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Balancing economic viability and safety

The topics of patient safety and clinical risk management are extremely relevant and controversial for hospitals in Germany. International studies have repeatedly confirmed that, from the perspective of patients and employees, hospitals are to be classified as high-risk institutions. Not only do they save lives and heal people, but they are also the site of many so-called ‘adverse events’. These risks entail consequences that often are of great seriousness for the affected persons. Hospitals in Germany have reacted accordingly and have introduced appropriate measures and methods – such as checklists, process standards or critical incident reporting systems (CIRS) – in order to reduce the extent of avoidable incidents. Despite this, the challenge of guaranteeing the safety of patients has by no means been completely mastered; it continues to be a highly relevant issue. The Robert-Koch Institute currently estimates that 500,000–800,000 cases of nosocomial hospital infections occur per year in Germany alone, of which up to 4000 prove to be fatal.
Patient safety – also an economic challenge  
There is one major reason for this: the central causes of deficiencies and cases where patients suffer harm cannot as a rule be traced back to the misconduct of individual persons such as doctors, nursing personnel or other employees. Instead, these incidents occur as a result of ‘system failures’ in which deficiencies in the coordination of the processes and in the interaction of information and resources led to results, which, in some instances, are catastrophic. In this context, it becomes evident that patient safety is not a purely medical topic, but also an organisational and economic issue that needs to be addressed on a continual basis in hospital management agendas. 
Until now, medical perspectives have dominated
One core problem in German hospitals up to this point, however, has been the absence of an integrated view of the problem of risk management in many facilities. Instead, a purely medical perspective has typically dominated. With such a perspective, the linked economic consequences are generally not taken into account nor are they addressed to the extent that they should be. From the hospital management perspective, the effects of clinical risks are frequently first perceived when financial losses occur in the form of payments for damages, or a reduction in patient figures stemming from reputation issues. At the same time, however, the strategies specified by hospital management in areas such as procurement or human resources can have a substantial influence on what type of clinical risks can occur and to what extent. For example, the continual reduction in average patient stays in hospital and the enormous concentration of tasks connected with this reduction has an effect on whether errors occur or whether they can be avoided. The same is true of making purchasing and procurement decisions solely on the basis of lowest prices. 
Establishing an open error management culture
Current studies on the design and implementation of clinical risk management in Germany indicate that hospitals have mainly created basic systems, methods and responsibilities and utilise these tools to systematically identify, evaluate and handle risks in patient care. However, a comprehensive strategic framework is often lacking, as is an active and open error management culture that is supported by the management. In addition, there are deficits in the purposeful collation of the different information, analyses, findings and evaluations into an integrated consideration and evaluation of the risk environment, the dimensions of which are shown in Figure 1.
The standardised process shown in Figure 2, on which both the clinical and financial economic approaches of risk management are generally based, can indeed serve as a basis for integrating these different perspectives. However, the resulting assessment questions and consideration of possible measures to be taken become even more complex with such an approach. And the controlling systems in hospitals are frequently not designed to handle such specific questions as the detailed estimation of the economic effects of particular clinical risks. The extent of the costs arising from various risks having to do with patients or with employees have been detailed in systematic studies, and make it clear that the costs stemming from a needlestick injury, a medication error or an avoidable hospital infection can take on exceedingly large dimensions (Figure 3).
Documentation is often inadequate
One problem with the evaluation of such risks is that there is hardly any clear documentation or record keeping regarding the additional days of treatment, therapy costs or personnel costs that can be attributed to any particular adverse event. There is simply a lack of transparency regarding direct and indirect error costs, as indicated in the results of a current study by the European Association of Hospital Managers in cooperation with the Frankfurt School of Finance & Management (Figure 4). It continues to be clear that management personnel in German hospitals are generally quite convinced of the benefits of clinical risk management in regard to quality or medical issues (Figure 5). When asked about economic benefits and the effects of risk management on profitability, however, they express clear doubts whether positive effects result for hospitals in this regard (Figure 6).
Such doubts seem to obstruct progress on a number of fronts – for example, in respect to a change away from a diagnosis-related group (DRG)-based case-oriented remuneration of hospitals towards a more strongly quality-oriented remuneration as is currently under discussion in Germany.
Likewise, these doubts can be seen as a hindrance towards an integrated risk management approach while also being strategically dangerous in respect to a goal shared by all hospitals – that of ensuring the highest possible level of safety in patient care while at the same time maintaining their own economic viability on a sustainable basis. 
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