be found at www.chubbgroup.com. The opinions and the positions expressed in this paper are the author’s own and not necessarily those of any Chubb company. Insurance is provided by Chubb American Insurance Company, Philadelphia, PA, or, in some jurisdictions, other insurance companies in Chubb Group. This publication is for educational purposes only. The suggestions and information are not intended to be professional or legal advice. The advice of a competent attorney or other professional should be sought prior to applying this information to a particular set of facts. Copyright © 2018, Chubb Group. All rights reserved.