Featured Guest: Tamara Johnson

What she does: Tamara is the Vice President of Quality and Risk Management at Phoenix Children's Hospital where she provides oversight to both the quality and risk management departments. This includes organization-wide risk reduction initiatives and strategic direction.

On risk:  "When we hear the word risk, I think there's a lot of immediate thoughts that come to mind, and they're likely not always positive … When you really look at risk and you realize it's something that we're all faced with every day and so everything about what we do is calculated risk.  Working in risk management, it's taught me to really think and try to anticipate risk, just knowing that it's a given and that there are risks that you need to accept, and many of those risks produce meaningful outcomes, but they're also very calculated … Most of the catastrophic events that occur, whether it's a very unfortunate patient injury, whether it's financial, consequence is because the risk wasn't anticipated. The only way that you can address it and mitigate it is to identify it and respond to it. That's why you really have to have a risk mindset in order to do that."

Transcript

Scott Nelson  0:01  
Welcome to The Risky Health Care Business Podcast, where we help you prepare for the future by sharing stories, insights, and skills from expert voices in and around the United States health care world with a mission to inform, educate, and help health care organizations and individuals, ranging from one doctor practices to large integrated systems and organizations throughout the dental, medical, and veterinary health care industry with risk, while hopefully having some fun along the way. I'm your host, Scott Nelson, a guy that grew up in Ohio and has been working all over the United States during my 20 plus year and counting career in the health care industry, with a commitment to accelerating health care performance through creativity, not just productivity. Let's dive in.

Scott Nelson  0:48  
When thinking of risk in health care, there can be a tendency to narrow the perspective to life threatening situations. Ambulances speeding with lights flashing and sirens blaring. Doctors, nurses, and other professionals running to a location in response to an alert - a code. Someone is having a heart attack. A stroke. There's been a car accident. Totally unexpected. But what if the patient was your health care business? What if your business suffered an unexpected shocking event? A cyber or ransomware attack. A lawsuit. Doctor or staff departures. Financial downturns. How would it respond? Would you or your business survive? A report from the Center for Healthcare Quality and Payment Reform found that more than 600 rural hospitals are at risk of closing in 2023. The report found two common contributing factors: persistent financial losses and low financial reserves with insufficient net assets to counter losses on patient services over a period of more than six years. Recently, a number of health care organizations have closed medical departments or ended services citing finances and staffing. Today we're speaking with Tamara Johnson. Tamara is the Vice President of Quality and Risk Management at Phoenix Children's Hospital in Phoenix, Arizona, where she provides oversight to both the quality and risk management departments. This includes organization-wide risk reduction initiatives and strategic direction. Prior to joining Phoenix Children's Hospital, she served as Senior Director of Patient Safety and Risk Management at Children's Hospitals and Clinics of Minnesota, where she was instrumental in the development and implementation of an integrated quality and risk management program. Tamara has been a frequent presenter on risk management, quality improvement and Patient Family Centered Care to health care organizations on a national level. Let's talk with Tamara about risk in health care.

Scott Nelson  2:38  
Tamara, welcome to the show.

Tamara Johnson  2:40  
Thank you, Scott. It's good to be here.

Scott Nelson  2:42  
Well, before we begin our conversation about risk in health care, let's go back to the beginning. How did you get into health care and where you are today?

Tamara Johnson  2:49  
Sure, well, it was a few years ago. I started went to a school in nursing, and got my undergrad in nursing and started out working in a hospital setting as a nurse and did that for a few years. And then from there, I actually went into risk management and started working for an insurance company doing medical malpractice insurance. And so I was doing risk consulting, and continued doing that and that was around the timeframe where the Institute of Medicine report came out about the number of patients that suffered a medical injury and had serious consequences including death. And so there was really the launch of the patient safety movement at that time. And that was of great interest to me. And I started to really make the connection between risk and quality and patient safety. And then from there, I moved into several roles working for hospital systems, as well as medical office practices, and did that and went back to the consulting side for a period of time and missed the provider and hospital work and so I'm back now in the hospital setting working for a pediatric health system. And here I am.

Scott Nelson  4:29  
Well you've had experience and cover a lot of big areas in terms of risk management, both on the clinical and the non-clinical side in insurance. I'd like to start by getting your thoughts on what is risk in health care. Risk is a topic could and usually does mean different things to different people. And likely depending on a job or a role or organization type or location. So thinking about it broadly and then maybe narrowing in how do you view and think about risk and health care? What is it to you?

Tamara Johnson  4:56  
Yeah, I think that's a good place to start. You know, I think when we hear the word risk, I think there's a lot of, you know, immediate thoughts that come to mind, regardless of what we do. And they're likely not always positive. And it's interesting, when you really look at risk, and you realize what it is, you know, it's something that we're all faced with every day, you know it personally and professionally. And so everything about what we do is really, I think, calculated risks. And we probably don't spend much time thinking about, you know, the everyday stuff, which is okay. But I think working in risk management, you know, it's taught me to really think, you know, and try to anticipate risk, just knowing that, that it's a given. And one thing that, you know, I've appreciated is that, you know, those, there are those risks that you need to accept, and, you know, we take risks driving to work every day. And many of those risks produce meaningful outcomes, we get to work on time, but they're also very, you know, calculated. And that's true, you know, in healthcare, and likely any industry. And so, you know, my job, and the team that I work with, is to really, you know, assess the risk in our environments, and make decisions about are those acceptable? Are those, you know, areas that that we need to attend to? Mitigate? Monitor? You know, and sometimes we even work to, to remove the risk, but not all the time. So it takes I think it spans, you know, gamut of a lot of different things, we try to look at, you know, the the risk is it is a risk for our patients? Is it a risk for our family, for our staff, for ourselves? Is it a reputational risk? Is it a financial risk, and and, you know, to think about it and segregate it, in categories that make sense for, you know, the environment that you're in.

Scott Nelson  7:12  
And that's a perfect, gets right into the, because when I was writing this down, as you were talking, I was thinking, are there different types of risk variations? And as you were mentioning patient, family, and staff, I was writing down different types or categories or levels. And I know that people may look at this at risk based on where they're working their organization, maybe their department, or even their geographic location around the country. If you kind of categorize patient, family, staff, reputation, and then there are a lot of others. I mean, when you touched on financial, is it a good approach to categorize and kind of look at these in a variation approach to then put into perspective to then begin to address?

Tamara Johnson  7:53  
I think it is, and one, one thing that I try to do and encourage our team to do is to really assess it, you know, you know, based on a two quadrants, and so, you know, how often, you know, is the risk? Is it constant? Is it periodic, you know, what's the frequency? And then what's the severity of it? And you can use a lot of different risk management tools, there's a lot out there, you can just Google it, and you'll come up with, you know, many, and they're likely all very good, but I think sometimes it's easy to get embedded in the tool and the nuances of it. And sometimes the academics of it, but for me, just that frequency/severity scale, is probably the most practical and the most useful. And in our my experience, I would say probably the best tool that has, you know, sustained in terms of, you know, just it's, it's always applicable, you can now always put risk into a frequency severity perspective.

Scott Nelson  9:05  
Why is it important to think about risk? Not just to think about it but to actively plan and prepare for it?

Tamara Johnson  9:11  
Well, I think, you know, most of the catastrophic events that occur, whether it's, you know, a very unfortunate patient injury, whether it's financial, you know, consequence is because the risk wasn't anticipated. And, and so, you know, the only way that you can, you can address it, and mitigate it, is to identify it and respond to it. And so, you know, that's why you just, you really have to have a risk mindset in order to do that. And, you know, one of the things that I've always tried, I've tried to do is to teach others to have that same risk mindset, you know, I work for an organization that is a large health system, you know, with several locations and and we have a risk team that can't cover everything. And so I've always said, you know, one of the things that we need to do well is to teach people to fish to teach people to recognize risk, because we need everyone out there to have the same kind of eyes and ears that we do, really assessing risk, and making decisions about what they need to do with it. So it's really just trying to mitigate that element of surprise.

Scott Nelson  10:42  
And that takes into consideration you know, when you're mentioning a lot of the different areas and teaching people these different things and having having the mindset to it. For a long time, from in my opinion, risk has always really been focused or talked about from a compliance or a coding and billing, quality and safety were a lot of times the focus and got a lot of attention. Recently, there's been a lot of conversation about IT and cybersecurity. Where do you think risk is in medical care? Where should medical care professionals and organizations be watching or monitoring when you talk about catastrophic events, patient safety, you know, with your background in nursing, but there's also a financial ramification for a lot of decisions that are made if organizations are beginning to look at patients that are coming in from the revenue and expense perspective, they're looking at doing strategic initiatives. Where is where can risk be viewed throughout an organization?

Tamara Johnson  11:38  
Yeah, it's a good question. I think, just knowing again, that risk is is everywhere is one thing, but sometimes that doesn't, you know, make it very practical, then. Because it's like, well, where do you start? And and I think, you know, it's very helpful to consider your data, you know, look at your own internal benchmarks around, you know, what issues have have occurred in the past? Where do you have high levels of change? Because we know that with change in and of itself, really doesn't matter what the change even is, there's inherent risk with that. So you know, where do you have processes changing? Where are you do you have a new site that you're building, or that you'll be onboarding, or maybe you're, you know, removing a practice or, you know, to some degree, your scope of service is changing, there's risk, there's inherent risk with that. External benchmarks, I think, are really helpful. Network, and, and find out, you know, what's happening outside of my organization, because if it can happen somewhere else, there's a strong probability that it could probably happen in my own setting. And so really just having an openness to to all of that, and, and then using that data to guide you, but not in a absolute way. It's really it's a data point. It's it's a piece of information. But it doesn't replace the value of you know, getting out in your own environment and really walking around listening to people and responding to your own situations and your own signals that are in your own environment.

Scott Nelson  13:30  
A lot of times risk can be viewed or engaged as a as a kind of a reactive model reactive process. So when you mentioned high levels of change, and looking at staffing, and if you're going to open up a new department or division or open up a new facility, those are things if they're being planned for how can risk and how should risk be factored into the to the prep work, the planning that's taking place in advance that I would expect might be able to help mitigate or manage some of those unanticipated events. If you're able to anticipate in advance how can that be worked into something in advance of that project going forward?

Tamara Johnson  14:08  
Well, I think it's important to you know, gather your stakeholders, your subject matter experts. And if your role is is the risk manager, or, you know, some kind of administrator leader role is to listen to people that are doing the work and understand from their perspective, you know, what are their concerns, and that's likely a very good and likely very accurate gauge for you. I think, again, the you know, frequency severity model is very helpful. There's other tools like a failure mode effects, analysis - an FMEA. That can be very helpful. Those are more detailed. Something that you might want to do with with already recognized high risk procedure if that's what it is. And then, you know, to determine where does this fall? A lot of times we think about and in the space of healthcare, if you just ask someone, where do you think the highest risks are, people are likely to point to those high acuity clinical acuity environments, like your ICUs. And it's interesting that when we look at look at claim statistics, and where accidents happen most, they're not in those highest acuity areas. They're, you know, in those moderate and sometimes even low acuity areas. And why is that? It's probably because people are thinking that they're in an area where risk is, is low, it's not, first and foremost, it's not top of mind. And that's when it's most dangerous, is when it's not top of mind for people. And so that's why again, helping to really ensure that everyone models that mindset, looking for and responding to risk.

Scott Nelson  16:07  
I would think that with your example of the ICU and in other places, it's you know, it's one of those things where it's top of mind. So if a patient's been seen in the ICU, that's really, the entire focus of the ICU is they are looking at every risk scenario, every contingency, that patient is being monitored on a very extreme basis. Whereas there's other parts of the organization that if it's not in that kind of high critical access period, just kind of the out of sight out of mind, again, going back to the gambling, that something may not happen, and that's where some things do slip in from time to time. 

Tamara Johnson  16:43  
Exactly. Yeah. 

Scott Nelson  16:45  
You mentioned stakeholders and getting those people to the table if you're doing planning or just in general. Who are the stakeholders and actors that are typically involved? How do or can they address risk? And then on the flip side of that, who should be involved?

Tamara Johnson  17:00  
Of course it's going to depend on the environment that you're working in. But I would say, as a rule, anytime that you can engage the frontline, as I said before, the people that are doing the work, they're the ones that are going to be able to give you the most helpful information and cues about where the risks are. Because they're the ones as I said, doing doing the work, they likely lived with these concerns for probably a while. And they know about it. I'm not suggesting to, you know, not tap into leadership as well. But if it's in the absence of you know, not including the frontline, I think you'll really miss some some vital information.

Scott Nelson  17:50  
There can be a tendency for risk to be overwhelming. So what can individuals and groups do to make it more manageable and easier to address? Like putting it into bite sized pieces. So if an individual or an organization wants to consider an approach and plan for risk, or better yet do it, how could they? So I'm thinking like a plan and a process, you know, some of the things you had talked about previously with, you know, the two quadrants of frequency and severity, looking at data and external benchmarks, the detail of the failure mode analysis. Are there ways to, if I'm a doctor's office, or a practice, or even an organization, a large organization to view and take a perspective on this, that they can address it in multiple ways?

Tamara Johnson  18:32  
I think that this is key. And this is something that I would say, I've probably learned the hard way, just because earlier, when we were talking about that risk is ever present, there's there's a lot of risks. And again, I don't think that there's any industry that, you know, is an exception to that. And so it's it's critical that you scale it. And so for me, that's really meant prioritizing what we believe to be the highest risks, and coming up with that list, whether it's a top three, top five, top 10, but a disciplined list or prioritized list of what we think are the highest priorities from a risk perspective. And I'll say that it's it's important to maintain the discipline because what we've found too is it can be very tempting to you know, something else pops up and that gets your attention and all of a sudden you forget about what was your top three. And and maybe that's where you need to be, but maybe it's not. And so just having that discipline to if we don't want to be too rigid that we fail to see something new because it wasn't in our top three. But I think just using that that reasoned approach to say okay, is there a reason that we need to change what our focus is? But we try to do is to have, you know, as an organization as a large health care system, what are our enterprise risk points? What are our prioritized risk points as an enterprise? And from an enterprise perspective, what we really need to do is to ensure that what those are, are tied to our strategic plan because the strategic plan drives the operation for the organization. And we want to make sure that that operational plan is successful. And so we really need to know what those risks are that could derail that, that strategic plan. And so those that that top three or whatever that top list is, should really align to what your strategic plan is. And then at the local operational level, each leader needs to have their own sense of for my area, what's what are my highest risks? Do I know, as a leader? And then very importantly, do my staff know? Because one of the best ways to derail effective work around how are we doing with our risk mitigation plan is to keep it in a silo. And so be very transparent about it, make sure that all of your staff can speak to it at any time, if there's a change in it, everyone should know about it.

Scott Nelson  21:36  
I love hearing your point about including risk in the strategic plan. As somebody who myself came up and got into health care because of a strategic planning class that I took in business school and came up through strategy and strategic planning I absolutely agree with that. And I love hearing about a strategic plan. That got me thinking about timing. And so usually, if you go through a strategic planning process for an organization, you do that, you know, once a year, and you'll have some touch points throughout the year, but you'll view and you'll look at at that strategic plan. How do you approach risk from a timing perspective? I feel confident saying well, you know, the sooner the better, don't put off until you know, the future, let's start planning on risk and let's start putting some things in place today. But is it something that if it's included in a strategic plan are you and your team or the local groups that are on the frontline are they looking at something, are they touching it, considering it twice a year? Monthly? You know, quarterly, weekly? How would they approach that?

Tamara Johnson  22:36  
Yeah, I mean, I think if it's identified as being important enough to, you know, be on your, your list of high priorities, I think that, you know, it needs an action plan, really right away. If it's, if it's a high priority, it's something that I think you should never sit on. If you can sit on it, it's probably not a high priority. And so what we do, once it's identified is to then, you know, make decisions about what is it that we need to accomplish? What's our objective here? And then what's our work to achieve the goal that we we identify? And it's something that we work on daily. We monitor and discuss not formally every day, but there's, there's work being done on it every day. And then usually, at least once a month, there's a report that would go up to an oversight committee around the progress for that, or barriers, because that's the other reality, everything isn't going to be progress. And sometimes the discussion is rather about the barrier that exists. And then what's our job as leaders to remove that barrier?

Scott Nelson  23:52  
What are some potential barriers that are there because I was actually was thinking about this in terms of pitfalls and threats or, you know, obstacles and barriers that that should be kept in top of mind that may have folks not getting off the starting blocks. So, you know, one that was we were talking comes in mind and maybe like complacency or indifference or just not knowing what to do and where to start and how to go about it.

Tamara Johnson  24:18  
Well, I think this is where you really need to lean into your your leadership team. Because if this is identified work that's critical, then I think it's, it's non negotiable. And it needs to be written into whether maybe, you know, not job descriptions, but if you think about goals that typically, you know, an individual will have goals that everyone's working on. And these are things that likely should be part of that improvement process. So whether it's an individual or it's a team, and then an individual's performance or a team's performance is really evaluated based on whether or not those goals are being achieved. And so you have to hardwire that into the accountability structure. Otherwise, it just becomes a nice thing to do that is likely not going to happen. And so it's we've the only way that we found that we can be successful with that and then to sustain that work, which is the other objective, it's not to just get it started, but it's to sustain it is, you know, to really build it into the accountability structure.

Scott Nelson  25:37  
If something does happen, and the best laid plans and everything's put into place, and we have tried to anticipate, if something does happen, how would one respond? Or how would a group respond if something does does come through?

Tamara Johnson  25:52  
Yeah. And that will happen. And and I think one of the, in our business, you know, the first thing is to make sure that the people that are involved are taken care of, both from a physical standpoint, as well as, as emotional. And that can be difficult. But that's typically our hierarchy is the people are taken care of. The next thing that we do is really fact-finding. We try not to do anything that isn't based on facts. So we're not making assumptions about what happened. But we're taking the time and effort to really do the analysis and investigation. And then we bring that information to the table with, again, your subject matter experts, your stakeholders, and you're identifying in that analysis what happened, what, you know, what were the contributing factors? What was the root cause? And and then you're making decisions about how do we ensure that this doesn't happen again. And maybe that information is going to reveal to you that you have new risks, or maybe you have risks that you identified before, but you weren't thinking about the same way. But now based on the event that occurred, it's it's illuminated new findings. And so you're approaching that risk in a different way. And I think it's it's really important that people don't see that as a failure, that we failed to identify this correctly the first time. This is part of the evolution of risk management. It's it's a continual process. And if we fail to, to learn and make adjustments, that's just it. We'll, we'll fail at that point. So to accept that it's fluid, and it's constant is just is part of the journey.

Scott Nelson  27:55  
Looking back through recent history, from a risk standpoint, what was expected versus unexpected in health care, and what could have been done differently?

Tamara Johnson  28:04  
Yeah, I think in health care, we, we've learned so much. I mean, when I think about 10 years ago, we used to see things that have happened, and just think it's, there's no way that we could prevent this. And I think the more that we learn about risk management, quality process improvement, the more we realize that there are actually ways that we can at least mitigate that risk, if not even prevent the situation from occurring. And so maybe today we've we've realized that there's there's avenues to prevent what we 10 years ago thought was not preventable. And so it's just, it's being open, I think to that, and it's being open to challenging the status quo. And that's where I think leaning into your external colleagues, you know, being a part of your professional associations, and using those groups to really understand what are others doing. We take no pride in reinventing the wheel, we really try not to do that. And so if someone else has is doing something that we think could be really helpful, we're all about, you know, adopting that or at least considering that as an option. And in the same spirit, we try to be very willing to share anything that we've learned with our colleagues and health care community.

Scott Nelson  29:42  
Now looking forward during this year, maybe even beyond, what do you see as potential issues in health care? What are you anticipating even in your in your own work? How can individuals and organizations or how are you anticipating them being prepared?

Tamara Johnson  29:55  
You know, I think whether it's health care or again, any other industry or even in our our own personal lives, there's just there, the competing demands are unrelenting. And and I think it can be overwhelming. And I think maintaining that focus is probably going to continue to be one of the most difficult things. And also one of the areas that I think can really get us off track. So not trying not to be overwhelmed by what those are, but seeing those as opportunities to really reassess and to pause and to be thoughtful about how we move forward. I think that's key.

Scott Nelson  30:44  
Do you think when you're talking about maintaining focus and being overwhelmed, have you gotten a sense or noticed any change in approaches or abilities or skill sets, you know, how people view things, since we've just come through a pandemic, and things that none of us have ever experienced before, most of us probably never experienced before anything like this, a different type of approach and people more open to considering things and being prepared, and saying like, well, we, we need to take a look at this now and keeping that focus in some of these areas?

Tamara Johnson  31:18  
Yeah, yeah, definitely. I think, after the pandemic, things have felt very differently, because I think they are very different. You know, our work settings, look different people are working differently. They're working in different places. And one of the things that I think we initially struggled with in coming back when people could come back into the office, of course, health care never shut down if you were doing direct patient care. But the administrative spaces did look very different. And they, and they still do now. And so one of the things that I think we're challenged with is how do we keep the connectivity? Because even though we can physically come together, I think we realize that there are efficiencies gained from utilizing virtual communication methods. And, and yet, we know that there's disadvantages with that, too. And so how do we keep that connectivity? And I wouldn't say that I have all the answers. But I think just again, knowing that that is also a risk. So we're trying to really look at how do we maximize this hybrid model that we now live in, and identify those activities where it's really not going to lend itself to a, you know, a virtual format, we need people in person. But then for those activities where we where that's not required we don't require it. Because we'd like to give our staff flexibility. And I think the marketplace is demanding that. I think you know, that's another risk point, too, is just your human resources. I've read recently that, you know, people are leaving the health care field in record setting paces. We know firsthand, these are oftentimes hard to recruit positions. And it's really critical that we keep a flexible mindset about the work environment that we are bringing people into. So all of those things, I think are challenges for us. But again, they don't have to be a barrier. But I do think it's it's how you approach it.

Scott Nelson  33:42  
Well, that's a great point to conclude our conversation. Tamara, thank you very much for your time and sharing your thoughts today.

Tamara Johnson  33:47  
Thank you, Scott. I appreciate the invitation.

Scott Nelson  33:48  
Thank you for listening to The Risky Health Care Business Podcast. You can listen to all episodes from the resource center page of the SpringParker website, springparker.com, or click the Listen link in the show notes to listen and subscribe for free on your platform of choice. And remember, accelerating health care performance is achieved through creativity, not just productivity.