Delivering better hospital risk management procedures


Delivering better hospital risk management procedures

Rajesh Khosla of riskLD explains how clinical practice guidelines can help to bring down obstetrics-related litigation costs in hospitals.

In 2010, University Hospitals (UH) in Cleveland, Ohio was averaging $14 million a year in obstetrics-related (OB) litigation costs. The head of UH’s captive insurance company found this unacceptable and sponsored a team to identify and implement a solution to this vexing problem.

The team consisted of a senior obstetrician and three senior obstetric nurses. Their full-time job was to 1) build a robust quality assurance (QA) process to identify sources of error and drivers of risk on the inpatient obstetric units; 2) review the literature and solicit internal expert opinion for how to manage labour and medical conditions (such as diabetes and hypertension) in the context of pregnancy, labour, delivery, and the postpartum period; and 3) construct clinical practice guidelines (CPGs) to help standardise care.


Their process was rigorous (Figure 1).

Figure 1: Creation of clinical practice guidelines






After five years of work, their CPGs started delivering startling results (Figure 2).

Figure 2: Reduction in OB litigation costs at UH after CPGs introduced





The human impact was just as great (Figure 3).

Figure 3: Reduction of serious safety events at UH after CPGs introduced





riskLD licensed from UH all the CPGs and knowhow to implement them in software. The riskLD system integrates with the electronic medical records and analyses over 130 data feeds, including real-time vital signs tracked every minute, problem list conditions, laboratory results, and administered medications/blood products to power its algorithms while the patient is on the labour and delivery unit.

There are two modules to the system. The first is the know your risk (KYR) module for risk management professionals. KYR produces automated, customised reports that show the time lapse from an alert for a serious condition to treatment. It targets five key clinical areas of risk to mothers and babies: labour management/dystocia; hypertensive disorders of pregnancy; intra-amniotic infection; shoulder dystocia risk; and obstetric hemorrhage, in addition to monitoring nursing adherence to charting protocols for maternal vital signs and foetal heart rate interpretation.

Importantly for risk managers, hospital captives and reinsurers, the system can provide a real-time assessment of risk on the labour and delivery floor.

The report details time to treatment of high-risk conditions by nursing shift and on a month-to-month comparison basis (Figure 4).

Figure 4: Comparison of times to treatment







If the KYR results are deemed outside the parameters of acceptable risk, the more expansive clinical decision support (CDS) module can be activated. CDS continuously looks for developing conditions and 1) monitors; 2) alerts; 3) suggests high-risk diagnoses; and 4) issues clinical decision support to the doctors and nurses in the unit. The tab within the patient chart provides detailed information on the course and risks of labour and delivery (Figure 5).

Figure 5: Course of labour chart for patient Jane Smith





Just as important, there is an “air traffic control” view of all the patients on the floor and their developing acuity to allow, especially in this time of nursing shortages, more efficient allocation of scarce, experienced clinical team members


KYR and CDS combine to provide a powerful labour and delivery risk management toolbox. Demonstrations of both modules can be provided.

Rajesh Khosla is the founder of riskLD. He can be contacted at:

litigation, labour, risk, clinical, CPGs, riskLD, Reduction, management

Captive International