Incident and Case Management

 

Establish a proactive, collaborative and sustainable process of identifying and resolving adverse incidents in the healthcare industry

“To err is human,” goes a popular saying. But in healthcare, ‘erring’ is unacceptable. After all, human lives, health and safety are at risk. Misdiagnoses, wrong treatments, or accidents in the operating room can all cause immense physical and psychological harm to patients, their families and even their healthcare providers.

There are other equally harmful adverse incidents that occur from deliberate human actions. Medical fraud, information security breaches, kickback referrals and bribes are found in even the largest and most well-known healthcare providers. And like many medical errors, they are also preventable.

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MetricStream Incident and Case Management Software Solution

Combating adverse incidents
Over the last decade, regulatory bodies and governments across the world have introduced regulation after regulation to protect patients and communities from adverse incidents. In response, healthcare providers are striving to implement regular audits, expansive internal control frameworks and on-going risk mitigation strategies.

Why Proactive Incident Management Matters…

  • According to a 2010 report, a total of 158 breaches were reported in the Medical/Healthcare industry, compared to just 52 in the Banking/Credit/Financial industry. 1
  • The financial losses due to healthcare fraud are estimated to range from $70 billion to a staggering $234 billion a year. 2

Yet mistakes still happen, and deviations still occur. Whether they are medical errors, or fraud, or even incidents arising from GRC processes, ultimately, the healthcare provider has to pay the price, just as much as the perpetrator of the incident. Therefore, it is critical to have a robust incident management system that can identify and resolve such incidents in time, while providing sufficient insights to ensure that the incident does not reoccur.

An incident management system enables healthcare providers and payers to establish a consistent method of dealing with incidents from start to finish. This is particularly important in demonstrating compliance with a host of regulations, and minimizing the likelihood of incidents.

One must remember that an incident management system by itself cannot prevent adverse events. But when supported by robust risk, compliance and audit processes and technology, it can make all the difference to the success or failure of one’s GRC strategy.

Challenges in managing Incidents and Cases

Complexity and variety of incidents
Adverse incidents range from medical errors, to compliance issues, to fraud. In turn, fraud incidents could range from billing for services not rendered, to performing medically unnecessary services, to accepting kickbacks for patient referrals. Sorting through these incidents, categorizing and resolving them can be extremely complex, considering the time, effort and costs that are involved.

How an advanced Incident Management System can help

  • Establishes a consistent, systematic method of resolving incidents
  • Provides in-depth insights into why an incident has occurred
  • Proactively detects and resolves potential incidents before they occur
  • Identifies trends and co-relations in incidents that can prevent future reoccurrences
  • Helps demonstrate sustainable compliance with regulations, and mitigate risks
  • Helps embed an enterprise culture of patient-focused safety and health
  • Reduces costs, resources and manpower

Regulatory pressure
Healthcare providers have to resolve incidents for a range of compliance regulations, ranging from HIPAA, PSQIA and FCPA in the US, to the Anti-bribery Act in the UK. Regulatory scrutiny for each of these laws is intense, and non-compliance penalties are heavy - not just in terms of monetary fines, but also in terms of brand impact.

Manual inefficiencies
Healthcare providers are under tremendous pressure to gather and report information on incidents. Some have established hotlines, others use emails, verbal communication and handwritten notes. Consolidating these channels of information, and managing them efficiently consumes substantial time and manpower. Moreover, the information is traditionally recorded and reported through manual processes and spread sheets which are laborious to manage, costly, and prone to human errors.

Disparate incident management processes
Given their vastness and complexity, healthcare organizations tend to manage incidents in independent silos. This lack of collaboration can result in redundant incident management activities. It also prevents management from gaining top-level, real-time visibility into the incidents, and gleaning the insights necessary to prevent reoccurrence. For instance, if an information security breach is identified and resolved in one department but not shared with others, it is bound to reoccur in another department, requiring additional time, resources and costs to resolve.

MetricStream Solution for Incident and Case Management

MetricStream solution for Incident and Case Management is acomprehensive solution that enables healthcare providers to establish and followconsistent procedures for incident capture, exception logging, loss event tracking,task management and status reporting. Built on a centralized platform, the incident management solution extends across the enterprise, consolidating all incidents in a single point of reference. It also streamlines and standardizes the development andimplementation of enterprise-wide remediation and corrective action plans.

Powerful dashboards provide real-time visibility thathelp healthcare providers trackeach incident through its lifecycle from initiation to closure - following theappropriate processes to ensure that nothing slips through the cracks. In addition, an advanced analytics and reporting capability helps managers perform a trend analysis, spot recurring problems, and identify their root causein a timely manner.

MetricStream solution provides the ability to identify and track the quantitative impact of loss events and liabilities related to incidents, which, in turn, helps drive effective operational and enterprise risk management.

Incident and Case ManagementRecording and routing
The solution allows healthcare managers to log an incident or initiate a complaint. It captures detailedinformation about the incident, and helps categorize it based on pre-defined criteria or severity levels. Depending on the case type and otherparameters, the incident is automatically routed to the respective department, asper the healthcare provider’s standard operating procedures for investigationand response. Documents and references can also be attached to the caserecord.

Review and reporting
The system routes the incident for review and analysis to authorized users, based onpre-configured rules for review, approval and disposition. The application’sdecision-tree functionality supports the identification of reportable events, as well asthe type of report that needs to be filed based on thresholds and escalationtriggers.

The process of reporting is simplified, as the system automaticallygenerates mandatory reports in prescribed formats and layouts. The reports aregenerated in standard file types such as MS Word, and can be further worked onbefore being submitted for management review or to a regulatory agency.

Investigation and remedial action
The solution enables triggering automatic alerts and notifications to the appropriate healthcare personnel for initiating immediate remedial action. This, in turn, helps contain the impact of theincident and ensure that the root cause is identified.

The investigation is drivenby collaborative workflows that ensure responsiveness by assigning investigativetasks to an individual or a team with due dates based on severity level. Once acorrective action or remediation is initiated, the case remains open till the actionplan is carried out, and results are verified for effectiveness. Managers can track thestatus of the case as it automatically moves from one stage to the next, based on the organization’s procedures.

Reports and metrics
Executive dashboards provide enterprise-wide visibility into the incident management process, and highlight high-priority cases that need to beaddressed. The solution also provides complete real-time visibility into the incident andexception data with analytics for trend analysis.

Reports for loss tracking,regulatory impact, status tracking, scorecards, risk heat maps and compliancedashboards can be readily accessed. Graphical executive dashboards andflexible reports with drill-down capabilities provide statistics and data by a variety ofparameters such as business units, processes and divisions.

Benefits

  • Streamlines, automates and consolidates multiple incident management processes across the enterprise
  • Provides top-level and real-time visibility into the status of incident management through powerful dashboards, with the ability to drill down to the finest level of detail
  • Built on a robust and scalable infrastructure, that can scale up to address future GRC needs such as risk, compliance or audit management
  • Embedded with best practices that adapt to changing business processes
  • Ensures secure Web-based access for all users with appropriate views and tabs for initiating actions, responding to events, managing to-do lists and assigned tasks, and viewing reports and dashboards
  • Contains built-in,customizable reporting tools for analytics and business intelligence
  • Easily integrates with external systems to retrieve, store and deliver data; leverages XML-based adapters for connectivity to other enterprise applications
  • Provides automatic threshold and event-based notifications, assignments, alerts and escalations to focus on critical incidents, and ensure timely completion of tasks
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