Utilizing Enterprise Risk Management in Patient Care Decisions

As defined by the U.S. Committee of Sponsoring Organizations of Treadway Commission’ (COSO), enterprise risk management (ERM) is "a process, effected by an entity’s board of directors, management, and other personnel, applied in strategy setting and across the enterprise, designed to identify potential events that may affect the entity, and manage risks to be within its risk appetite, to provide reasonable assurance regarding the achievement of entity objectives."

An organization may choose to break down the ERM process into the following components: financial, legal, internal environment, external factors, risk assessment, risk response, control activities, information, technology, and communication. Basically, the process includes all facets of an entity’s operations and areas of potential vulnerability. Some risks are more predictable and easier to manage than others. Bioethics is one area for providers that impacts a multitude of components and operational areas.

One facet of bioethics that should be closely assessed from an ERM vantage point is ethical decision-making, especially in the pediatric and geriatric patient populations. In a recent issue of Bioethics Reflections a publication of the Cleveland Clinic, Eric D. Kodish, MD, chairman of the clinic's department of bioethics views the amplification of the complexities of bioethics in these two patient groups as, "a bell-shaped curve, with autonomous decision-making at the top of the bell and extremes on either end. On the left side of the curve, you have children, who are completely dependent on us when they are born but eventually develop into autonomous beings. On the right side are geriatric patients, many of whoem become completely dependent before they die." Cost is a related issue that plays heavily into an ERM analysis and is often associated with complex treatment.

Undoubtedly, considering whether or not to withhold treatment based upon financial considerations is a difficult conversation for physicians, patients, families, and institutions (i.e., hospitals or long-term care facilities) to engage in. Considered from an ERM perspective, some of the components impacted include the following:

• Legal - Will the providers face a lawsuit for withholding the care?

• Financial - How will this impact the patient and how will it impact the providers’ accounts receivable, as well as the ability to render charitable care to others?

• Communication - Who is involved in this process and is it curtailed to the specific patient?

In essence, by designing an entity-wide ERM road map for addressing bioethics issues, an organization can anticipate areas of vulnerability and liability and be ready to respond.

"It’s important to look both backward and forward in time - backward to guide decisions that are true to what the patient with prior capacity would have wanted, and forward to protect the patient’s future and/or to minimize suffering," writes Kodish.

Medical ethicists and various centers devoted to bioethics such as Cleveland Clinic or the Baylor College of Medicine’s Center for Bioethics are critical persons in the bioethics ERM process. Because bioethics encompasses such a range of issues from end-of-life decisions to refusal of treatment to a pediatric patient’s input into their treatment, developing a strategy from an ERM perspective can help in anticipating, planning, and prevention of events.

Author Disclosure: Rose is an affiliated faculty member with the Baylor College of Medicine's Center for Bioethics.