PUBLISHED BY THE PUBLIC RISK MANAGEMENT ASSOCIATION NOVEMBER/DECEMBER 2016
Addressing Safety & Liability Concerns While Improving Customer Relationships PAGE 6
ALSO IN THIS ISSUE
SUPERBUGS:
Wanted Dead, Not Alive! PAGE 12
DIVERSITY AND INCLUSION:
The Risks and Opportunities PAGE 15
MAKING IT RIGHT... CAN TAKE A LONG TIME
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NOV/DEC 2016 | Volume 32, No. 10 | www.primacentral.org
CONTENTS
The Public Risk Management Association promotes effective risk management in the public interest as an essential component of public administration.
PRESIDENT Terri L. Evans Risk Manager City of Kingsport Kingsport, TN PAST PRESIDENT Dean R. Coughenour, ARM Risk Manager City of Flagstaff Flagstaff, AZ PRESIDENT-ELECT Amy J. Larson, Esq. Risk and Litigation Manager City of Bloomington Bloomington, MN DIRECTORS Brenda Cogdell, AIS, AIC, SPHR Risk Manager, Human Resources City of Manassas Manassas, VA
Engaging Your Community:
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ADDRESSING SAFETY & LIABILITY CONCERNS WHILE IMPROVING CUSTOMER RELATIONSHIPS By Michael G. Fann, ARM-P, MBA and George D. Dalton, ARM-P, MCM
Scott J. Kramer, MBA, ARM City/County Director of Risk Mgmt Montgomery County Commission Montgomery, AL Jani J. Jennings, ARM Insurance & Safety Coordinator City of Bellevue Bellevue, NE Scott Moss, MPA, CPCU, ARM, ARM-E, ALCM P/C Director Oregon Public Entity Excess Pool Salem, OR Lori J. Gray Risk Manager County of Prince William Woodbridge, VA Donna Capria, CRM, CIC, AINS Risk & Insurance Coordinator WaterOne of Johnson County Lenexa, KS NON-VOTING DIRECTOR Marshall Davies, PhD Executive Director Public Risk Management Association Alexandria, VA EDITOR Jennifer Ackerman, CAE Deputy Executive Director 703.253.1267 • jackerman@primacentral.org ADVERTISING Jennifer Ackerman, CAE 703.253.1267 • jackerman@primacentral.org
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Superbugs:
Diversity and Inclusion:
By Kevin Glennon, RN, BSN, CDMS, CWCP, QRP
By Victoria Nolan, ARM, CSP
WANTED DEAD, NOT ALIVE!
IN EVERY ISSUE
THE RISKS AND OPPORTUNITIES
| 4 NEWS BRIEFS | 19 ADVERTISER INDEX
Public Risk is published 10 times per year by the Public Risk Management Association, 700 S. Washington St., #218, Alexandria, VA 22314 tel: 703.528.7701 • fax: 703.739.0200 email: info@primacentral.org • Web site: www.primacentral.org Opinions and ideas expressed are not necessarily representative of the policies of PRIMA. Subscription rate: $140 per year. Back issue copies for members available for $7 each ($13 each for non-PRIMA members). All back issues are subject to availability. Apply to the editor for permission to reprint any part of the magazine. POSTMASTER: Send address changes to PRIMA, 700 S. Washington St., #218, Alexandria, VA 22314. Copyright 2016 Public Risk Management Association
NOVEMBER /DECEMBER 2016 | PUBLIC RISK
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MESSAGE FROM PRIMA PRESIDENT TERRI L . EVANS
I
Kindness
recently responded to a vehicular accident where a citizen drove off the road at an intersection and struck our stopped vehicle. This pushed our vehicle into the curb, and the claimant’s car proceeded into a private business. Our employee was injured; the citizen was not. Through a series of unfortunate decisions, this citizen was uninsured and not wearing their corrective eyewear. They were visibly upset when I arrived on scene, surrounded by family. I spoke with them, advising that we would require a legal promissory note to repay the damages to the vehicle and the workers’ compensation expenses for our injured employee. It was obvious the damages to the city vehicle would be several thousand dollars, and we all know what EMS transport and emergency room care can cost. This citizen advised that she works at a local fast food restaurant but would do her best to pay back every penny. I’ve been doing this a long time. I know the likelihood of recouping our loss is very slim. However, I treated the citizen as I would any other. Before I left the scene, the entire family thanked me for my kindness and honesty in dealing with the situation. They went on and on. All I could think was—how sad is it when what I consider to be normal human interaction is met with such astonishment? How sad it is that we, as a society, are no longer kind and gracious to one another? I discovered years ago that a little kindness, gentleness, respect and professionalism can go a long way in diffusing a difficult or tense situation, even with those claimants who, right or wrong, are furious at the circumstances and are lashing out at me. I do my best to keep my actions at an even keel, and the uglier they get, the kinder I get. I have even lowered the volume in my voice so they have to stop if they want to hear what I say. It works in the vast majority of instances. They may not end up any happier with the situation, but at least they are no longer infuriated and are listening by the time I leave. That’s not to say I have not dealt with folks who are so upset, and wanting to take it out on me, that I feel unsafe. I have had more of those claims than I wish to remember. However, they make up a tiny portion of the claims I have had over 30+ years. My reaction to claimants
I discovered years ago that a little kindness, gentleness, respect and professionalism can go a long way in diffusing a difficult or tense situation, even with those claimants who, right or wrong, are furious at the circumstances and are lashing out at me. I do my best to keep my actions at an even keel, and the uglier they get, the kinder I get.
has been perfected over time and with age. I try to treat this person as I would want my favorite family member treated in the same circumstances. I am perfectly willing and able to stand up for myself if the need arises, but I do so with respect. I do not suggest anyone be a doormat, but remember that interactions are a two-way street. Your actions may cause reactions of a negative nature. One piece of advice from these exchanges—always position yourself between the claimant and your exit, whether it be the door to the house or your car! I have had to make a couple of hasty retreats in my career. I say all this to remind us that until we, as risk professionals, need to stop reacting and focus on interacting. Treat injured employees with care and concern—I remind supervisors that they must treat their biggest “problem child” with as much consideration as they would treat their best worker. This is the beginning of a successful workers’ comp settlement. Liability claimants are most often our citizens. Do we want them to have a positive or negative opinion of our entity? While their only contact with the entity may start on a negative note, it is much easier to negotiate and mediate a liability or lawsuit settlement if the claimant has a generally positive attitude about their dealings with you. Other people’s actions and reactions are not about me; they are about them. Each of us has a propensity to lash out, deflect and blame others for our troubles. We all need to remember that, even if someone does something that causes you
loss or difficulty, it is rarely an intentional act against you. Getting yourself upset and acting out does absolutely nothing to solve the problem or change the situation. It just raises your blood pressure and creates discord. Think of the training we provide our police officers and fire fighters in de-escalation. The same applies to our interactions each day, with citizens, our families and each other. We need to be prepared to give ground in order to calm the tensions so we can have a meaningful discussion. In the spirit of the upcoming holiday season, I urge you to take a moment and be thankful for what you have—your family, your job, your friends, etc. Then try to be thankful and full of kindness for those who cause you frustration— your co-worker, your in-laws, your nosy neighbor. Try to imagine what has happened to make them “difficult to love” and have empathy for them. Try to set aside your differences, at least in your mind, and see them as an equal human being on this planet, one who suffers from unknown turmoil. Perhaps all they need is a little kindness.
Terri L. Evans 2016–2017 PRIMA President Risk Manager City of Kingsport, Tenn.
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NEWS BRIEFS
NEWS Briefs
GOT A DRONE PROBLEM? CALL DRONE BUSTERS About as long as hobbyist drones have been popular, there have been people who want to knock them out of the sky. Maybe the drones were flown over brush fires, disrupting fire fighting efforts. Others are sometimes flown near airports, causing alarm and, occasionally, grounding flights. In a truly scary turn, ISIS militants have even used drones to carry small bombs. Even though most drone pilots behave responsibly, there are clearly times when the drone should simply not be there. That’s where the drone busters come in. Various private companies, universities and government entities are currently developing systems to get drones out of the sky. One of the strangest efforts comes from the Netherlands, where the Dutch police have been training eagles to snatch drones out of the air, reports NextGov.com.
Since hobbyist drones operate on known radio frequencies, some companies are developing jamming devices that can be aimed at drones in flight, disrupting their ability to communicate with the remote control on the ground. Most hobbyist drones today have built-in software that causes them to hover in place or fly to their taking-off point when they lose connection with the pilot, so the jamming method is a good way to bring drones down without damaging them, or hurting someone on the ground.
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One such device is the DroneDefender, built by Battelle, an Ohio-based defense R&D company. The DroneDefender is currently being used by the Homeland Security Department and the military. Technically, it’s
“
illegal for anyone else to use because it operates on Federal Communications Commission frequencies supposed to remain open, but the company is hoping to get approval to sell it to regular consumers.
Even though most drone pilots behave responsibly, there are clearly times when the drone should simply not be there. That’s where the drone busters come in.
“
Others, like Theiss UAV Solutions, are targeting drones with nets, either launched from the ground or from other drones. It’s cool to see, when it works, but snaring a drone with a net is not easy and probably not practicable in the short-term.
AS PITTSBURGH GEARS UP TO DEBUT SELF-DRIVING UBERS, SAFETY EXPERTS WORRY Uber’s decision to bring self-driving taxis to the streets of Pittsburgh is raising alarms among a swath of safety experts who say that the technology is not nearly ready for prime time, reports the Washington Post. The unprecedented experiment will launch even though Pennsylvania has yet to pass basic laws that permit the testing of self-driving cars or rules that would govern what would happen in a crash. Uber is also not required to pass along any data from its vehicles to regulators. Meanwhile, researchers note, autonomous cars have been thrown off by bridges, a particular problem in Pittsburgh, which has more bridges than any other major U.S. city. “They are essentially making the commuters the guinea pigs,” said Joan Claybrook, a consumer-protection advocate and former head of the National Highway Traffic Safety Administration. “Of course there are going to be crashes. You can do the exact same tests without having average citizens in your car.” But advocates of autonomous vehicles say that the technology might never have happened if companies had to wait for governments to pass rules first. With nearly 37,000 Americans dying in car crashes every year, largely because of driver errors, technologists have stressed the critical need to push forward on testing driverless cars on public roads.
CHILDREN, REJOICE! CHOCOLATE MILK MAY RETURN TO MENUS IN AMERICA’S LARGEST SCHOOL DISTRICT After a five-year drought, chocolate and strawberry milk are making their way back into public school lunchrooms in Los Angeles, reports the Tribune News Service. With a vote of 6 to 1, the Los Angeles Unified School District loosened a district-wide ban on sugary, flavored milk that took effect in 2011. The board approved a pilot program to study the effects of reintroducing flavored milk in a small group of schools, all of which must volunteer to take part in the experiment. It is not that board members believe children aren’t consuming enough sugar. Rather, the decision to re-examine milk offerings stemmed from concern that the district is throwing out an obscene amount of food—600 tons of organic waste each day, according to a 2015 district study. Much of what’s being taken to the landfill is the plain milk that schools are encouraged by federal law to offer, but that students aren’t enthusiastically drinking. “Right now we are…taking garbage bags filled with milk to landfills, and that just doesn’t make any sense to me,” said board member Monica Ratliff, who introduced the idea of the flavored milk experiment. “We can’t continue to ignore this issue.” What Ratliff proposed, and the board endorsed, is a four-part study in 21 schools that would treat school cafeterias as behavioral science laboratories. Will L.A. Unified school children drink more plain milk if they are also offered the sugary variety, as one study suggests? How might they respond if plain milk is offered to them in an appealing display case, or if they are shown an information campaign about how milk is good for them? Her proposal references a 2014 Cornell University study, which found that when Oregon elementary schools banned flavored milk, students’ caloric and sugar intake dropped, but they also rejected plain milk in increasing numbers. The health benefits of that milk went down the drain, as students threw their half-empty cartons into the trash.
Parents and health advocates had lobbied successfully for the flavored milk ban, arguing that the drinks had unnecessary added sugar and contributed to childhood obesity. When the board approved a five-year, $100-million dairy contract, there wasn’t a drop of chocolate milk allowed. Brent Walmsley, founder of the advocacy group SugarWatch, said the board made the right call in 2011 and shouldn’t retreat from its position in the name of reducing food waste. “I can’t think of anywhere else we would do this. We wouldn’t serve caramel apples to increase apple consumption. We wouldn’t glaze carrots with sugar to get increased carrot consumption,” Walmsley said. “Milk is getting this odd pass here.” But among school board members, tastes, and minds, have changed. “At every school I go to, the request is for flavored milk. There’s not one school that I’ve gone to where they say they don’t want flavored milk,” said board member Scott Schmerelson. The lone no vote came from board member Monica Garcia, who said she would rather leave it to L.A. Unified staff to propose food waste solutions. Board members were unanimous on one point—their desire to change the U.S. Department of Agriculture’s school meal regulations, which require schools to offer milk with meals in order to receive reimbursement. But their decision Tuesday may have a more immediate effect on flavored milk than on the federal government. The school district’s milk supplier has said it’s willing to lower the amount of added sugar in order to find an equilibrium palatable to both students and parents. Student board member Karen Calderon said that when she met with a focus group of 14 L.A. Unified students, 13 of them endorsed the idea of dismantling the district’s flavored milk ban. “This is something I’ve been passionate about for years now, so thank you,” Calderon said.
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ENGAGING YOUR
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ADDRESSING SAFETY & LIABILITY CONCERNS WHILE IMPROVING CUSTOMER RELATIONSHIPS BY MICHAEL G. FANN, ARM-P, MBA AND GEORGE D. DALTON, ARM-P, MCM
hat do you do when the “perfect storm” of socio-economic stress, cultural differences, and political drama come together with catastrophic results? ... risk management, of course. And risk management would have had you prepare for the catastrophe long before it occurred with contingency thinking, enterprise-wise preparation and discussions, and an intentional engagement of your entity’s diverse stakeholders such that your entire community feels “a part of” your public entity instead of “apart from” your entity. Community engagement...do it...now. The great and always entertaining Yogi Berra, favorite son of Missouri and New York Yankee Hall of Famer, is famously quoted as saying, “The future just ain’t what it used to be.” This is an appropriate mantra for the public sector and its relationships with its citizens and stakeholders going forward.
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ENGAGING YOUR COMMUNIT Y
The relationship that law enforcement has with your community certainly grabs the headlines and the lead story on the six o’clock news, but adverse and negative encounters with members of the general public can happen within any department or discipline when you’re responsible for providing public services. Most people know why effective land use regulations are important to building a good quality of life in your community… until it’s YOUR piece of property that you can’t get re-zoned. Most people know why appropriate building and fire codes are important to home values and life safety in your community… until it’s YOUR new deck or garage that is having to be rebuilt because the construction doesn’t meet code. And most people know why having effective speed limits are important to life safety and quality of life in a community… until it is YOU being pulled over for speeding when you are late for a meeting with your boss. And this potential negative “lean” when providing public services can occur in every department or functional service area.
to help shape them in a positive manner. In other words, a negative event is coming. It may be a zoning request turned down, a failed fire inspection, a traffic accident that is the fault of one of your entity’s maintenance workers, a severe injury at a city park, or a tragic use of deadly force by one of your law enforcement personnel. To think in terms of a balance sheet or ledger, the big “debit” is coming, so what are you doing daily to create “credits” on your side of the ledger?
customers, the response from those depending upon those services tends to manifest as disengagement, indifference, apathy, frustration, and even anger. And the results of that anger have been making the headlines in recent years in the form of riots, vandalism, serious injuries, liability lawsuits, and destruction of property. Your “community” is better than that… for truly, “we are all in this together.” An assertive community engagement effort will help in addressing these tragic losses.
COMMUNITY TRUST ACCOUNT
MANAGING THE INTERPERSONAL TRANSACTION
The absence of adequate credits on the entity’s side of the ledger feeds a natural development in any organizational relationship of “us versus them” or “in versus out.” The natural development of a negative “lean” when public services are being provided is exacerbated during adversarial relationships and tragic encounters. Therefore, the public entity must be about developing emotional capital within its community, building credits on its community ledger, and maximizing its “community trust account.”
Government and other public entities impact, influence and even control many aspects of community life. Perceptions of how public services are being provided shape citizens’ opinions about its local government or service provider. Perceptions will get shaped… so the public entity had better be about doing its best
When the perception of the public entity is that it provides poor service on the front end, poor customer service on the back end, a lack of transparency regarding its operations, and/ or that it simply will not listen to citizens/
“…If we are asking our community to see things from the service provider perspective and not rely on assumptions, the organization should at least make an effort to understand the citizen/ customer perspective… Let us resolve to interact with our citizens/ customers with respect as far as it is within our power to do so.”
The vast majority of your citizens/customers value and appreciate the services public entities provide. Given an equal set of circumstances, the reasonable members of your community will line up behind their public entity. Obviously, you’re not going to reach everyone and there are some within your community who will oppose you no matter what. But that is a small percentage of most every community. We all know that it doesn’t take much to make a first impression. This can either be positive or negative. Most interpersonal interactions are neutral until one party or the other assigns either a positive or negative value to that interaction or transaction. Even if one of your organization’s employees continues to assign a positive value to an interaction with a member of your community, this does not preclude them from remaining diligent to the possibility that this interaction could turn negative (or even dangerous) based upon the actions/values of the other party.
To paraphrase noted police training expert, Lt. Col. (ret) Dave Grossman, the public is made up of wolves and sheep. Law enforcement’s calling (and to a degree, public servants in general) is to serve as sheepdogs… to stand between the sheep and the wolves who would do them harm. And we depend upon a public servant’s ability to know the difference. A public servant can’t treat the wolves as though they are sheep for their own safety… but they absolutely can’t treat the sheep as though they are wolves. As Grossman points out, the primary difference between the wolves and the sheepdogs is compassion for the sheep. The bottom line is this: if we are asking our community to see things from the service
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ENGAGING YOUR COMMUNIT Y
provider perspective and not rely on assumptions, the organization should at least make an effort to understand the citizen/customer perspective and not rely on assumptions. Let us resolve to interact with our citizens/customers with respect as far as it is within our power to do so.
INTERNAL ENGAGEMENT PLAN
Leadership must make community engagement an organizational priority. An engagement coordinator should be appointed, and then the organization should begin to build its engagement team. That engagement team should then begin to develop a comprehensive engagement plan that seeks to educate internally and inform externally to draw input from the diverse elements within your community or customer base. The plan must be intentional about identifying every stakeholder segment within your community and create multiple avenues for each segment to be engaged. The plan should also be intentional about trying to shape the
perceptions of the services being provided and the people that are providing them. The internal engagement plan must address how to keep customer/citizen efforts current and fresh. Further, the plan must include multiple methods of infusing the appropriate engagement culture into the organization.
EXTERNAL ENGAGEMENT PLAN Out of the internal engagement plan comes a natural cultivation of the external engagement plan. The engagement team (and by extension, the entire organization) needs to study and know the community, citizens and customers. Assess and understand their needs. Again, the foundation of engagement is that citizens/customers feel “a part of” the community and the services being provided, not “apart from” the community. Seek greater opportunities to engage citizens, customers and community groups to build relationships
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PUBLIC RISK | NOVEMBER /DECEMBER 2016
and trust. Provide multichannel avenues that include a comprehensive array of communication vehicles, such as telephone, mail, email, social, mobile, web-based, etc. The external plan should contain methods of identifying and then developing relationships with civic groups, homeowners associations, clergy, and other community leaders. In short, community engagement must be deliberate, inclusive, intentional, ongoing, and NOT simply in response to a crisis. The crisis response approach will be perceived as disingenuous and condescending.
RESPONSIBILITY
Remember, each employee must serve as a “Good Will Ambassador” for your organization. In employee evaluations, personnel should be evaluated on their ability and performance to that end. When citizens/customers think about your organization, they think of their experiences with the individual employees of your organization with whom they’ve been in contact: the maintenance person; the building inspector; the receivables clerk; the sanitation collector; the police officer. This is your daily opportunity to draw the reasonable members of your community to you, as opposed to building a wall between you… or worse, pushing them away. A proactive community engagement effort will go a long way toward creating preemptive, constructive “action” that builds community… instead of creating an environment ripe for explosive “reaction” that tears a community apart when that tragic, adverse and/or negative event occurs. What every community needs when that tragic event occurs is an objective evaluation of the facts surrounding the event, and the degree to which your organization has engaged its community and built “credits” in its community trust account will go a long way toward a reasonable resolution of any conflict… and help mitigate the loss exposures to your people, the public, and your property. Michael G. Fann, ARM-P, MBA, serves as director of loss control for The Pool, a risk management pool specializing in providing workers compensation, liability and property coverage for municipalities and municipal agencies in Tennessee. George D. Dalton, ARM-P, MCM, serves as assistant director of loss control for The Pool.
BY KEVIN GLENNON, RN, BSN, CDMS, CWCP, QRP
S
UPERBUGS—strains of bacteria that are resistant to multiple types and classes of antibiotics—are becoming a worldwide health problem. The Centers for Disease Control and Prevention (CDC) estimates that more than two million people in the U.S. contract superbug infections each year, causing 23,000 deaths. Another study projected that, if governments worldwide don’t take action, superbugs could kill an extra 10 million people by 2050, making these infections deadlier than cancer.1
Not surprisingly, health leaders characterize these microbial agents as “nightmare bacteria”2 that pose a catastrophic threat. Everyone should be concerned. In this part I of a two-part series, we’ll discuss how superbugs developed, and what can be done to combat the problem. We will also review several deadly and dangerous strains, and how they impact medical care and costs.
THE RISE OF ANTIBIOTICS
In 1928, Scottish scientist Alexander Fleming discovered penicillin. The discovery of antibiotics propelled us into a new era of medicine. Physicians had a cure for deadly diseases, such as tuberculosis, scarlet fever, and bacterial meningitis. Surgery for heart disease and organ transplants could succeed because antibiotics wiped out potential infections that could arise after treatment. In the 1940s and 1950s, new antibiotics emerged, arming physicians with novel ways to combat infections. Eventually, the distinction between broad- and narrow-spectrum antibiotics was introduced to target either a wide or narrow range of bacteria, which provided more treatment options.
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INCREASING RESISTANCE TO ANTIBIOTICS
Fewer than 100 years after antibiotics were first discovered, they’re losing their lifesaving effectiveness. When bacteria are exposed to antibiotics in concentrations that are not strong enough to kill them, they develop resistance to those drugs. Ironically, it’s the overuse of antibiotics that is enabling bacteria to evolve and become impervious to the current stable of antibiotics. Scientists and public health officials have long warned that if drug-resistant bacteria continued to spread, treatment could become vastly restricted. Routine operations could become deadly. Minor infections could be life threatening. Pneumonia would become difficult to treat. And common procedures, such as treating a wound, could prove fatal—all due to a lack of effective antibiotics. If actions aren’t taken to stem this tide, we’ll lose many of the benefits of modern medicine.
OVER-PRESCRIPTION: A KEY PART OF THE PROBLEM
Antibiotics are the most commonly prescribed drugs. However, 50 percent of antibiotics used in humans are estimated to be unnecessary.3 Over-prescription has complex roots. In hypothetical situations, physicians follow treatment guidelines. But in actual patient encounters, they will show compassion for patients who are sick and request antibiotics to make them feel better. However, common colds and the flu are not caused by bacteria—but by viruses that are not susceptible to antibiotics. Using antibiotics won’t reduce the duration of a cold or cough. In these scenarios, they could worsen a patient’s condition.
HOSPITALS: A BREEDING GROUND FOR SUPERBUGS
Every year, an estimated 648,000 people in the United States develop infections during a hospital stay and about 75,000 die from them, according to the CDC.4 There are many reasons hospital patients are vulnerable. Certain superbugs are difficult to remove from medical tools that are placed into the body, such as catheters, breathing tubes and scopes. Superbugs can live on surfaces for days, and they can be passed from person to person on the hands of healthcare workers. In addition, people
in hospitals are already sick or in a weakened state, so they’re more susceptible to infection. To prevent some of these exposures, hospitals must practice scrupulous hygiene. Hospitals are also accused of overusing antibiotics—almost 50 percent of hospital patients are prescribed at least one antibiotic, but up to half the time it’s inappropriate.5
LIVESTOCK: MISUSE TO PROMOTE GROWTH
The overuse of antibiotics in hospitals and doctors’ offices pales in comparison to the overuse that occurs in the meat and poultry industries. Around 1950, researchers discovered that by giving antibiotics to livestock, animals gained weight faster while consuming less feed. To boost profits, adding antibiotics to feed became a standard practice to promote growth—rather than to treat disease. Today, the Food and Drug Administration (FDA) estimates that 80 percent of antibiotics sold in the U.S. are given to animals raised for food6 —including pigs, cows, chickens, and turkeys. Due to this exposure, bacteria commonly found in food have become increasingly resistant to antibiotics. And these drug-resistant bacteria can easily spread to people. In August 2015, pork contaminated with salmonella immune to four antibiotics sickened 152 people in the state of Washington.7
SUPERBUGS: THE MOST “UNWANTED” LIST
When dangerous bacteria become resistant to antibiotics, they represent a serious threat to public health.8 The CDC ranks bacterial risks, considering a plethora of factors, including how many people are killed by these bugs each year; how quickly and easily these bugs spread and how many antibiotics are available to treat them. Using these and other considerations, the CDC developed a comprehensive list of the most “urgent” and “serious” superbug threats. Below we consider a few of the most deadly and dangerous9: CARBAPENEM-RESISTANT ENTEROBACTERIACEAE (CRE) CRE is a family of bacteria normally found in a person’s gut. As its name suggests, this bug is resistant to carbapenem, an antibiotic of last resort.
Healthy individuals are typically not susceptible to CRE infections. Most cases occur in the hospital setting. These bacteria often come to reside on medical tools, and they’re difficult to remove even with cleaning. That’s what happened in California after doctors unknowingly used contaminated medical scopes to view the interior of patients’ bodies. Once in the body, CRE can cause lifethreatening blood infections. These bacteria kill up to 50 percent of patients who are infected.10 The CDC believes CRE is among the country’s most urgent threats. CLOSTRIDIUM DIFFICILE (C. DIFF) C. diff also inhabits the intestines. Usually, it does so without harm. But overuse of antibiotics can knock out other beneficial bacteria in the digestive tract. Without healthy flora in the gut, C. diff can proliferate and take over. This infection can cause symptoms ranging from mild diarrhea to life-threatening colitis. In severe cases, patients may need to remove part of their infected intestine or undergo a fecal transplant. From 2000–2007, deaths spiked 400 percent when a new drug-resistant strain began to appear.11 On an annual basis, C. diff infects 290,000 Americans in hospitals and other healthcare facilities; approximately 27,000 people die from these infections,12 and they cause about $1 billion in additional medical costs.13 METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) Over the years, Staphylococcus aureus (S. aureus) have stayed in lock step with antibiotic development, continually developing new resistance. The latest strain is resistant to methicillin—noted as MRSA for short. By 2002, nearly 60 percent of S. aureus cases were identified as MRSA.14 Early on, S. aureus infections occurred mostly in hospitals, where bacteria find their way into patients’ bodies through the lines and tubes that deliver medication and nutrition, or via surgical incisions. Once in the body, they can spread to surrounding tissue and blood. Today, approximately a quarter of infections occur outside the healthcare settings.15 For example, there were several recent outbreaks among athletes.
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SUPERBUGS: WANTED DEAD, NOT ALIVE!
In 2005, an estimated 100,000 Americans suffered severe MRSA infections, and nearly 20,000 of them died—more than from HIV and tuberculosis combined.16 As dangerous as MRSA is, an infection can be cured if treated promptly with vancomycin. However, with increased use, this drug, too, has begun to lose its efficacy. A newer strain is vancomycin-resistant (VRSA). The progression of antibiotic resistance continues, as linezolid can treat VRSA, but linezolid-resistant S. aureus (LRSA) has developed as well.
TRANSFERENCE: BACTERIA’S SUPERPOWER
Bacteria have a superpower with regard to developing antibiotic resistance. They’re able to exchange small, circular pieces of DNA called plasmids, which carry genes of resistance. Whereas a genetic inheritance typically occurs vertically from parents to progeny, plasmid genetics can be transferred horizontally to other bacteria.17 This ability to transfer resistance amplifies the superbug threat. In July 2016, clinicians found a strain of E. coli in a Pennsylvania woman with a colistin-resistant gene. This gene known as MCR-1 exists on a plasmid, meaning it can be easily transferred to other bacteria. If it ends up in bacteria that already possess resistance to other antibiotics, this could result in a truly pan-resistant superbug—which would be virtually unstoppable.
ANTIBIOTIC STEWARDSHIP: A GLOBAL FOCUS
Antibiotic stewardship is the best solution to this complex problem. It involves the prudent use of antibiotics to ensure they’re used only when necessary in order to avoid overexposure. While this sounds good in principle, it is a challenge to implement. First, stewardship must be a global effort. As people travel internationally, drug-resistant bacteria travel with them. Second, all parties must be in agreement or mandated to follow policies, including farming. Colistin, which is typically an antibiotic of last resort, has been widely used in Chinese livestock. In other countries, like India, antibiotics are sold over the counter. It’s plausible that antibiotic resistance could develop in these countries and travel the globe.
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BETTER DIAGNOSTICS, BETTER STRATEGY
One of the best hopes for effectively treating bacterial infections is the development of reliable, rapid diagnostics. These tests should identify both the microbial cause of the infection and the bug’s drug-resistant profile within hours, rather than the existing two-day turnaround. Currently, as physicians wait for results, they make an educated guess as to the type of bacteria they’re treating and the class of antibiotics to prescribe. If the infection is life threatening, they may start a course of aggressive broad-spectrum antibiotics, which will indiscriminately attack both pathologic and beneficial bacteria and could lead to a C. diff infection. With better diagnostics, doctors can prescribe with more precision using narrow-spectrum drugs. In certain lines of insurance, such as workers’ compensation, nurses serve as clinical specialists on complex cases and provide oversight that ensures safe antibiotic use. These clinical specialists work in conjunction with prescribing physicians to utilize an infusion therapy program. In this way, a three-day supply of broad-spectrum medication could be authorized. Then, when culture results are received, a narrow-spectrum antibiotic can be initiated, decreasing the risk of a superbug complication.
AN ONGOING SEARCH FOR NEW ANTIBIOTICS
Today, most large pharmaceutical companies have abandoned antibiotic research because of unfavorable economics. Drug development is risky and expensive. Generally, it can take approximately 10 years and a billion dollars to bring a new drug to market. But complicating this is the fact that an antibiotic is a rare find. It must survive a challenging set of requirements, which include the ability to deal a lethal blow to one or more bacteria, while harmlessly being absorbed into the human body. Plus, the evolving nature of bacteria calls for a constant cycle of discovery to enable modern medicine to stay a step ahead of drug resistance.
TAKING ACTION
Although difficult to calculate, the total economic impact of antibiotic resistance to the U.S. economy is estimated to be as high as $20
billion in healthcare costs and an additional $35 billion a year in lost productivity.18 Antibiotics are the foundation on which all modern medicine rests. In addition to a global approach, each individual must take steps to limit personal use of non-essential antibiotics. People should get a full understanding of the antibiotics prescribed to them. Having conversations with physicians can encourage a thoughtful approach. Also, when possible, choose meat and poultry products free of antibiotics. Stewardship by all parties will contribute to lengthening the effectiveness of our antibiotics and preserving their use for generations to come. In the second part of this article series, we’ll be discussing how public risk managers may begin to see the impact of superbugs in their workers’ compensation programs, and how to mitigate those risks. Kevin Glennon, RN, BSN, CDMS, CWCP, QRP is vice president-clinical services with One Call Care Management. FOOTNOTES
1 Review on Antimicrobial Resistance. Antimicrobial Resistance: Tackling a crisis for health and wealth of Nations. 2014. 2 Dr. Tom Friedman, director of the U.S. Centers for Disease Control and Prevention 3 Katherine E. Fleming-Dutra (2016). Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011,” Journal of the American Medical Association, 315(17):1864-1873. 4, 5 How Your Hospital Can Make You Sick, Consumer Reports, http://www. consumerreports.org/cro/health/hospitalacquired-infections. 6 Katherine Xue (May-June 2014). Superbug: An Epidemic Begins. Harvard Magazine. 7 Making the World Safe from Superbugs, Consumer Reports, http://www. consumerreports.org/cro/health/the-riseof-superbugs, 2006-2016. 8 Centers for Disease Control and Prevention, Antibiotic Resistance Threats in the United States, 2013. 9 White House Report (March 2015), National Action Plan for Combating AntibioticResistance Bacteria. 10, 11 Kelli Miller (April 17, 2015). Superbugs: What They Are and How You Get Them, WebMD, http://www.webmd.com/ news/20150417/superbugs-what-they-are 12 How Your Hospital Can Make you Sick, Consumer Reports, http://www. consumerreports.org/cro/health/hospitalacquired-infections, 2006-2016. 13, 14, 15, 16, 17, 18 Katherine Xue (May-June 2014). Superbug: An Epidemic Begins. Harvard Magazine.
W
BY VICTORIA NOLAN, ARM, CSP
hile the terms diversity and inclusion may be familiar to many risk professionals, it may not be as easy to make the connection between risk management and diversity and inclusion. To start the discussion of how diversity and inclusion is intertwined with risk management, let’s start by establishing the focus of the discussion.
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DIVERSIT Y AND INCLUSION: THE RISKS AND OPPORTUNITIES
For the purpose of this article we are talking about people, be they the employees of the organization, constituents of the entity or customers of the services provided. In this context we then want to look at the terms ‘diversity’ and ‘inclusion’ and how there are risks and opportunities for any organization relating to these concepts. In broad terms, ‘diversity’ is any dimension that can be used to differentiate groups and individuals from one another. This may include differences in ethnicity, race, gender, age, national origin, disability, sexual orientation, education and religion. Not all differences are obvious, some traits you can see or get a sense of through interactions, but others may not be easily recognized or even kept hidden by the other person. The term ‘inclusion’ is generally used to describe a process and outcomes where differing viewpoints and/or differing needs are considered in the discussions and implementation of processes or the delivery of services. Sometimes organizations find themselves excluding people, either intentionally or unintentionally through the application of their “corporate culture” in either their selection processes (“They weren’t a good fit for this organization.”) or their bias (“You know what happens when John is in the meeting.”). Organizations that have purposeful intent on making sure they get a variety of differing perspectives involved are well on their way to creating or maintaining an inclusive culture.
THROUGH THE RISK MANAGEMENT LENS
Looking at some recent history, we can see that the discussion about diversity and inclusion has been expanding, and at times can be quite controversial. In his 2015 State of the Union address, President Obama included the words, transgender and bisexual, a historic event as these terms had never been included in a major presidential address before. This followed a year in which diversity and inclusion concepts had been expanded beyond the more traditional thought process of race and women’s equality. The year 2015 also saw the Supreme Court rule on the issue of same sex marriage, striking down the Defense of Marriage Act, legalizing same sex marriage in all 50 states. Other legal opinions,
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regulations and administrative rules have since been issued covering sexual orientation, gender identity and other discrimination issues that had previously been unprotected or unclear. But this has not been without controversy and backlash. In some cases, it has been public entities, mostly initiated by elected officials including legislatures and governors that have fueled the controversy, but in some cases a vocal public has created the backlash. What some could consider a simple progression of society and basic rights for all, others are compelled to speak out against what they believe is immoral or otherwise a decay of their view of a proper society. While the topic is clearly politically charged, it is still a topic worth looking at through the lens of risk management.
IT’S COMPLICATED
Most organizations recognize employment liability as the most obvious risk for their organization in relation to diversity. If there is discrimination of a protected class, either direct or through disparaging treatment, there is a risk of claims that can result in penalties and/ or claim payments. In general, public entities tend to be more diverse and inclusive in their employment practices; however, there may still be issues with unconscious bias within the organization. Most public entities function with an understanding that they need to be diligent in their hiring and retention practices to avoid unlawful discrimination. The challenge comes when the entity has not done the work needed to ensure that employment liability risks have been mitigated, mostly through individual managers or workgroups that either do not understand, or do not agree with the practices that the organization has put in place. Examples could include a supervisor telling an employee that they cannot wear an item of religious clothing or intentionally not using the preferred pronouns with a transgender or gender non-conforming employee. This can also be complicated, not every jurisdiction has the same set of laws or policies that they are working from. While all states have some form of protection for sexual orientation in public employment, there remain five states that do not provide protections for gender identity in public employment and in
private employment; there are only 20 states and the District of Columbia that offer protections in both private and public sector employment.1 The protections outside the employment arena remain even murkier with only 22 states and the District of Columbia with discrimination protections in public accommodations.1 To try and address this, Congress has made multiple attempts to pass federal legislation to eliminate this patchwork approach but has failed to pass what is known as the Equality Act. This leaves the legal landscape murky for many public entities relating to discrimination claims from both employees, the public and the direct customers or the clients they serve. As an example, the EEOC’s position is that the civil rights act’s protection under the term “sex” includes sexual orientation, gender expression and gender identity.2 Cases brought forward by the EEOC have had mostly favorable results to the EEOC’s position, however there has been at least one recent case where the court ruled against the EEOC.3 However, even with this loss, the shifting landscape was evident when the court went as far as to say that while they ruled that Tittle VII does not currently cover gender identity, the matter should be addressed by the Supreme Court or by legislation. Aside from court cases, there are other laws and regulations where public entities may be impacted in both the employment and external arenas. There is reference within the regulations for implementing the Affordable Care Act, requiring that health plans that receive any form of federal financial support do not contain exclusions relating to sexual orientation or gender identity (along with pre-existing conditions and disabilities). While these rules would not cover every situation, it covers enough that the advice to most organizations is to remove blanket exclusions and provide at least essential coverage to all plan participants and those whom services are provided. In addition to the employment and the risk of business loss, there can be liability from the customers or constituents of the services the entity offers or is responsible for. If the organization’s diversity and inclusion practices are absent, there could be claims of discrimination that originate from citizens.
Examples could include the denial of services such as issuing marriage licenses to same sex or transgender couples or disparaging treatment. The ease of managing these risks will often be tied to the organization’s overall diversity and inclusion efforts. When there is an active and positive process in place to provide leadership, education and accountability for diversity and inclusion efforts throughout the organization, the risk of events occurring that could lead to liability claims is lowered. This is due to the awareness and discussions that are generated before a situation arises that could otherwise lead to missteps and thus a claim. Then there is risk that is much harder to control and that is the risk of violence coming from someone who intends to do harm to a minority group or disruption from groups responding to acts of violence or events viewed as discriminatory (protests or riots). Public entities that include law enforcement or other emergency responders would have a high potential of impact but even seemingly benign entities could be impacted by the social unrest and/or feel the impact from employees who relate to the events occurring within their communities, both where they live and the groups they relate to. One of the worst examples of this occurred in Orlando, Fla., when a gunman attacked the crowd at Pulse, a nightclub known to be frequented by a predominately gay clientele. Outside of the direct impact to the victims, their families and the responders, this event was felt worldwide in particular by the LGBT community.
HOW DOES IT IMPACT YOUR ENTITY?
While the above risks are more communitywide issues where any one entity may only have a small impact on the overall risk, an individual entity can have an impact through their own diversity and inclusion efforts. This may be in the form of awareness programs, affinity groups and the effectiveness of the entity’s diversity and inclusion programs which can increase their employee’s awareness of potential trouble areas, show support to employees who may be impacted by such events and through public interface that can reduce the likelihood of the entity being a target of public outrage.
So what about the opportunities and how do they relate to risk? The most obvious is the reduction of employment liability risk. If an organization has a well-executed diversity and inclusion culture the risk of an employment liability related claim goes down. Studies have also shown that organizations with and effective diversity and inclusion culture will also be more productive in every measure including output, financial health and creativity.4 This presents organizations with opportunities to make improvements by tapping into the creativity, efficiency and synergy that can be leveraged by their employee groups. By learning and understanding concepts such as unconscious bias, and covering by employees, organizations can quickly find gains that can reduce their risks while reaping the benefits. Unconscious bias is a broad term used to describe the various inputs, our experiences and events in our lives, both good and bad, that are processed within our brains without our awareness that influence our decision making. In his book “Everyday Bias” Howard J. Ross states “If you are human, you are biased” and explains how the various types of bias and how these biases impact our lives.5 Relating to bias and how people may find ways to hide aspects of their lives in order to “fit in,” people may not disclose, or “cover” those aspects they believe may impact them in negative ways. Covering can take on different forms such as not revealing one’s sexual orientation, not displaying religious or ethnic symbols or hiding a disability. When employees are covering they may not be able to contribute as much to the organization. This is due to the effort and interference that the efforts to cover take. An example might be a gay or lesbian employee that is constantly having to think about not revealing their orientation for fear that they would be subjected to scrutiny or worse by their coworkers or managers. Allowing people to bring their authentic selves to work can create an environment where productivity and creativity pays dividends to the organization. Another opportunity relates to the community in which the entity provides services. When the organization understands the diversity of the community in which it operates and is inclusive in how it conducts its business, the entity will see benefits including a more involved, and
most likely, supportive community. This can be important when there are needs to seek public approval for revenue increases, boundary decisions or other voter approved issues. This can also be beneficial for the entities reputational risk which can impact the ability to attract businesses, employees and the public’s view of the entity. So how does an organization become more diverse and inclusive? On the employment front, it starts with leadership being committed to creating a more diverse and inclusive organization. This may start with learning about the unconscious bias’s we all have and understanding how to recognize and acknowledge them then learn how to not make decisions based on them. Reviewing job descriptions, recruitment materials and performance evaluations with an eye toward bias can assist reduce the impact of bias. When thinking of who to include in the various discussions of the organizations, being aware that there may be people being excluded from the conversation that could have valuable input and insight to bring to the discussion can help foster inclusion. But isn’t the whole concept of diversity and inclusion a liberal concept that excludes conservative views? Not at all, you cannot have a truly diverse and inclusive culture if you do not involve all views, just be aware that some views may not be legal, protected, or in the best interest of the organization. By openly discussing diversity and inclusion issues organizations can measure their potential for the associated risks and examine the opportunities to be gained by improving their overall diversity and inclusion efforts. Victoria Nolan, ARM, CSP, is the risk and benefits manager for Clean Water Services. FOOTNOTES
1 Human Rights Campaign map of state laws and policies 2016, http://www.hrc.org/ state_maps 2 Facts about Discrimination in Federal Government Employment Based on Marital Status, Political Affiliation, Status as a Parent, Sexual Orientation, and Gender Identity, EEOC website, https://www.eeoc.gov/ federal/otherprotections.cfm 3 EEOC v. R.G. & G.R. Harris Funeral Homes, Inc. 4 Innovation, Diversity and Market Growth, Center for Talent Innovation, 9/1/2013; 2016 Global Report “When Women Thrive”, Mercer 5 Everyday Bias, Howard J. Ross, Rowman & Littlefield, 2014
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