We all make mistakes. Human error is a part of life. In many everyday situations, each of us makes errors, and most of the time, these errors bear no significant consequences for our lives or the lives of others. You mistake your brown shoes for the black ones and end up looking mismatched for the rest of the day. Likely, you’ll recover from your inadvertent fashion faux pas. But if you’re a healthcare provider, and you mistake one medication for another, the consequences could be much more serious.

Historically, the healthcare field has been marked by a punitive mindset, such that all mistakes, even those that bore no ill consequences, were reprimanded. This punitive attitude, which initially developed from the desire of healthcare organization to safeguard themselves against all potential damages, eventually grew into an atmosphere that deterred even minor mistakes from being reported out of fear of punishment.  This kind of atmosphere stifles constructive learning and tends to make providers feel unsupported by the healthcare systems in which then work.

Mistakes Can Grow Knowledge In Learning Culture

A healthcare learning culture is the opposite. A healthcare learning culture takes everyday occurrences, even mistakes, and uses them so that both organizations and providers can grow in knowledge, performance, and competence.  A learning culture engenders a just culture, and a just culture fortifies a learning culture.  Just culture seeks to create and reinforce a learning culture by providing a framework for managing mistakes and actions.  Just culture acknowledges that all people, including system designers, make mistakes.

So, for the healthcare provider who mistook one medication for another, a just culture promotes an environment where the provider who made the error should not fear to come forward.  A just culture investigates to see if the error was part of a system failure such that any provider in a similar situation would have made the same mistake.

A just culture, then, differentiates among unintentional human errors, system errors, mistakes made because of poor decision making, mistakes made because of disregard for procedures, and deliberate actions intended to be harmful. This differentiation helps determine the level of accountability and allows for a response on the part of the organization that is fitting and fair for the mistake maker.

Shift Focus to Management of Behavioral Choices

Just culture is founded in the belief that all stakeholders -from healthcare providers to business leaders- are responsible for the quality and safety of services. It demands that providers adhere thoughtfully and safely to clinical standards; furthermore, it expects that even minor errors are reported so that broader learning needs and system failures can be identified. In a just culture, errors become opportunities for the organization and all its providers, not just those who make mistakes, to learn and improve, which greatly reduces the chance that an error will be repeated.

Just culture shifts the focus of quality improvement from punishment and faultfinding to the management of behavioral choices in the context of the systems in which providers work.  Medcor has found that embracing a learning culture and a just culture increases providers job satisfaction and adds significant value to our quality improvement processes.  Just culture treats our advocates with fairness and respect and makes our leadership consider how we can improve our systems to promote the best outcomes for our employees, patients, and clients.

Author Dr. Sharon Moise, Chief Medical Officer, Medcor. Dr. Moise joined Medcor in 2015. Sharon is board-certified in emergency medicine and has extensive experience in occupational health, urgent care, clinical education, and clinical quality. Sharon provides broad clinical oversight for Medcor’s Worksite Clinics, Injury Triage Service, and supports all Medcor’s lines of business. In addition to involvement in many of Medcor’s projects and initiatives, Sharon is passionate about clinical quality and chairs Medcor’s Clinical Quality committee.

If you’ve ever been intrigued by police investigations in TV shows or detective novels, you might want to use that enthusiasm to investigate workplace injuries. Approaching a workers’ comp claim investigation claim in ‘detective’ mode will lead to better results; meaning, reduced costs and superior outcomes for injured workers.

The Workers’ Comp Claim Investigation

The ultimate goal of managing a workers’ compensation claim is to help the injured worker recover and get back to work as soon as possible, without the payer spending unnecessary costs. But often there are many gray areas to a claim. Determining exactly what happened and, therefore, what should be covered by workers’ compensation can be difficult.

Investigating a claim should uncover as many details as possible. Employers/payers can get all the information they need by implementing a precise system that kicks in immediately after an injury occurs. At the very least it should include:

1. The Basics

The workers’ comp claim investigation process should begin with statements from the employee, employer, and any witnesses. There should be separate forms for each which should have open-ended questions, rather than boxes to check.

Additionally, there should be a separate attachment for details on each form. A form from a witness that says, ‘Joe slipped and hurt his back,’ really doesn’t reveal anything and won’t help determine whether and to what extent the claim is compensable.

The essential pieces of information that should be included about the injured worker and the incident include:

• Date of birth
• Name of the employee
• Social security number
• Average weekly wage
• Date of injury
• Date of hire

Too often such information is either not included or is inaccurate.

Another ‘basic’ procedure that makes a tremendous difference in a claim is the way the injured worker is treated. Anyone involved with managing the claim at any point should treat the person as if it is a friend or spouse and approach the employee in the same way as they would want that person treated.

2. Preserve the Scene

Preserving the scene is where reading and watching cases in which detectives try to understand what has happened comes into play. Just as a detective on a case is trying to get to the truth, so too is the employer/payer.

Once an accident occurs, the area should be roped off to whatever extent is possible. If it is an area in which many people are working and is crucial to business operations, this might take some creativity. But the idea is to ‘protect’ any evidence that could indicate what and how the injury occurred.

Looking at the scene might reveal a cause. For example, water on the floor could indicate the worker slipped and fell. Or, there might be evidence that a piece of equipment was faulty, which could result in subrogation from a third party.

A thorough examination of the accident scene may help reveal the mechanism and extent of an injury. That could be advantageous if, say several months later the injured worker claims additional injury from the initial accident.

3. Talk to Others

Witnesses play an important role in a workers’ comp claim investigation. While the injured worker experienced the accident, he may not know exactly how it happened. Someone who saw it might be able to fill in some of the blanks; for example, that a heavy box on an upper shelf fell, triggering the worker’s fall.

Also, identifying all witnesses as soon as an injury occurs prevents ‘new’ witnesses the injured worker may try to bring in later on.

4. Record

While witness accounts of a situation are important, they may not always be reliable. Sometimes what people think they saw or remember may vary greatly from one witness to another. That’s why it’s also important to record the scene in as many ways as possible.

Just as a detective investigating a crime scene might seek out video footage of the area, getting recorded descriptions of the scene can help determine how the injury occurred and can be extremely valuable later on, if the case is litigated.

Video cameras may be present in or near the work area. There may also be video cameras around the building, or even on nearby buildings. The footage may reveal more information about the incident.

If no videos were present in or near the accident scene when it happened, taking a video of the accident area via a smartphone can also help provide information about what may have contributed to the injury. The person filming should also include narration to describe various objects, direction, location, etc.

Photos can also provide details. These can be taken from a distance as well as close up, to get different perspectives and angles.

5. Document, Document, Document.

Every step taken during the workers’ comp claim investigation should be written down; from interviews with witnesses and others, to bits of information observed at the scene, and any other potentially relevant information.

Documentation pertaining to maintenance and training schedules and previous corrective actions involving the injured worker should also be included in the investigation materials. Information about prior medical treatment to the injured body part can also be relevant and should be included in the documentation

Conclusion

Conducting a thorough workers’ comp claim investigation provides the best opportunity to ensure the payer covers all of what should be funded and nothing more. It also signals the entire workforce that this is a normal process; meaning a worker will think twice before trying to fake an injury.

Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center.

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://blog.reduceyourworkerscomp.com/

©2019 Amaxx LLC. All rights reserved under International Copyright Law.

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

In the popular TV show Property Ladder, real estate junkies seek to find homes in need of repair, fix them and then flip it for a profit.  Like the show, members of the claims management team should be on the constant look-out for parts of their program that need to be improved to increase client satisfaction and ensure it is being run ethically and honestly for the ultimate stakeholder – the employee!  This takes a lot of hard work, but the ultimate result can improve the satisfaction of clients and improve the experience for persons who have sustained a work injury.

Finding a Home to Renovate – Effective Injury Response

Like a broken home, the employee who suffers a work injury is in need of help and tender loving care. A fast and effective response to every work injury, no matter how minor, can pay dividends in the future.

All workplaces need to have a plan in place to deal with work injuries.  This includes the accessibility of first aid kits and other medical equipment.  Factors to consider include having a plan for all types of injuries and emergencies, making employees aware of the plan and proper implementation.  Do not forget that even if your company is not required to have one, the inclusion of a safety chair and emergency response team can assist in a program renovation.  This team can be used for the following tasks:

• Maintenance and use of various fire extinguishers;

• Knowledge and ability to perform cardiopulmonary resuscitation (CPR);

• Understanding on how to contain and dispose of bloodborne pathogens;

• Proper chemical handling, storage and containment procedures; and

• Dealing with and responding to incidents involving hazardous materials and workplace fumes.

Other items to consider should include teaching employees basic first aid and other features such as lifesaving equipment that can include a portable defibrillator.

Fixing Up the Property – Workplace Ergonomics and Safety

A great way to ensure a safe workplace should include a review of workplace ergonomics.  This can include features such as assessing risks in the workplace on an ongoing basis, correcting the problems and encourage physical health.  Suggestions can include:

• Onsight or easily accessible health clinics that include vaccinations, immunizations, and wellness information;

• Encouragement to use a gym or health club – be sure to include discounts on medical insurance for frequent users. Onsite stretching activities, yoga, and mindfulness can also promote a safe work environment; and

• Training on preventing and dealing with workplace violence and “active shooter” situations.

Flippin’ the House for Profit – Ongoing Employee Satisfaction

Like a completely remodeled home, a workers’ compensation program that is in pristine shape will add value and create its own demand.  This will improve company morale and improve return to work rates following an injury.  Interested stakeholders should look for opportunities to add value through a workers’ compensation program’s “curb appeal.”  This can be accomplished by promoting medical and behavioral health consultations to assist employees manage their lives in and outside the workplace – and enhance one’s work/life balance.

Addressing the needs of employees mental health needs is important in today’s fast-paced society.  This is especially the case when employees work during a clinic’s hours of operation.  By making these services available to employees on-site or at a convenient location, people are more willing to receive the care they may need.

Addressing the mental health needs of all employees are important both before and after a work injury.  Studies suggest that people who receive mental health counseling following a work injury have a lower chance of re-injury or malingering.  This translates into lower workers’ compensation insurance premiums.

Conclusions

Members of the claims management team should seek to climb the property ladder to add value and reduce costs to a workers’ compensation program.  This includes simple steps that can be taken to renovate a program, make it better and increase its value.  When a program is strong, it also adds value to the clients it serves.

Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%.  He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center .

Contact: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://blog.reduceyourworkerscomp.com/

©2018 Amaxx LLC. All rights reserved under International Copyright Law.

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.

If you or a loved one has ever been hurt or sick, you know well that healthcare and insurance systems are complicated; the challenges can seem endless and overwhelming.

Health navigation helps individuals and companies through these challenges. It includes clinical services, of course, but it’s much more than that. Knowing what services are needed, where to get them, and in what timeframe are critical elements to getting on the right path to recovery.

Fundamental Premise of Health Navigation

People can’t always tell at the onset how serious an injury or illness is. So, sometimes they go to an ER when they could have gone to a doctor’s office, or they go to a doctor’s office when they could have cared for themselves. Other times people underestimate or don’t recognize symptoms, and look back wishing they had realized how serious something really was – this regret can make them more likely to overreact the next time they are confronted with a health concern.

The fundamental premise of health navigation is getting people the care they need when and where they need it, which removes burdensome guesswork. A best-in-class health navigation provider should:

• Have clinicians which navigate people to the right level of care at the right time, in the right place.
• Have systems to help people determine the severity of each case and the best course of action for treatment.
• Provide the needed care or guide patients in self-care whenever possible.
• Make a referral when further care is required

People know overtreatments and over prescribing exist, but they don’t know how to tell when it is happening to them. What’s the best practice?

Evidence-Based Medicine

Evidence-based medicine is the best practice; it represents the science of proven medical effectiveness. Protocols, algorithms, and guidelines need to be built on evidence-based medicine. As a result, unnecessary treatments and prescriptions are avoided while required treatments are obtained right away.

People want to believe that all providers follow best practices, but still unnecessary care persists, including surgeries, prescriptions, therapy, and other interventions that contribute to high costs for everyone.

The healthcare and insurance systems have evolved to include many conflicts of interest, financial biases, and administrative costs. Effective navigation requires guiding patients to the right destination rather than following the momentum and pressures of a complex claims-driven system. Working with a provider who operates transparently and without conflicts of interest offers the key difference of advocating for patients rather than treating them.

Access to Care

It can take weeks to get an appointment. Lack of access to care drives frustration and drives people to go to more expensive options such as urgent care centers and ERs.

Clinics can and should be convenient and accessible, mobile units should go to patients, virtual health services should be available on-demand 24/7, and a telephonic triage service should be pre­loaded with clinics that accept walk-ins and new patients. In addition, staff should know the in-network providers in their patient’s communities, establish relationships, and have the tools necessary to gain appointments.

Serious illness and injury involves a lot of emotion, which affects people’s decision making. It feels awkward to tell a provider you want a second opinion or other options. It is not easy to know if a provider is in-network or out-of-network, and it is near impossible to find out in advance what services cost.

Decision Support

Navigation requires decision support – not just information, but recommendations. People need reassuring, they want to know the risks, and they appreciate assistance.

Health navigation gets people through the system to achieve better clinical outcomes and lower costs. That’s good for individuals, and it’s also good for their employers, who bear much of the cost of caring for their employees and their families, and who want their employees to be healthy and productive.

Author Curtis H. Smith, Executive Vice President, joined Medcor in 1995. He helped develop Medcor’s injury triage system and holds several US and foreign patents on injury assessments methods.  Smith has taught and practiced in EMS as paramedic and dispatcher.  He currently supports Medcor’s business development and marketing teams. http://medcor.com. Contact: csmith@medcor.com