From risk management to risk mastery

• Repayment obligations on unmet eligibility criteria
• Financial penalties, duplicating 340B program and Medicaid drug rebate discounts
• Financial losses associated with improperly segregating 340B and non-340B eligible patients
• Drug diversion or misuse the as result of weak controls over 340B purchased inventory

• Assess compliance with 340B eligibility criteria
• Verify eligibility status on a regular basis
• Implement tracking and reconciliation processes to prevent duplication of claims
• Implement an effective split billing software
• Provide staff training to accurately identify 340B and non-340B drug usage
• Develop robust processes to track drug utilization and prevent diversion

• Financial losses incurred when third-party vendors fail to meet contractual obligations or deliver products or services that do not meet expectations
• Financial penalties incurred from regulators if a third-party vendor violates compliance regulations
• Operational or clinical disruptions associated with third-party vendors failing to meet service level agreements, experiencing data breaches or cyberattacks, or failing to comply with regulatory requirements
• Risk of reputational damage if associated with a third-party vendor that engages in unethical activities

• Implement a performance monitoring system to track key performance indicators and contract compliance
• Assess the performance and identify improvement opportunities for all third-party vendors on a periodic basis
• Diversify vendors for critical services and develop a business continuity plan to mitigate service disruptions and ensure minimal impact on operations
• Develop a comprehensive due diligence process that evaluates the financial and reputational health of prospective third-party vendors
• Identify a strategy for exiting a third-party vendor relationship and planning succession

• Fines and penalties for noncompliance
• Administrative burden to develop policies, implement systems and train staff on new requirements
• Challenges negotiating rates with insurance companies for out-of-network costs
• Reputational risk and patient dissatisfaction as a result of noncompliance or inaccuracy with information or estimates provided

• Develop hospital’s governance framework and establish new policies where appropriate
• Assess your organization’s billing practice by collaborating with stakeholders within key areas such as revenue cycle, legal, compliance and patient experience
• Implement cost-estimation tools to accurately predict the costs of medical procedures and services
• Establish dispute resolution process
• Strategize how to reduce the out-of-network gap

• Lack of governance structure to plan for and oversee compliance
• Lack of resources within the organization to help with compliance
• Lack of clarity and understanding of regulations.
• Possible corrective action plan from CMS for noncompliance or violation
• Potential civil monetary penalties

• Implement effective program governance to establish efficient processes, controls, and materials
• Implement key program-level internal controls to ensure regulatory compliance
• Detect errors or irregularities
• Monitor and report appropriately
• Leverage price transparency as a strategic growth opportunity

• Financial costs associated with utilizing skilled/registered nurses for tasks outside of their job description and experience level
• Increase in nurses’ workloads due to system factors and expectations (e.g., nonprofessional tasks such as delivering and retrieving food trays; performing housekeeping duties; transporting patients; and ordering, coordinating or performing ancillary services)
• Lack of sufficient time to perform tasks that can have a direct effect on patient safety
• Reduced time spent by nurses collaborating and communicating with physicians, therefore affecting the quality of nurse-physician collaboration
• Poor nurse-patient communication
• Lack of defined job descriptions and clinical ladders, affecting staff retention, productivity and job satisfaction

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• Open dialogue with nursing teams to assess staff levels, staff qualifications and patient needs
• Provide ongoing training and education to help nurses develop new skills and to learn emerging health care practices
• Perform analytics/benchmarking by location, specialty, surgeon and more to identify outliers and remediate issues
• Use clinical ladders to effectively staff nurses

• Potential fines due to patient privacy violations or HIPAA violations as a result of AI misuse
• Unreliable and false claims and estimates due to improper AI monitoring and governance
• Outputs in which AI can reflect the biases in the underlying data which can lead to incorrect recommendations, negatively affecting patients
• Security and privacy risks such as the potential for data breaches
• Lack of understanding among key stakeholders, leading to mistrust in the AI tool
• Bias in outputs that negatively affect patient outcomes, ethics and health care equity
• Potential generation of false claims, incorrect health care cost estimates and inappropriate/duplicative/surprise billing, which may compromise fraud, waste and abuse compliance, price transparency and NSA billing compliance
  

• Establish organizational AI strategy and governance frameworks and periodically reassess
• Implement internal controls to ensure data leveraged for AI systems are equitable and unbiased
• Integrate data privacy rules and regulations into the design and implementation of AI model(s)
• Establish cybersecurity controls to ensure AI systems/model(s) are protected
• Understand input and output processes of the AI model(s)

• Lack of qualified staff and high turnover
• Challenges associated with finding the right balance of centralized/standardized vs. localized/customized processes
• Lack of robust data analytics capabilities to review financial performance evaluating cost of staffing, supplies contracts

• Establish standardized reporting, key performance indicators, policy and process
• Leverage analytics to identify root causes and operational inefficiencies
• Identify automation opportunities
• Document cost savings
• Enhance quality metrics and patient experience
• Establish governance leading to process improvements

• Financial costs associated with prolonged hospital admissions; CMS penalties for high readmission rates
• Increase in utilization of nurses for patients with prolonged hospital admissions
• Risk of inadequate discharge with fewer facilities for patients to transition into
• Need for recertification for continued hospitalization if the physician does not find available beds in participating long-term facilities to transition the patient into
• Poor communication between staff, teams, hospital and external providers negatively affecting documentation, discharge delays, follow-up care and health outcomes
• Noncompliance with CMS transition care management services requirements

• Achieve discharge planning/assessment within 24 hours of admission
• Achieve separation of duties between clinical care and discharge,
• Achieve appropriate staffing ratio of patients to providers and case managers
• Reduce delays in discharge
• Ensure adherence to multiple requirements
• Encourage continuous relationship-building efforts with external long-term care facilities
• Provide efficient case management, owned by case manager/care coordinator/social worker

• Inconsistent, time-consuming, manual processes
• Inaccurate reimbursement rates that do not reflect increasing costs
• Insufficient nurse-patient ratios affecting quality of care
• Cost of alternative staffing models creating strain across the system
• Emerging nursing shortages caused by inadequate staffing, heavy workloads, increased use of overtime, a lack of sufficient support staff, and adequate wages

• Modernize clinical labor pricing to help recruit and retain clinical labor staff
• Implement competitive compensation packages that recognize sustainable rate increases
• Leverage productivity enabling technology to free up capacity and alleviate pressures caused by labor shortages
• Implement an accurate payroll system and regularly conduct audits to identify and correct any payroll errors
• Review employee classifications to ensure staff qualifications align with job roles
• Establish effective communication channels with staff and union representatives

• Poor inventory management, physician preferences, lack of good data, lack of standardization and inefficient practices contributing to a system that is costly, ineffective, prone to fraud/abuse and influences clinical quality
• Multiple operating rooms that utilize single supply room
• Unclear roles and responsibilities of vendors across the inventory life cycle, especially for high-dollar implants and orthopedic supplies
• Varying inventory control considerations, requirements, expiration dates creating an opportunity for human error, manual workarounds, waste/loss/theft

• Leverage supply chain data to identify operational gaps
• Monitor how much was paid, what patient was charged and how much was reimbursed by the payor
• Identify supplies that are purchased across multiple locations for greater purchasing power or standardization
• Leverage dashboarding opportunities to track and discard items that have expired or been recalled
• Prevent fraud or optimization by identifying mismatches in use vs. charges