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Managing the risks of ACOs


In any given week, a health care risk manager can find themselves involved in something new – investigating a patient injury, preparing a statement for a liability claim, educating staff on safety, assisting in designing risk transfer or financing strategy for the organization, or ensuring compliance of a new law or regulation. With the passage of healthcare reform, risk managers may feel the rules they previously understood to guide their jobs have changed. In reality, much will remain the same, although the law will transform many aspects of healthcare delivery.

Many of the skills risk managers already possess will be necessary to manage risks inherent in providing care through the new structure envisioned by the Affordable Care Act – the Accountable Care Organization (ACO). Under the ACO model, the primary goal is to enhance the coordination of care to ensure patients get the right care at the right time while avoiding unnecessary duplication of services.

The triple aim of ACOs is to provide:

  1. Better care for individuals
  2. Better health for populations
  3. Lower per capita costs of care without any harm whatsoever to patients

When an ACO succeeds in delivering high-quality care and in spending healthcare dollars more wisely, it will share the savings it achieves for the Medicare program with its providers. It is also likely that when an ACO succeeds in achieving those goals, risks will be reduced and safety will be enhanced. Some believe that focus on care coordination and focus on quality are more strongly embedded into the type of care under an ACO, and thus likely to be greater drivers of how care is provided than cost savings alone.

When the rule governing ACOs initially passed, many speculated that the cost of setting up the organization would be significant and the ongoing operational challenges would make it impossible for all but the largest systems to participate in this new model. With a softening of the regulations and greater clarification of some of the features that seemed to contradict well-established law regarding physician referral, financial incentives, and billing, ACOs are rapidly emerging as the preferred model of care for Medicare patients. If they are able to deliver on the goals established, it is likely this model will also be effective in treating non-Medicare patients, as well.

Since ACOs will generally operate outside the four walls of the hospital and manage patients across many different healthcare encounters, risk managers must pay close attention to the common risks associated with providing care in any setting. The risks associated with ineffective communication can be problematic; effective communication is necessary when a patient is receiving acute care by a team of providers, as well as when that patient is handed off to a team of healthcare professionals who will be assisting with care and support following the acute stage of illness.

Care can be compromised when there is an absence of teamwork. In the ACO setting, the team of providers is likely to be larger than those providing inpatient-only care, so it is important to proactively address any potential impediments in communication caused by hierarchy or between primary and ancillary providers across the continuum of care. Electronic health records will be necessary as patients move between multiple facilities. The risk manager will need to ascertain that all information security and privacy concerns have been addressed. Clearly the need to communicate across all sites of care and between all providers will be essential as well-coordinated care is necessary to achieve optimal outcomes.

If a risk manager is already aware of current communication and hand-off issues causing quality of care problems in the organization, she or he may wish to provide TeamSTEPPS®* training to ACO providers, or design specific tools/checklists which can be used to create a standardized protocol for the transfer of all relevant information. This will help ensure that patient hand-offs do not contribute to medical error or serve to degrade the continuity of care. Using simulations to identify issues that can impede teamwork skills is also a great proactive strategy risk managers can employ to prepare providers for this change in care delivery.

Leadership remains essential to safe care, and risk managers can assume leadership roles by carefully examining the aggregate root causes of error in the current organization and determining the impact they might have on the organization's new ACO. Valuable communication tools and training strategies are available and risk managers can begin educating providers and staff on the importance of implementation – creating a culture of teamwork that supports effective communication, safe hand-offs, and optimal patient outcomes. Only then will the ACO achieve its risk management goals and share in the financial reward envisioned by the ACO model.

To learn more about the additional legal risks, financial risks, and operational risks risk managers must address for ACOs, read more in our Professional Liability Risk Resource newsletter or attend my presentation on this topic at ASHRM. Send us your questions or share your own tips for managing the risks of ACOs in the comments below.

Barbara Youngberg, BSN, MSW, FASHRM, Senior Healthcare Risk Management Specialist

* TeamSTEPPS is an evidence-based teamwork system to improve communication and teamwork skills among healthcare professionals. See

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