Patient care delivery systems and patient-facing technology, while offering many benefits, may create added risks and hazards.
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Patient care delivery systems and patient-facing technology, while offering many benefits, may create added risks and hazards. Such risks will impact the healthcare industry and have the potential to dominate the headlines. Again, as we saw last year, 2023 offers an ever-changing landscape of opportunities and challenges impacting all care segments, including acute care, physician practices, home-based programs, and senior living, among other areas. Leadership, as always, will need to stay ahead of the next “big” issue and, in doing so, will find value in an enterprise risk management approach to preparedness and planning.
With emerging technologies and the continued advancement of artificial intelligence, all bets are off. Operational disruptions and ongoing changes are fair game today.
The following list summarizes some the emerging and evolving risks for 2023. Some risks are a carryover from years past, while other concerns reflect new risks that may well take us into 2024.
Two primary categories are reflected below, safety and technology:
Safety
Human capital
The human capital issues faced by healthcare systems have continued to be a front and center priority for 2023. Although there have been staffing concerns for many years, the COVID-19 pandemic allowed us to see just how dire the situation has become.
Summarized below are key areas that helped place human capital at the top of the list for our top patient safety concerns for 2023. Healthcare team members serve their patients, organizations and communities and are on the front lines meeting issues, challenges and stressors head on. The emotional toll of the past three years has been widely discussed. Burnout is at an all-time high.
Staffing
The care team
Staff shortages of both clinical and non-clinical professionals, such as RNs, certified nursing assistants, respiratory therapists, registrars and others will continue to dominate.
Caregiver burnout continues to be at the forefront threatening staff retention efforts.
The total supply of RNs decreased nationally by more than 100,000 nurses from 2020 to 2021 — the largest drop observed in the past four decades.
Sourcing staff from outside the U.S. is not new but, since 2020, the volume of caregivers presenting for work here with English as a second language has expanded.
Approximately 40% of nurses are over the age of 50 in the United States. COVID-19, among other pressures, has brought forth workers rethinking retirement plans, with many retiring or leaving the profession for less stressful work opportunities.
A shortage of registered nurses is projected to spread across the country through 2030, with the most intense shortage in the Western region of the U.S.
Demand for travel nurses saw a sharp decline of 33% in 2022.
The provider
Physicians play a critical role in healthcare delivery. With an aging U.S. population, population growth, and more available insurance coverage, physicians are in increasing demand. However, looking at current trends, medical school enrollment, recruitment and the need for both family practice and specialty physicians, shortages remain an issue. Many of the issues experienced by nursing and all other members of the care team have impacted providers.
The physician workforce continues to grow older, on average: 46.7% of active physicians in the U.S. were age 55 or older — up from 44.9% in 2019 and 37.6% in the first specialty report, which covered 2007.
According to new data published today by the AAMC (Association of American Medical Colleges), the U.S. could see an estimated shortage of between 37,800 and 124,000 physicians by 2034, including shortfalls in both primary and specialty care.
Continued population growth and aging demographics will drive demand.
As of Q4 2021, according to Definitive Healthcare, a total of 230,609 healthcare providers in the U.S.s have left the profession.
Staff physical and mental wellbeing
Episodes of violence and aggression in the workplace continue to escalate. Another concern rests with domestic partner violence that may carry over into the work setting. Not all patients are found in hospitals or physician offices. Travel risk exists for employees who see patients outside of the hospital setting (home health, hospice). Road safety is an additional concern. The home-based nurse and care team may often walk into un-safe situations. Without an emergency preparedness plan, they may be left to navigate a myriad of risks with little to no assistance or direction.
Frontline caregivers are working longer hours resulting in physical and emotional exhaustion, putting the team and their core energy reserves to the test.
Beyond burnout, many are experiencing post-traumatic stress (PTSD) and, for some, the significant levels of stress are creating an increase in suicide risks. Physicians and frontline care team members are all potentially at risk.
Staff shortages are impacting access to mental health care, with some prospective patients waiting weeks for a first appointment.
Long COVID-19 symptoms will continue to impact staffing coverage for those staff affected personally by COVID-19.
Will staff shortages and an exhausted care team create the perfect storm in which patient safety incidents increase? The potential impact staff shortages on patient safety is under review by regulatory agencies, patient safety forums and accreditation organizations.
Risk mitigation
Ensure for an effective onboarding process.
Survey the care team members regularly and learn where their pressure points are — what issues need to be addressed as a priority.
Conduct rounds on your employees; invest in time spent being a visible and accessible leader.
Use orientation buddying for the first 90-days by assigning a long-term team member or provider to be a resource to your new team member.
Ensure that staff and providers know where and when to call for help.
Enhance professional training on such topics as dealing with the difficult patient and family, documenting the difficult encounter.
Track and trend incident reporting data related to violence and aggression in the workplace; ensure that an organization-wide prevention of workplace violence plan is active, measurable and that staff are well-educated to the need for reporting events that impact their workday safety.
Train staff in verbal de-escalation techniques, such as those described by the Crisis Prevention Institute (CPI).
Create emergency preparedness plans for non-traditional healthcare settings, such as home health and community outreach.
Patient-safe environments
In the complex environment of healthcare today, there are many factors that influence the quality of patient care delivery. Contributing factors resulting in negative outcomes may include staffing vacancies, technology mishaps, increasing number of serious patient harm events, relationship conflicts, ineffective workflow, medical devices and violence against workers.
With less than optimum staffing, the best-practice approach to care may not be realized. Poor handoff and care coordination may occur from shift to shift due to staff shortages. Complex medical equipment and computerized devices add to potential patient risks. Understanding the definition of what is considered a medical device according to the Federal Drug Administration is an essential step. A typical hospital may have upwards of 15,000 devices to manage. Across the country, 10 to 15 million with 10-15 connected devices for each patient.
Medical device management
Device recall
The device recall process is one of the challenges of medical device management. Not only are there concerns with device recalls in the healthcare system but also in the home environment. In the latest report from ECRI, recall of home-use medical devices tops the list of hazards. Unlike hospitals, medical consumers living in a residential environment are not receiving the safety notices and warnings for the devices they are using. In addition, there is no central data that ties the user to the medical device resulting in notification delays.
Underreporting of device-related issues and failures
Medical device mishaps will occur but, taking such events lightly when the medical consumer has not been harmed, leaves the next users of the device at risk. Staff may not have time to immediately submit an incident report, there may be confusion as to when to report device-related concerns to the FDA. The care team may not know what and how to report such events to the risk management, patient safety or supply chain teams. The worse outcome beyond harm to a person would be allowing for a device to remain in service when the functionality and safety of that device has come into question.
Risk mitigation
Ensure that the organization has a written recall preparedness plan.
Know when to report a device mishap or other adverse event to the FDA and when to report an issue to the FDA MedSun program.
Ensure that staff know the internal process for reporting medical device issues. Keep the process simple by identifying one department to serve as a notification point. The workflow after the report is filed can be determined by the safety team.
Educate the team as to how to sequester a questionably faulty device.
When using online event/incident reporting software or platforms, customize your program with the general and specific event types that offer the most detail needed from the reporter, such as lot numbers and serial numbers.
Ensure, through written policy and training, that partner departments, such as clinical engineering staff, risk management and patient safety, understand FDA reporting requirements.
Although the severity and frequency of medical device events may vary — even without patients or employees being harmed — near miss analysis and data trending will be essential to anticipate future risk.
Technology hazards
Summarized below are key areas that helped keep technology on the list of hazards.
Cyber threats
Data breaches, ransomware, phishing attacks, email compromises and more, round out the list of potential cyber threats. Coming in at first place is cybersecurity and ransom attacks, which continue to grow in number and remain as a prominent concern in all industry sectors. Additional risks may be found in cloud-based clinical systems as well. However, hospitals are at a greater risk not only because of a breach of patient information but also for the potential for compromising patient care directly.
Beyond the desktop computer and the electronic medical record, a significant portion of medical devices found in healthcare settings are at risk for a cyber-attack as well. Infusion pumps, patient cardiac monitors and glucometer (for blood testing for diabetics) are the most vulnerable.
Risk mitigation
Consider whether the disruption interrupted your business operation and to what extent.
Enable multi-factor authentication or two-factor identification for your web applications.
Encourage your team to use strong passwords.
Train the entire organization to recognize threats: spear phishing, social engineering, business email compromise and phishing. Include proper handling of sensitive information on mobile devices.
Conduct vulnerability, penetration and security risk assessments to identify where your organization is most vulnerable.
Ensure that emergency preparedness and downtime plans supporting cyber incidents are up to date and that drills occur at least twice a year.
Contact your broker and insurance carriers for assistance as soon as possible.
Use threat detection software.
Ensure staff know how to promptly report any concerns or workflow missteps.
Care available everywhere
Virtual care. Nothing inspires innovation and creative problem solving like a pandemic. Telehealth and virtual care have been available for some time, particularly for mental health care or underserved communities in need of specialty care. However, this care platform expanded at the start of the Covid-19 pandemic. Telehealth, retail care, expanded home care and the virtual appointment are no longer an exception, but now an option for the patient to consider when scheduling for their care needs.
Remote monitoring has also expanded to include high-risk pregnancy monitoring and mobile ultrasound both within and outside of the traditional hospital. Wearable devices have gone beyond the clunky Holter monitor to slick patches worn on the skin that can identify cardiac changes. Cloud-based care is now generating a unified view of the patient’s medical record across multiple care locations and different health systems. From a patient’s perspective, options for receiving care are essential. Amazon, CVS, Walgreens, Walmart and others have disrupted primary care by offering the convenience of care while taking that trip to the store. Meeting the needs of the patient also means knowing that patient, and satisfaction surveys are now coming to a text message near you.
However, there are limitations and risk to these delivery processes, including:
Less than accurate physical assessments of the patient can occur in the telehealth setting.
Computer access and network connections may limit virtual care options for some demographics.
The ability to connect online and stay connected throughout the appointment may be problematic.
Alignment with reimbursement for virtual care has been in flux.
Risk mitigation
Train staff on the legal and regulatory aspects of telehealth.
Create staff competencies to ensure staff are effectively following virtual care policies.
Audit, through observing a patient encounter conducted via telehealth or virtual care. Provide feedback to the team.
Work to make your telemedicine process as streamlined as possible for the patient. Provide clear instructions as to what the virtual visit will offer, the extent of care that can be provided and who can help when troubleshooting connections.
Artificial intelligence
There are risks and benefits in utilizing artificial intelligence (AI), specifically in the realm of diagnostics and monitoring. Examples of AI include predictive analytics, clinical pathway decision-making, wearable tech, off-site or home-based patient monitoring and more. AI may also offer a future that quite possibly reduces caregiver burnout by taking over some of the traditional monitoring often provided by nurses and cardiac monitoring technicians. AI may also help alleviate the stresses of burnout that drive physicians out of practice.
However, at issue with regard to risks and benefits is the possibility that AI may not be able to interpret all human nuances resulting in biases, lapses and unintended consequences in care. The AI system must be consistently monitored with checks and balances in place to ensure safety. Sophisticated equipment is used for monitoring of patient vital signs. Such devices offer alarms, bells and whistles to alert the care team to a potential life-threatening problem. With such alerts also comes alarm fatigue. From the staff perspective, digital and AI solutions may offer a way to alleviate some of the load on the care team while also providing training tools that are cutting edge.
However, there are limitations and risks to these delivery processes, including:
Although there are many opportunities for AI, a report from the World Health Organization points out associated challenges and risks, including unethical collection and use of health data, biases encoded in algorithms, and risks to patient safety, cybersecurity and the environment.
Privacy may not be assured for virtual care or AI, and personal health information may be at risk of breach.
AI requires massive data sets in order to “learn,” thus needing volumes of patient health information for training and validation.
When bad events happen with AI making medical decisions, the provider will still be ultimately responsible.
What can AI do for work processes? Ensure that staff understand the limitations of AI.
Learn more about the ethical issues being raised regarding AI and where possible missteps may occur.
Risk mitigation
Create policies and procedures for AI-based devices and wearables.
To ensure for safety, “test” the effectiveness of the processes that are using AI through the use of Failure Mode and Effects Analysis.
Privacy laws may not have yet caught up with the use of AI. Be cautious with AI vendor contracting and insert federal privacy requirements into the agreement.
Summary
2023 promises to bring forth continued risks and hazards for the healthcare industry. With less than optimum staffing, the best-practice approach to care may not be realized.
Ensuring the safety of healthcare workers is now paramount and a leading priority for healthcare organizations. The concern for employee safety also extends to ensuring the safety of the patient as both issues go together. The work to reduce error rates and mistakes will require continued monitoring.
From the front line to senior leadership, employee safety will continue to be one of the highest priorities. In a time of uncertainty where high emotions are coming from peers, patients and their families, staff need to feel safe and heard. Continually escalating episodes of violence at the workplace will further exacerbate burnout, staffing shortages and turnover. Leadership visibility and problem-solving difficult patient encounters can provide much needed emotional support to staff.
Disclaimer
Willis Towers Watson hopes you found the general information provided in this publication informative and helpful. The information contained herein is not intended to constitute legal or other professional advice and should not be relied upon in lieu of consultation with your own legal advisors. In the event you would like more information regarding your insurance coverage, please do not hesitate to reach out to us. In North America, Willis Towers Watson offers insurance products through licensed entities, including Willis Towers Watson Northeast, Inc. (in the United States) and Willis Canada Inc. (in Canada).
