Managing Risks in Physician Practices

Care provided in physician offices represents the largest and most widely used segment of the U.S. healthcare system (Cherry et al.). Historically, however, physician practices operated independently, and they adopted many different approaches to patient safety and risk management. With the passage in 2010 of PPACA, 20 million more people gained health insurance, including 6.1 million young adults ages 19 to 25 (HHS). Moreover, PPACA spurred the creation of ACOs, highlighting quality improvement measures and outcomes (Peccoralo et al.). Some experts predict that the most successful practice model of the near future will be a group practice with primary care practitioners and specialists (Sharara). While some practices have long been part of larger care systems, solo practices and newly acquired practices are experiencing a sea change. Both hospitals and large health systems are purchasing practices to facilitate ACO formation; physicians in these practices become employees rather than owner-operators. In other situations, physician practice owners are becoming partners with hospitals or health systems. In any event, "the modern physician organization must be large enough to manage population health, nimble enough to cultivate teamwork across multiple specialties, and small enough to give each patient a home for his or her care." (Song and Lee)

These changes and a focus on diagnostic error have shone a spotlight on the risks inherent in this setting. Hospital risk managers tasked with oversight of practices will have to adopt new strategies to manage these risks.

As the move toward ACO formation continues to strengthen, physician practices may worry that they will be subsumed entirely by a larger system. A 2012 study found that this is not the case. Of each of the four ACOs examined, none saw itself as an overarching entity. Participants at all sites, researchers emphasized, understood that ACO formation was intended to incentivize the value of patient care over volume, improve coordination of care, and strengthen data collection and sharing. Individual site "identity," however, was not lost. In fact, one larger healthcare system in the study, when integrating into an ACO, took the approach of "supporting" physician practices to preserve their sense of independence. (Kreindler et al.) Still, a majority of physicians do not view the trend as positive for their profession, according to panelist Bruce Whitmore, speaking at the annual conference of the American Society for Healthcare Risk Management (ASHRM) in September 2016 (Kelly et al.).

Indeed, a sense of independence may be the most significant factor to consider when folding physician practices into an ACO. Most solo practitioners consider their independence to be the most important benefit of solo practice, affording them the ability to focus on quality with no oversight—often seen as a hindrance. (Sharara)

While a culture of safety should be nurtured, ACO formation does not necessarily require imposing a dominant social culture on smaller practices. ACOs are "about offering levers (primarily financial and technical) for improving care coordination without disrupting the local form of social organization . . . The ACO model appears flexible enough to be used in synchrony with whatever social strategies are most suitable for the unique context" (Kreindler et al.).

The mix of providers is also expected to continue to change in the coming decade, with significant numbers of advanced practice nurses and physician assistants working in hospital-affiliated practices (Kelly et al.). These changes require risk managers to find new strategies to manage risks. Whitmore noted that physicians accustomed to working in small practices likely have little experience with risk management. They have been motivated by patient satisfaction and quality of care, balanced against the possibility of being sued. (Kelly et al.)

ACO formation is intended to strengthen the continuum of care by improving coordination of care and communication about a patient's care among caregivers. Staff working in individual physician practices must possess or develop skills to strengthen teamwork, communication, and collaboration. Training, support, and organizational culture must echo these goals (Press et al.), exactly as they must in a hospital environment. Physician practices, therefore, are facing the same cultural shifts that hospitals began to address over 15 years ago. Fitting the culture of safety to a physician practice requires an accurate assessment of current practices and culture, the creation or adaptation of patient safety goals, and compliance with the new goals. (Saxton et al.) As hospital staff know, creating and fostering a culture of safety does not happen instantaneously. Change will be incremental, and must be encouraged and nurtured. The environment of a physician practice requires that...