You helped me draft a proposal for this topic (attached).

The instructor wants references for the statements I have put (add ref.) after.

Additionally, he wants a section explaining the uniqueness of the culture and healthcare structure in UAE, as in the different authorities, different governance, different type of healthcare facilities available across the 7 emirates which in turn are affecting the uniqueness of the risks and risk management systems required.

Moreover, kindly find the proposed framework in Figure 10 in the article attached, we are proposing the same framework, but need to customize it (or change it) to fit in the UAE context, a sit is not a one size fit all thus this framework as well will be adjusted accordingly, but we need to prove what and why.

Or if you find another model/framework to propose and customize, please do not hesitate to introduce itEvaluation of Enterprise Risk Management in Healthcare Organizations in the United Arab Emirates Introduction (remove frame) Over the recent past, the healthcare industry has increasingly adopted contemporary risk management practices across the world add ref. In particular, the adoption of these practices is informed by the need for increased security and quality in providing care to patients (da Silva Etges et al., 2018). Besides, healthcare organizations have a general trend to minimize inherent risks and respond to actual risk events add ref.. In the UAE, healthcare organizations are exposed to numerous risks that threaten their security systems and the quality of care and services offered to patients. The nature of operations within healthcare organizations in the UAE necessitates effective enterprise risk management to reduce the vulnerability of organizational systems. According to Carroll (2016), effective enterprise risk management Page 1 systems facilitate accurate consideration of all risks and opportunities in organizational operations. Ultimately, healthcare organizations within the UAE have numerous opportunities for the implementation of sound enterprise risk management systems. Background (The Current Situation of ERM in UAE Healthcare services) Currently, the United Arab Emirates government is significantly aspiring to develop a global competitive healthcare system. According to Koornneef et al. (2017), the government has adopted the application of ERM to enhance healthcare services qualities for improved health outcomes for its people. However, United Arab Emirates does not have a specific framework followed when addressing healthcare risks but uses ERM depending on the nature of the risk that needs to be addressed. As an example for the current situation of ERM in UAE, this can be explained by looking at how the nations addressed the COVID-19 pandemic, which has threatened their healthcare facilities. Hasan et al. (2021) argue that UAE deployed data-driven modeling and forecasting as a comprehensive framework to make informed clinical decisions to curb the COVID-19 pandemic. The country has completed more than 4.9 million Covid-19 tests, which is the primary source of data for the ERM process (Hasan et al., 2021). ERM in UAE healthcare facilities extended to the development of protective decisions like the closure of learning institutions, place of worship, night curfew, and restricted movement with the country. Paying attention to this form of ERM in UAE healthcare was dependent on the situation created by COVID-19. Hasan et al. (2021) stipulate that the adoption of movement restrictions, isolation, and a more comprehensive National Screening Program in the COVID-19 ERM dramatically reduced the daily reported cases. They conclude that the United Arab Emirates lacks a specific ERM framework but addresses healthcare risks depending on their nature. Change verb to present Motivation and Justification The current dissertation is based on the realization that risk management is not a one-size-fits-all approach or proposition. Despite the universality of risks associated with healthcare organizations, the organizational culture and structure in the UAE is uniquely different from that of other countries (example/reference/elaboration – how these unique aspects/factors will influence the research design). Consequently, healthcare organizations warrant a unique and different approach to risk management (elaborate). The present dissertation is also based on the inherent benefits of enterprise risk management approaches in the healthcare industry. According to Gates (2016), enterprise risk management Page 2 systems are holistic in assessing risks and the associated management practices. Still, the justification for the dissertation is informed by the need for more efficient programs that facilitate accountability and risk oversight responsibilities within healthcare organizations. Indeed, enterprise risk management systems have the potential of helping healthcare organizations to accurately identify, manage, and communicate critical risks within the scope of their operations. Existing Gap The potential for the adoption of enterprise risk management systems in UAE healthcare organizations is expansive. Indeed, effective ERM contributes to holistic frameworks through which risk management decisions are achieved. There is an inherent need for systems of risk management that reduce risk and uncertainty, thereby maximizing value creation and protection within healthcare organizations. While most healthcare organizations in UAE have structured risk management systems, they do not meet the specific goals and objectives of the management. In part, most of these approaches have a traditional focus on clinical events through reactive strategies for risk management (Almansoori and Ali, 2020). (2020) further explained, Almansoori and Ali However, the dynamic nature of modern healthcare organizations necessitates the integration of systems that underline the significance of shared responsibilities in the identification, mitigation, and management of risks. While some healthcare organizations have benefitted from the implementation of enterprise risk management systems, they have been limited in their efficiency based on ineffective and unresponsive models. Research Questions This proposal seeks to explore the implementation of enterprise risk management systems within healthcare organizations in the UAE. In particular, the dissertation will evaluate the current implementation status of enterprise risk management systems among healthcare facilities in the country. In pursuing this research objective, the dissertation will survey and analyze executives (justification-individuals who take Page 3 strategic decisions) from different healthcare organizations in seeking answers to the following research questions: 1) exploring the current status of ERM in UAE (based on theoretical framework) 2) evaluating the effectiveness of ERM accordance to the UAE uniqueness/context (highlight the reason of deviations in implementing ERM – regulations, governance, type of HC org, etc.) 3) proposing a framework which deems to be suitable for the HC. Org in the UAE 1. What are the most critical risks for healthcare organizations in the UAE from the executive point of view? 2. What is the significance of enterprise risk management for these healthcare organizations within the UAE context/culture(environment)? 3. Are the current tools and processes in implementing enterprise risk management sufficient to identify and measure risks in healthcare organizations? (refer to framework) 4. What are practical steps in improving the effectiveness and efficiency of enterprise risk management in UAE healthcare organizations? Framework fitting the UAE environment 5. What are the factors leading to different ERM implementation? Literature Review The concept of enterprise risk management is increasingly gaining prominence within healthcare organizations across the world. In part, the absorption of enterprise risk management systems within healthcare industries is based on the transformation of healthcare service delivery. According to da Silva Etges (2018), the operation of healthcare facilities has dramatically changed from a volume-based approach to a delivery model that is more focused on value creation and sustenance. In their study on the value of risk management systems in hospital transformation, the author found that ERM’s are significant in enhancing efficiency and quality improvement. Inherently, the need for alignment of healthcare organizations with physicians, healthcare professionals, and other providers is justified through this approach. Similarly, effective enterprise risk management systems focus on financial management and productivity that facilitate Page 4 efficiency in operations. Besides improving efficiency, effective enterprise risk management systems focus on improving patient safety and quality of care. The role of risk management professionals in enhancing the effective implementation of strategies is also widely covered in the literature. As noted in Rao (2007), professionals engaged in risk management are uniquely positioned to respond to any potential challenges in the implementation of risk identification and management of risks. Inherently, the role of risk managers in assessing the potential risks associated with services or practices following their introduction within healthcare organizations. While the study focuses on the specific role of risk managers in averting potential risks in the offer of services and the practice of professionals, Elamir (2019) considers the value of collaborations. In their study on effective risk management, the authors consider the necessity for collaborative efforts in managing and identifying risks within healthcare facilities. Particularly, the study identifies the need for aligning risk management with robust organizational programs on patient safety. The significance of enterprise risk management systems in healthcare organizations is based on their potential to achieve safe service delivery. According to Martin (2020), enterprise risk management facilitates the attainment of reliable and secure healthcare services for patients. Similarly, effective risk management can be integrated into patient safety programs in a structured framework based on the implementation of sound ERM systems. In addition, the approach provides an interactive platform through holistic risk identification, treatment, and analysis. In articulating the role of enterprise risk management in healthcare organizations, the authors are accurate in defining the superiority of proactive and interactive approaches over-reactive and traditional approaches. In turn, the value of sound risk management systems is evidenced by the entrenchment of risk management's identified principles in organizational operations. Moreover, the study also identifies the need for realignment of risk management approaches to comply with organizational strategic planning processes. Still, the use of enterprise risk management systems imparts value in healthcare organizations through holistic management. In particular, the approach provides an opportunity for managers to apply crossPage 5 functional approaches in the assessment, evaluation, and measurement of risks. According to Roberta (2017), the benefit of cross-functional approaches in risk management is that it informs decision making processes. In identifying the centrality of enterprise risk management systems, the author explores the role of recent trends and a broader focus on corporate governance as integral in the adoption of the new system. Accordingly, the shift from traditional and reactive approaches towards the interactive enterprise risk management system is based on various factors, including the developments in corporate governance. The inherent value of ERM approaches in healthcare facilities is also responsible for the widespread adoption of the systems. Besides, the system has the potential of improving the value of healthcare organizations through the prevention of financial losses and enhancement of gains in reputation. The implementation of enterprise risk management systems is also beneficial through investments in expanded healthcare services. In turn, the concept of enterprise risk management benefits the community and the healthcare organization. The ERM approach goes beyond the traditional models, whose focus on avoidance, control, and risk transfer was largely ineffective. As noted in Kaya, Ward, and Clarkson (2019), traditional risk management approaches emphasized the transfer of risk through insurance, among other means. Through the insurance of services and assets, conventional methods of risk management were based on risk control activities in safeguarding the security of organizations. In contrast, however, enterprise risk management considers the prospects of risks as assets by focusing on the potential for both gains and losses in activities that produce risk. Still, the ability of enterprise risk management systems to predict and avert risks in the pursuit of organizational profitability makes them more efficient. In this regard, therefore, enterprise risk management has significant advantages over traditional risk management approaches. The concept of ERM further extends beyond the identification and management of clinical risks within healthcare organizations. According to (Zakaria et al., 2019), enterprise risk management systems provide a platform through which potential risks are identified, measured, and acted upon. In turn, ERM is significant to the operations of healthcare organizations as it goes beyond mere financial losses. Instead, enterprise risk Page 6 management facilitates the solution of potential risks by increasing value for all critical players, including suppliers, healthcare professionals, and patients. Similarly, the concept of enterprise risk management imparts enhanced effectiveness in management, thereby providing greater stability within the organization. In this regard, ERM systems are not limited to the alleviation of traditional risks of loss of property or financial resources. Instead, contemporary enterprise risk management systems are critical in sustaining positive reputations for organizations while increasing the levels of confidence in the boards of management. In essence, ERM systems achieve greater success in uplifting the overall image of healthcare organizations. The potential for ERM systems to address the challenges of organizational management in a holistic approach is also the subject of scientific studies. In Martin (2020), the benefits of ERM are considered in light of their potential to consider risks collectively. In contrast, traditional approaches focused on managing risks in functional departments, with each set of risks being explored separately. However, in enterprise risk management systems, risks are considered interrelated, thereby necessitating collective management to maximize operational efficiency. In their study on operational risks in the healthcare sector, the author found that healthcare organizations are exposed to risks in the form of the conduct of their core business. In particular, the provision of care to patients exposes healthcare organizations to various operational risks. Moreover, the ERM system can accurately identify operational and financial risks associated with the pursuit of an organization’s core business. Still, enterprise risk management systems are associated with increased effectiveness in the identification of strategic risks in healthcare organizations. According to Almansoori and Ali (2020), ERM systems have the potential of reducing the exposure of healthcare organizations to the demerits of strategic choice such as mergers and acquisitions. Moreover, the program provides a structured framework through which reputational risks can be minimized by sustaining performance expectations from patients and community relations. Carroll (2016) is accurate in asserting that effective ERM systems contribute to better management of human capital and legal risks by limiting an organization’s exposure. In part, the minimization of occupational hazards and effective management of harassment and discrimination through ERM systems is Page 7 a significant factor in managing healthcare organizations. Similarly, the systems have the capabilities of identifying and managing risks associated with regulatory risks, including accreditation and compliance. Research Design The current dissertation is based on a quantitative research design targeting healthcare organizations in the UAE. In particular, the study will use surveys addressed to executives and managers drawn from contemporary healthcare organizations in the UAE. According to Callegaro and Yang (2018), the use of surveys in quantitative research designs is based on the collection of data from a sample population. Inherently, these surveys will be utilized in recording and describing the opinions, behaviors, and attitudes of the managers and executives towards enterprise risk management systems in their respective healthcare organizations. The research design will be used to provide answers regarding the proposed research questions. The study will be based on a survey of healthcare organizations through their managers and top executives. In turn, the survey results will be used to analyze data on the types of risks that are critical for healthcare organizations in the UAE. Besides, the use of surveys effectively assesses the current status of implementation for ERM systems in healthcare organizations. *Not sure qualitative or quantitative, based on the questions asked in the survey (the survey design) TBC Sampling The selection of participants for the proposed study will be achieved through purposive sampling. According to Sharma (2017), purposive sampling entails selecting participants through reliance on the researcher’s judgment. This sampling method is relevant as it allows the researcher only to limit the choice of participants to managers and executives from healthcare organizations in the UAE. The managers will be drawn from seven emirates, with two managers and executives selected from each of the seven emirates. Each of the fourteen participants will provide responses to the questions in the survey. The initial contact with the participants will be made through email requests before signing their informed consent form. The participants will be notified of their voluntary participation in the research study and allowed to opt-out at Page 8 any time if they want. The research study will also comply with ethical standards on privacy and confidentiality of participants. Potential Contributions and Implication The proposed study seeks to showcase the inefficiencies of the current status of enterprise risk management systems in UAE healthcare organizations. In turn, the study proposes the adoption of a new ERM model for use in healthcare organizations intending to improve operational performance and efficiency. The proposed ERM framework is based on the use of indicators to avert potential financial risks by identifying and managing cash flow at risk (Etges et al., 2019). Indeed, healthcare organizations are highly vulnerable to variations in cash flow because of the immediacy of services and supplies. The implementation of this framework is likely to impart changes in the management of risks in the healthcare sector through proactive approaches. In particular, alleviation of risks in the healthcare sector has the implication of reducing the vulnerability of these organizations and eventually resulting in performance improvement. The proposed model of enterprise risk management puts the ERM department lower than the strategic decision-making level. In turn, the position of the ERM department is evidence of the centrality of risk management in the organizational structure. The proposal further advances the idea of staffing the department with professionals from diverse and multiple competencies (Etges et al., 2019). The diversity of professionals in the ERM department is based on their mastery of routine operations in the healthcare organization. In the positioning of the risk management department, staff has easier access to risk management information, thereby providing sufficient information to facilitate decision making. As part of the changes in the hierarchy proposed by the model, the top leadership achieves unlimited access to the ERM department. In turn, this has positive implications for the healthcare organization in terms of sustained performance and quality of care services. Besides, the integration of the proposed ERM model in UAE healthcare organizations is likely to enhance the quality of services. In particular, the centrality of medical care processes within the organizational structure Page 9 helps in prioritizing patient satisfaction. In particular, this approach is consistent with the primary goals of healthcare organizations in providing relevant assistance to patients. By adopting a process-based approach in risk management, healthcare organizations in the UAE can achieve greater efficiency in identifying risks. According to Rao (2007), ERM approaches enhance the identification of risks across all processes and their specific activities. Besides, the approach also facilitates accurate identification of risks at the interconnections between different processes. In this regard, the vulnerability of the organization to risks is minimized. Moreover, the ERM model considers risks as a whole and not by limiting them to specific sectors of the organization. Through this shift in management, organizations have the opportunity of exploiting synergies to improve their performance across different sectors. Still, the proposed model of the ERM program espouses the significance of value creation in the organization. Indeed, the model facilitates interaction between creation and protection of value through astute management of identified and perceived risks. As noted in Etges et al. (2019), the use of sound ERM systems positively influences the determination of costs of services offered within the healthcare organization. Through the use of the model, healthcare organizations achieve the most accurate prices, thereby making them more competitive and profitable in the long term. By accurately identifying economic risks in the management of healthcare reorganizations, ERM approaches facilitate streamlining of resource utilization to the benefit of the organization. The gains achieved from ERM systems have the prospects of ensuring financial transparency and procedural management. Similarly, the proposed model is expected to contribute to the proactive identification of flaws and opportunities for considering healthcare organizations in the UAE. Page 10 References Almansoori, A. S., & Ali, M. (2020). Risk Management Measurement Models of UAE Public Hospitals using Confirmatory Factor Analysis (CFA). Psychology and Education Journal, 57(9), 5472-5481. Callegaro, M., & Yang, Y. (2018). The role of surveys in the era of “big data”. In The Palgrave handbook of survey research (pp. 175-192). Palgrave Macmillan, Cham. Carroll, R. (2016). Identifying risks in the realm of enterprise risk management. Journal of healthcare risk management, 35(3), 24-30. da Silva Etges, A. P. B., Grenon, V., de Souza, J. S., Neto, F. J. K., & Felix, E. A. (2018). ERM for Health Care Organizations: An Economic Enterprise Risk Management Innovation Program (E2RMhealth care). Value in health regional issues, 17, 102-108. Etges, A. P. B. D. S., de Souza, J. S., Kliemann Neto, F. J., & Felix, E. A. (2019). A proposed enterprise risk management model for health organizations. Journal of Risk Research, 22(4), 513-531. Elamir, H. (2019). Enterprise risk management and bow ties: going beyond patient safety. Business Process Management Journal. Gates, S. (2016). Incorporating strategic risk into enterprise risk management: A survey of current corporate practice. Journal of Applied Corporate Finance, 18(4), 81-90. Hasan, A., Putri, E. R. M., Susanto, H., & Nuraini, N. (2021). Data-driven modeling and forecasting of COVID-19 outbreak for public policy making. ISA transactions. Kaya, G. K., Ward, J. R., & Clarkson, P. J. (2019). A framework to support risk assessment in hospitals. International Journal for Quality in Health Care, 31(5), 393. Koornneef, E., Robben, P. & Blair, I. (2017). Progress and outcomes of health systems reform in the United Arab Emirates: a systematic review. BMC Health Serv Res 17, 672. Page 11 Martin, N. (2020, July). Enabling effective oversight: Enterprise risk management and board governance in healthcare. In Healthcare management forum (Vol. 33, No. 4, pp. 182-185). Sage CA: Los Angeles, CA: SAGE Publications. Rao, A. (2007). Evaluation of enterprise risk management (ERM) in Dubai–an emerging economy. Risk Management, 9(3), 167-187. Roberta, C. (2017). Enterprise risk management: The impact on healthcare organizations. Principles of risk management and patient safety, 115. Sharma, G. (2017). Pros and cons of different sampling techniques. International journal of applied research, 3(7), 749-752. Zakaria, H., Bakar, N. A. A., Hassan, N. H., & Yaacob, S. (2019). IoT security risk management model for secured practice in healthcare environment. Procedia Computer Science, 161, 1241-1248. Page 12 See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/322337350 A proposed enterprise risk management model for health organizations A proposed enterprise risk management model for health organizations Article in Journal of Risk Research · January 2018 DOI: 10.1080/13669877.2017.1422780 CITATIONS READS 14 3,319 4 authors: Ana Paula Beck da Silva Etges Joana Siqueira de Souza Universidade Federal do Rio Grande do Sul Universidade Federal do Rio Grande do Sul 44 PUBLICATIONS 103 CITATIONS 35 PUBLICATIONS 52 CITATIONS SEE PROFILE SEE PROFILE Francisco José Kliemann Elaine Felix Universidade Federal do Rio Grande do Sul Universidade Federal do Rio Grande do Sul 104 PUBLICATIONS 358 CITATIONS 21 PUBLICATIONS 46 CITATIONS SEE PROFILE SEE PROFILE Some of the authors of this publication are also working on these related projects: Agricultural risk management through the Enterprise Risk Management perspective View project Enterprise Risk Management in Healthcare View project All content following this page was uploaded by Ana Paula Beck da Silva Etges on 09 January 2018. The user has requested enhancement of the downloaded file. Journal of Risk Research ISSN: 1366-9877 (Print) 1466-4461 (Online) Journal homepage: http://www.tandfonline.com/loi/rjrr20 A proposed enterprise risk management model for health organizations Ana Paula Beck da Silva Etges, Joana Siqueira de Souza, Francisco José Kliemann Neto & Elaine Aparecida Felix To cite this article: Ana Paula Beck da Silva Etges, Joana Siqueira de Souza, Francisco José Kliemann Neto & Elaine Aparecida Felix (2018): A proposed enterprise risk management model for health organizations, Journal of Risk Research To link to this article: https://doi.org/10.1080/13669877.2017.1422780 Published online: 09 Jan 2018. Submit your article to this journal View related articles View Crossmark data Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=rjrr20 Download by: [Fundacao Getulio Vargas] Date: 09 January 2018, At: 05:13 Journal of Risk Research, 2018 https://doi.org/10.1080/13669877.2017.1422780 A proposed enterprise risk management model for health organizations Ana Paula Beck da Silva Etgesa and Elaine Aparecida Felixb , Joana Siqueira de Souzaa, Francisco José Kliemann Netoa Downloaded by [Fundacao Getulio Vargas] at 05:13 09 January 2018 a Industrial Engineering, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; bSchool of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil ABSTRACT Health care organizations are environments with high management complexity and subject to a constant exposure to risks. Enterprise risk management (ERM) has been studied and applied in different economic environments with the aim of improving organizational performance. However, the health sector still suffers from a lack of attention in this context, in particular with regard to the need for a high degree of financial transparency and for the establishment of process-orientated management, and this provides the motivation for the study described in this paper. An ERM model for health organizations is proposed, based on a systematic literature review and on seven case studies in Brazilian hospitals. An approach to economic risk assessment using indicators such as the cash flow at risk and the variability of costs and receipts from the proposed model is suggested. The health organizations involved in the case studies all interpret ERM as a source of information contributing to corporate governance, and the indicators listed provide constructive data for improvement-driven decision-making. Given the interest expressed by the organizations involved, further application and validation of the proposed model in subsequent studies is suggested. ARTICLE HISTORY Received 15 September 2016 Accepted 3 December 2017 KEYWORDS Enterprise risk management; risk management and health; corporate governance; economic risk analysis 1. Introduction The widespread adoption of risk management (RM) practices in hospitals has been stimulated by the dissemination of a security and quality culture following the publication of the book entitled To Err is Human: Building a Safer Health System. Among the motivations behind this seminal publication, a number stand out: the existence of high risks in health environments due to the large numbers of staff; the high degree of interdependence between different areas of activity (Celona, Driver, and Hall 2010); the technological complexity of the procedures involved in health systems; and the large numbers of standards and laws to which these procedures are subject (Troyer, Brashear, and Green 2005). With the intention of developing a uniform approach to security and management across different health care systems, organizations such as the Joint Commission International (JCI 2013) and the American Society for Health care Risk Management (ASHRM 2006) have started to devote efforts toward the improvement of patient safety and hospital management. Conveying value to patients must be the main objective of health care delivery in a health organization, with this value being defined as the results achieved for each dollar spent (Porter 2010). CONTACT Ana Paula Beck da Silva Etges anaetges@producao.ufrgs.br © 2018 Informa UK Limited, trading as Taylor & Francis Group Downloaded by [Fundacao Getulio Vargas] at 05:13 09 January 2018 2 A. P. B. DA SILVA ETGES ET AL. Management that is balanced and guided by value must be among the strategic priorities for the leaders of a health organization: while the clinical body attributes value to the quality of its practices, the executive administration focuses on realizing the value generated by its financial resources (Orvik 2016). Porter, Larsson, and Lee (2016) presented the following unification of the two pillars of value perception: on the one hand, when value is perceived and continuously improved, patients and suppliers benefit and the economic sustainability of the hospital increases; on the other hand, when high quality is assured, value increases and economic results are generated. Enterprise risk management (ERM) is an approach to facilitating value-focused management that enables financial transparency and increases the efficiency of health enterprises, in particular by developing a management strategy driven by business values (Troyer, Brashear, and Green 2005; Celona, Driver, and Hall 2010). In the context of a hospital’s corporate management, the implementation of ERM practices, although still at an early stage, has been described in the literature as a strategic approach to improving service quality (Haney, Church, and Cockerill 2013; Bruney and Salter (2014) and to guaranteeing the financial well-being of health organizations (Gallagher et al. 2006). When considering ERM as the subject of this study, the model developed by the Committee of Sponsoring Organizations of the Treadway Commission (COSO), which is responsible for the dissemination of ERM concepts, was selected. This model has influenced authors such as Damodaran (2009); Schiller and Prpich (2014); Cagliano, Grimaldi, and Rafaele (2014) in their development of studies exploring the economic assessments that are enabled by systemic and strategic RM. Although it is widely used, the COSO model does not provide tools to facilitate its application (Souza 2011; Cagliano, Grimaldi, and Rafaele 2014), because it is considered a theoretical model that is difficult to implement in practice (Caron, Vanthienen, and Baesens 2013; Schiller and Prpich 2014). With the aim of filling this gap, the Model for Identifying and Managing the Degree of Risk in Companies (MIGGRI) is based on the concepts of the economic management of risk presented by Damodaran (2009), together with the necessary tools, in order to evaluate the risk involved in an enterprise and in its business units (Souza 2011). In hospital environments, one of the reasons of using models based on ERM is to improve performance while taking account of those features that are specific to hospitals in contrast to other organizations (Celona, Driver, and Hall 2010). The World Health Organization (WHO), through the International Classification for Patient Safety, has interpreted the main concepts related to RM in hospitals and has suggested a hierarchy categorizing types of risk. The JCI has started to consider as part of its accreditation procedure the execution of practices orientated around RM in accredited hospitals. Other regulatory organizations for hospitals around the world have laid down guidelines with the purpose of enforcing practices that will turn RM into a matter of routine for hospital managements. These organizations include the Health care Insurance Reciprocal of Canada (HIROC Integrated RM for Healthcare Organizations 2014), the American Society of Health care Risk Managers (ASHRM, 2006), and the UK National Health Service (NHS). The book Risk Management Handbook for Healthcare Organizations (Carroll, Nakamura, and Troyer 2010) also stands out. It aims to adapt the concepts of RM and ERM already employed in different business environments to the health care context and to provide some guidance to hospitals and managers who wish to implement ERM. This book highlights the improvements to risk investigation and the economic benefits that ERM can provide, but it does not present any sort of complete guide to ERM or the orientation that should be adopted with regard to its application. To remedy these deficiencies, the study described in this paper has as its main objective the development of a preliminary model of ERM for hospital environments. The specific objectives are to provide a theoretical basis for each step of the proposed model through a systematic literature review (SLR) and to develop the proposed model in collaboration with professionals practicing RM in Brazilian hospitals Hospital management must take account of the complexity of a hospital’s financial structure, with costs being concentrated on indirect resources and with multiple sources of revenue (Souza 2013). Improving the financial health of hospitals and developing methods that allow better management of such complex environments are essential tasks in the current economic climate, where both minimization JOURNAL OF RISK RESEARCH 3 of costs and improvement of quality are key aims (Troyer, Brashear, and Green 2005; Gallagher et al. 2006). The main justification for the research reported here is the need to understand how hospitals have been organizing themselves to assist regulatory bodies and improve their performance. Downloaded by [Fundacao Getulio Vargas] at 05:13 09 January 2018 2. Research methodology This research uses an SLR together with case studies to construct a realistic environmental model (Yin 2005). In the first phase, the SLR is used to establish the theoretical basis of the model. In the second phase, case studies of JCI-accredited hospitals and other organizations are performed to assess how the ERM methods listed in the literature are implemented in practice. In the final stage, a preliminary ERM model is proposed based on the results from the first two phases. For the SLR, the following guidelines adopted in the studies by Tranfield, Denyer, and Smart (2003); Kitchenham et al. (2009) were used: (i) definition of the research problem and selection of the search criteria (keywords); (ii) selection of the main sources for investigation; (iii) selection of major studies; (iv) critical evaluation of their results; and (v) synthesis. Thus, the research began in a number of databases using the keywords enterprise risk management and hospital or health for research published between 2005 and 2015 considering only articles in English, Spanish, or Portuguese. A total of 40 articles were found (4 in PubMed, 33 in Scopus, and 3 in Science Direct). Repeated papers were then eliminated and the titles of the articles were evaluated to exclude those focusing on themes that deviated from the objective of this study, such as clinical medicine or technical medical errors, neuroscience, use of ERM in research organizations that do not involve health care or movement of patients, and research on specific cases of implementation of technologies that have no goals related to ERM application. This left for analysis 26 articles that were aligned with the research objectives. On the basis of this SLR, a preliminary model was developed in a modular form, with economic risks being measured through a procedural and value-oriented approach to ERM. Preliminary studies were also suggested to highlight the importance of each component of the model in facilitating ERM in health organizations. With the objective of involving real hospitals in the construction of the model, JCI-accredited Brazilian hospitals were contacted, since these were listed by a magazine America Economia (2014) as the best hospitals in Latin America. In addition, although they were not accredited, some other hospitals were also selected because they had RM teams. The group of hospitals selected for the study was heterogeneous in terms of geographical location, size (i.e. number of beds), revenue, and accreditations, in order to allow determination of whether these characteristics have any effect on RM. In total, seven health organizations were studied. Their characteristics are summarized in Figure 1. Health Organizations Number of beds Classifi cation Medical School Number of staff Accreditations A 660 Private Yes 3900 ONA 2 e Gaucho Program of Quality and Productivity B 842 Public Yes 6000 JCI C D E 380 346 292 Private Private Private No No Yes 3150 2400 930 F 615 Private Yes 12000 JCI JCI e ONA American Association of Blood Banks, American College of Radiology, College of American Pathologists, Foundation for Accreditation of Cellular Therapy, ISO 14001, JCI, OHSAS 18001 6000 JCI, HIMSS (6), Accreditation Canada International, ISO 14001, OHSAS 18001, CARF-Accredited G 451 Private Figure 1. Hospitals involved in the research. No Downloaded by [Fundacao Getulio Vargas] at 05:13 09 January 2018 4 A. P. B. DA SILVA ETGES ET AL. Individual interviews were conducted with the employees involved in the implementation of RM and with the executive directors; in four cases, on the suggestion of the hospital, in addition to the financial director or enterprise risk manager, the clinical risk manager was also interviewed. The interviews were conducted by the researchers personally and had a duration of two hours. The questionnaire used was prepared on the basis of the results of the SLR and the previous experience of the authors, who have been working with ERM for the last five years. At the end of each interview, the preliminary model was shown to the interviewee, and the opinion of the latter about the ERM was obtained. The interviews were complemented by direct observations by the researchers, allowing them to gain some understanding of the routine RM practices at the hospitals involved in the study. Contact was maintained with the main professionals involved so that any ERM action at each hospital could be captured as it occurred. It should be noted that although some hospitals have medical care RM departments, in others the initiative for implementing ERM has come from the executive board (legal and financial), in the context of the organization’s strategic planning and involving staff from a number of disciplines. The information obtained was documented on a spreadsheet to facilitate its analysis. This information was separated into the following classes: general information; risk management; ERM; economic evaluation; and opinion. In this documentation, an attempt was made to link the views expressed by the interviewees with the theoretical results found previously, with suggestions about the preliminary theoretical model being highlighted. On the basis of the case studies, it was possible to evaluate how Brazilian hospitals are dealing with ERM in practice, compared with the results previously published in the literature. 3. Results and discussion In this section, the results obtained in each of the phases described above are presented and discussed. 3.1. Systematic literature review The SLR allowed identification of what has been documented on ERM. From the 26 articles that were analyzed, it could be seen that ERM was used mainly in American hospitals (20 papers), with some use in Canada and England (2 papers each), and Australia (1 paper). (One paper did not fit with the research topic, since it was focused on veterinary hospitals.) From the studies found in the SLR, it was possible to observe the presence of the following phases suggested in COSO (2008) and in ISO 31000 (2009) as being common to all implementations of ERM: contextualization; technical analysis of risk; economic risk assessment; and treatment and monitoring of risk. However, it should be noted that none of the models of ERM described in any of these studies focused on health organizations. 3.1.1. ERM contextualization The relationship between ERM, corporate governance, and strategic management of hospitals is considered to be the starting point for proactive management with an orientation toward performance improvement in health organizations (Celona, Driver, and Hall 2010; Bruney and Salter 2014). Under the assumptions of corporate governance, one task of ERM is to provide monitoring of strategic settings and thereby contribute to the economic sustainability of an institution, which is a fundamental aspect of value creation (Core, Holthausen, and Larcker 1999). For ERM to be applied in a value-focused way in association with financial and service efficiency as part of executive management (Orvik 2016), it must be possible to monitor interrelated decisions that are of interest to shareholders and investors. To achieve this situation of management autonomy that allows the generation of information for governance, the position of the ERM team in the organizational hierarchy should be immediately below executive board level. It must have direct connections with the other large-scale structures into which the hospital is stratified, including legal, financial, health care, and quality, among others (Sandrick JOURNAL OF RISK RESEARCH 5 2010), so that management is procedural in nature, covering the interconnections between the different hospital activities (Kicklighter and Miller 2011; Haney, Church, and Cockerill 2013). With the ERM department being positioned below corporate management, it is thus given autonomy to exercise its role of managing processes across the corporate management structure (Bruney and Salter 2014). In addition to this positioning, the literature indicates that the ERM team should be managed by a Chief Risk Officer (CRO) with expertise in strategic positioning of the business, knowledge of the tactical and operational processes involved, and good ability to interact with different levels of the organizational hierarchy (Sandrick 2010). The following subsections describe ERM in terms of three modules based on the stages described in ISO 31000 (2009): technical analysis of risk; economic risk assessment; and treatment and monitoring of risk. Downloaded by [Fundacao Getulio Vargas] at 05:13 09 January 2018 3.1.2. Technical analysis of risk The relevance of procedural structure is due to the strong presence of risks at points of interconnection between different parts of the hospital structure, such as communication between teams (Gallager et al. 2006; Burnaby and Hass 2009). When hospitals are organized into departments, the risks in individual departments do not arise in isolation (Carroll, Nakamura, and Troyer 2010): risks in one department are related to those in other departments, and this interdependence must be analyzed synergistically as part of strategic management (Haney, Church, and Cockerill 2013). Therefore, it is suggested in the literature that, when the processes are mapped, those aspects that might be bottlenecks in the treatment flow should be identified. Such aspects are characterized by the involvement of multiple professionals, the use of highly complex equipment, or the need for scarce resources (Teoh and Cheong 2008). Identification of risks should be focused on these bottlenecks, taking account the factors suggested in COSO (2008). Thus, the first stage of this risk analysis technique does not involve any economic risk assessment. 3.1.3. Economic risk assessment It is pointed out in the literature that when structuring the ERM in procedural form, it is necessary to pay attention to the flow of value among hospital areas and manage this in order to incorporate any possible variability of healthcare costs (Gallagher et al. 2006; Remus 2008; Celona, Driver, and Hall 2010). The way in which value is delivered to the patient is determined by the various stages of the cycle of care in the hospital (Porter 2010). It is worth including in the ERM a procedural approach that has previously been suggested for business units (Damodaran 2009; Souza 2011; Schiller and Prpich 2014), with the addition of modules to facilitate operationalization of ERM in complex environments such health organizations that are characterized by multiple clients and processes (Remus 2008). With the objective of achieving ERM based on value, Celona, Driver, and Hall (2010) at the Medical Center of Stanford University proposed a procedural model that considers the value flow in terms of a trade-off between value creation and value protection. According to these authors, overprotection of an organization can lead to opportunities being missed, while, on the other hand, when investing in opportunities, risks must be managed because they may affect the financial health of the hospital. Therefore, the implementation of an ERM must involve a balance between benefit and cost, as indicated by Troyer, Brashear, and Green (2005); Courson (2008); Hillard (2012); Haney, Church, and Cockerill (2013). Celona, Driver, and Hall (2010) believe that for implementation of ERM, the following are essential: (i) a top-down approach directed at value; (ii) a focus on security based on identification of risk events; (iii) a decision analysis addressing systemic risks and correlations among different areas of value creation arising from the opportunities identified by the practice of RM; and (iv) implementation of an indicator of appetite for risk. For these authors, the value flow in a hospital is designed to meet any event that may have an economic impact on the organization as a whole. With regard to point (iv), it should be noted that defining a degree of appetite for risk is important because it provides a parameter 6 A. P. B. DA SILVA ETGES ET AL. of comparison for the hospital, facilitating evaluation of its performance with reference to a previously established standard (Courson 2008). However, although the model of Celona, Driver, and Hall (2010) is based in value and economic outcome, it has been criticized because it does not indicate how a financial manager should evaluate the risk in a hospital or estimate the variability in cost arising from risk events. Downloaded by [Fundacao Getulio Vargas] at 05:13 09 January 2018 3.1.4. Treatment and monitoring of risk Following the analysis and evaluation stages, the ERM procedure is completed with the treatment and monitoring of risks. With regard to this aspect, it is important to emphasize the need for participation of all those involved in the hospital’s organization, and therefore the need for employees to be trained and educated about ERM (Miller, Miginsky, and Connelly 2012). It is also worth highlighting here the need for an organizational culture based on educating professionals in ERM, as pointed out by Haney, Church, and Cockerill (2013); Bruney and Salter (2014), who have shown that for ERM to be effective it should be constructed by those directly involved in the activities of an organization. The existence of connection with governance can be seen by considering together the reasons that stimulate the implementation of ERM: financial transparency (Troyer, Brashear, and Green 2005; Celona, Driver, and Hall 2010) the need for rapid innovation with regard to a hospital’s procedures (Abke 2005) the possibility of medical errors and the consequent need for legal protection (Gallagher et al. 2006); the possibility of corruption among professional staff (Burnaby and Hass 2009); an increase in the number of elderly patients (Kicklighter and Miller 2011); and the management of family members with various religious and cultural backgrounds (O’Donnell et al. 2013). Information about financial transparency, the presence of corruption, and medical errors is highly relevant when establishing institutional governance. 3.1.5. Motivations and theoretical justification for ERM implementation Figure 2 illustrates the characteristics described in the text and listed as premises or justifications for the ERM implementation. The characteristics listed by authors as motivating or influencing investment Characteristics Description Benefit x Cost Future opportunities Improvement of the Information Flow Financial transparency Justifications Gallagher et al. (2006) and Gaffey (2009), Celona et al. (2010), Miller et al. (2012) and Sandrick (2010). Troyer et al. (2005), Celona et al. (2010), Sandrick (2010) Troyer et al. (2005), Teoh e Chong (2008), Gallagher et al. (2006), Celona et al. (2010), Kicklighter and Miller (2011), Burnaby and Hass (2009), Miller et al. (2012), Haney et al. (2013) and Bruney and Salter (2014). Synergy among teams Troyer et al. (2005), Couron (2007), Teoh e Chong (2008), Remus (2008), Celona et al. (2010), Sodomka et al. (2010), Haney et al. (2013) and Bruney and Salter (2014). Culture and education ERM book Premises Process and value flow vision Risk Events in interconnections Profile of degree of acceptance of risk Authors Troyer et al. (2005), Remus (2008) , Sandrick (2010), Kicklighter and Miller (2011), Hillard (2012) and Haney et al. (2013), Troyer et al. (2005), Courson (2008), Gallagher et al. (2006) and Celona et al. (2010). Miller et al. (2012) Troyer et al. (2005), Courson (2008), Remus (2008), Gallagher et al. (2006), Gaffey (2009), Sandrick (2010), Celonaet al. (2010), Kicklighter e Miller (2011), Burnaby and Hass (2009), Hillard (2012), Haney et al. (2013) and Bruney and Salter (2014). Remus (2008), Teoh and Chong (2008), Gallagher et al. (2006), Celona et al. (2010), Burnaby and Hass (2009), Kicklighter and Miller (2011), Hillard (2012) and Miller et al. (2012). Remus (2008), Celona et al. (2010), Kicklighter and Miller (2011) and Miller et al. (2012). Figure 2. Characteristics of the ERM and authors. JOURNAL OF RISK RESEARCH 7 in ERM have been classified as justifications. The characteristics identified as favoring the facilitation of ERM have been categorized as premises. 3.2. Proposed theoretical model Downloaded by [Fundacao Getulio Vargas] at 05:13 09 January 2018 The initial model shown in Figure 3 was based on an SLR of the literature on the guidance laid down in COSO (2008); ISO 31000 (2009). 1- Bruney and Salter (2014) 8 - Remus (2008) 18 - Gaffey (2009) 2 - Oppenber (2013) 9 - Courson (2008) 19 - Abke (2005) 3 - Haney et al. (2013) 11 - Woodruff (2005) 20 - Dónnell (2013) 4 - Hillard (2012) 12 - Celona et al. (2010) 21 - Maley et al. (2006) 5 - Kicklighter and Miller (2011) 14 - Kazucata et al. (2006) 22 - Sodomka et al. (2010) 6 - Burnaby, Hass (2009) 15 - Troyer et al. (2005) 23 -Gallagher et al. (2006) 7 - Teoh e Chong (2008) 16 - Miller et al. (2012) Figure 3. Preliminary model. 8 A. P. B. DA SILVA ETGES ET AL. 3.2.1. Contextualization and strategic positioning With regard to the model structure relating ERM to the strategic positioning of the hospital, the literature confirms that this connection is essential (Kicklighter and Miller 2011). It is in this context that the suggestion is made that the ERM department be positioned immediately below the level responsible for strategic decision-making in the organizational structure. This department should be formed by professionals from multiple disciplines who together have mastery of the routine procedures of the hospital and knowledge of the organization’s tactical and strategic positioning. The model suggests that this team be managed by a CRO who, according to the literature guidelines, has easy communication with the different levels of the hierarchy, as well as sufficient leadership capacity to act across corporate management and gather essential information for decision-making by the corporate management based on ERM. Downloaded by [Fundacao Getulio Vargas] at 05:13 09 January 2018 3.2.2. Module 1: technical analysis of risk Following the guidelines from Gallagher et al. (2006); Celona, Driver, and Hall (2010) for managing risks by targeting better value management (and presented as an important premise highlighted in Figure 2), a picture of the processes involved in the functioning of the health organization is proposed in terms of their responsibilities and functions and of the interactions among them. Figure 4 illustrates such an organizational structure based on the proposal by Celona, Driver, and Hall (2010). Basing this structure on value and processes allows risks to be thought of in a corporate way and not as being isolated in departments (Haney, Church, and Cockerill 2013). In addition, the flow of information is identified and mapped in conjunction with the activities. This facilitates an overview of the process and permits the identification and management of risks linked to business strategy. The placement of the medical care process as central is relevant since it represents the industry to which the organization belongs. The other processes exist in relation to the feasibility of medical care. The main function of a health organization is to provide appropriate assistance to patients while ensuring both quality and safety. Consequently, the process-based view aims to identify risks for each process and especially at the interconnections between these processes, as can be seen from the SLR and illustrated in Figure 2 as a premise for the operationalization of ERM. Therefore, identification of risks will occur at the level of the activities involved in each process, as well as the activities involved at the interconnections, as shown in Figure 5. Figure 4. Enterprise risk management structure in the organization. JOURNAL OF RISK RESEARCH 9 Downloaded by [Fundacao Getulio Vargas] at 05:13 09 January 2018 Figure 5. ERM – processes view. Some studies and guidelines suggest that a health organization should be divided into various processes related to value: medical assistance; research and teaching; people management; information technology and systems; strategic marketing; financial and administrative; and legal (ASHRM 2006; Sandrick 2010; NHS Commissioning Board: Serious Incident Framework 2013). The value-based flows established from these processes may involve activities that require the collaboration of teams from different processes. The possibility of risks caused by disruptions to these flows emphasizes the need to consider synergy among the teams to carrying out ERM, and the need to identify connection points between different areas as well as potential bottleneck activities (Celona, Driver, and Hall 2010; Sandrick 2010). Thus, the hospital should approximate from what Bromiley et al. (2014); Eckles, Hoyt, and Miller (2014) have indicated as being extremely relevant in the ERM, namely, considering risk as a whole and not in isolation in specific sectors. The next step involves mapping the risk events in the flow activities. Staff in positions involving decision-making and at operational levels must be surveyed to allow a systemic analysis and the creation of adequate typologies of risk. This procedure begins with the identification of risks related to the bottleneck activities, which are critical, and to the connection points, which can be critical (Courson 2008; Miller, Miginsky, and Connelly 2012). At the end of this activity, those risks that are linked with critical points of the flow are defined and mapped, indicating criticalities. The prioritization considers probability and impact through risk analysis methods suggested by COSO (2007) and the studies considered in the SLR. Among the most common methods is the use of probability and impact matrices. Knowledge from experts is used for these methods, as can be seen in the studies by Malekdar (2012); Bahrami, Bazzaz, and Sajjadi (2012); Penning-Rowsell (2014). Finally, as a result of this analysis, the critical risks are identified and are found to be represented most strongly at the intersection between probability and impact, linked to critical activities of the hospital processes. Through this result, it is possible to observe the inter-relationships between different areas and processes, as well as the enterprise risks. This analysis model was also used in previous studies, including ASHRM (2006); NHS Commissioning Board: Serious Incident Framework (2013); Haney, Church, and Cockerill (2013); Celona, Driver, and Hall (2010). 3.2.3. Module 2: economic risk assessment Influenced by the importance of value creation, ERM implementation carries in its structure an interaction between protection and creation of value, or between the benefit of managing risks over the cost of management (Troyer, Brashear, and Green 2005; Celona, Driver, and Hall 2010). The search for financial transparency also provides a justification for the use of ERM and thus encourages the best treatment of costs and revenues. To evaluate risks from an economic perspective, the processes identified in Module 1 must be measured in terms of economic factors. The results of Module 1 suggest the use of activity-based costing (ABC) for the mapped flows. In adopting this method for the distribution of indirect costs, it is acknowledged Downloaded by [Fundacao Getulio Vargas] at 05:13 09 January 2018 10 A. P. B. DA SILVA ETGES ET AL. that multiple products consume the same activities and resources of the company structure in different proportions (Cooper and Kaplan 1991). Thus, when using ABC, the cost of a product or service is determined more accurately, especially when it is formed from a portion of indirect resources (Cooper and Kaplan 1991). Waters, Abdallah, and Santillán (2001) drew conclusions regarding the relevance of financial unit costs of hospital services through ABC from a study of a hospital in Peru. They emphasized the importance of this approach for providing the best pricing of services and gathering arguments as a basis for negotiating with governments concerning support for public health systems. Kastberg and Siverbo (2007), in addition to working with current expenditures by activity, expanded the concept and used it to analyze activities in Swedish hospitals. They demonstrated that the implementation of such methods in the financial management of a hospital streamlines the consumption of resources and consequently improves the hospital’s results. The use of ABC enables identification of the cost of critical activities, which can be expensive with only a few risks attached, or can be less costly with many associated risks (Waters, Abdallah, and Santillán 2001). This approach is necessary because a small risk event in an expensive activity may represent a significant monetary variation, while the presence of many risks in a less expensive activity can represent a significant variation in the process cost. All those risks linked to critical activities are defined as critical risks II, and a variation is projected in the cost likely to arise, given that the risk events and the associated costs are known, which allows the total variability that may occur in the hospital cost to be estimated. Working in this way is a step forward compared with previous studies that, in spite of stressing the importance of considering economic factors in ERM implementation, did not indicate how to operationalize the measurement of the process in a cost-effective way. This model, through Modules 1 and 2, and by proposing the management of the hospital according to processes, enables proactive assessment of variability in the hospital finances, allowing anticipatory action of managers and thus favoring better economic performance. Risks are identified according to the criticality of processes, allowing the triggering of actions for prevention and ensuring greater knowledge about the future results of the health organization. Following this, the appetite for risk is stipulated, or the cost variation that the organization accepts is specified (Courson 2008; Kicklighter and Miller 2011). In this regard, the financial and strategic management of the hospital must be involved to determine how much value the hospital is willing to offer, assuming some risks while, on the other hand, preventing financial breakage due to the need to protect value. 3.2.4. Module 3: treatment and monitoring of risks Using the results of the technical analysis and the economic risk assessment, the hospital must analyze which risks have the greatest effect. The health organization should seek to mitigate hazards and exploit the opportunities present for each risk event (Damodaran 2009; Bromiley et al. 2014). When identifying critical risks from an economic and technical point of view, there is a need to develop plans for systematic monitoring. Those responsible for the risk stability of named critical risks I (technical) or II (economic) must be identified in order to maintain the expected performance of the hospital. When considering the procedural perspective and the identification of critical points and activities, the use of the concept of continuous improvement and the management of innovation and change are indicated in order to improve procedures and consequently reduce the criticality of risks. Finally, documents on ERM should be developed into an ERM book to educate the professionals involved and disseminate the ERM culture throughout the hospital. The cycle of phases described in the proposed model, as previously mentioned, follows the stages of COSO and ISO 31000 (2009). What is sought in this model is a precise matching of the system to the environment, which requires a differentiated approach to its management as well as a means for addressing the uncertainty associated with people’s lives. JOURNAL OF RISK RESEARCH 11 3.3. Case studies The case studies involved seven Brazilian health organizations (Figure 1). Personal visits were undertaken, and at each of these organizations the healthcare and corporate risk managers were interviewed; if such positions did not exist, the financial and administrative directors were interviewed instead. The interviews were complemented by examinations of systems, spreadsheets, and reports generated by the RM of the organizations, in order to understand how ERM was established. The interviews focused on understanding the positioning of ERM in hospitals and on interpreting how organizations structure ERM, considering the method’s main phases: contextualization and strategic positioning; identification and technical analysis; economic assessment; and treatment and monitoring. Downloaded by [Fundacao Getulio Vargas] at 05:13 09 January 2018 3.3.1. ERM positioning in hospitals The organizations with ERM in progress are A, C, and F. About one year ago, these hospitals invested in developing ERM practices, but none implemented a particular model or provided results for assessment. It is worth noting that all of these hospitals claimed to include initiation of ERM as part of their strategic plans. The motivation for this was improvement of the financial sustainability of the organizations, in line with the view of Porter (2010), according to which the economic success and the transmission of value within a health organization depend on ensuring the quality and safety of the healthcare service. Organizations E, B, and C took the view that ERM should be at the center of the hospital culture, emphasizing the importance that has been given to this task. On the basis that discussion of ERM in organizations should be based on strategic goals, it was possible to divide the hospitals into two groups depending on how ERM was conceived: either as a process oriented to both strategic and departmental management or as a process oriented to strategic management alone. In the first group, the models have a more qualitative character and less capacity for economic measurement; risks are identified from strategic planning, estimated in terms of economic impact and probability without detailed analysis, prioritized through matrices, and treated and monitored through action plans that involve the areas responsible for risks. In this format, ERM is allocated in parallel with the administrative management of the organization, it has the power to take strategic decisions, and it considers the processes and the interconnections among the departments of the corporate structure. This format was perceived and valued by organizations A and D. The view that the ERM should be oriented to both strategic and procedural management, according to the model proposed in this study, is based on studies by Gallagher et al. (2006); Celona, Driver, and Hall (2010), Haney, Church, and Cockerill (2013), and others (shown in Figure 3). This was seen in organizations B, C, E, F, and G. Among them, we can highlight C, F, and G. Private organizations emphasize the need to be managed by processes in order to allow the hospital to function more efficiently. It should be noted that this second form for structuring of ERM also includes the modular logic of the first format. There is a need to link with the strategic management, to tie risks to strategic objectives but manage them by processes. Therefore, as Figure 3 illustrates, ERM involves management across the corporate structure. It has autonomy and aims to identify risks at points of interconnection between processes as well as risks related to costly activities that can limit the generation of value within the organization. In exploring the operationalization of process-oriented ERM, the importance of viewing the health care process as central is emphasized, as illustrated in Figure 4. The interviewees from organizations B, C, E, and G stated that the business of the hospital is healthcare, although it receives support from other areas, such as legal, financial, and research, to deliver to the patients the best model of health service. This is how the business adds value and sustains itself economically. In this sense, the positioning of health care RM as an important pillar of ERM was validated in a unanimous vote; it is involved in ERM and, like other processes, must deliver results to managers and the strategic board. 12 A. P. B. DA SILVA ETGES ET AL. Downloaded by [Fundacao Getulio Vargas] at 05:13 09 January 2018 3.3.2. Relationship between ERM positioning and the proposed ERM model This subsection describes how institutions are positioned in relation to a few points in each phase of RM. Figure 6 illustrates the analysis performed, noting when the feature is present in the organization. It is noteworthy that only in hospitals with ERM based on processes can the healthcare RM be absorbed by ERM. However, the interviewees were unanimous in their opinion that this should always happen. This contradiction can be explained by the fact that in all the organizations, ERM starts from the healthcare RM, as it is set up and encouraged by the institutions that regulate the hospitals. Therefore, ERM starts after the establishment of a culture of ensuring the quality of care and safety of patients, which provides a basis for the specific characteristics and distinct objectives of the ERM. The positioning of the ERM structure should also be highlighted. In all hospitals, when ERM is established within the existing structure, it is related to the area of compliance and auditing, below the executive administration and motivated by the improvement of processes in a systemic approach. In the identification module and the technical analysis of risk module, the identification and dissemination by hospitals of an RM culture was investigated. The use of reputable guides on the subject and the recognition of the need for such a culture in the institutions that regulate the hospitals were also incorporated in the scope of this part of the study. Figure 7 illustrates this aspect of the study for the hospitals. Significantly, in practice, RM is still reactive. In spite of the interviewees who mentioned the importance of managing the organization with an orientation to value and to guaranteeing the expected performance, management actions still take place on a reactive basis. Again, this practice may have started originally with health care RM, which is based on notification of risk events that have already occurred. Only hospitals G and F in this study support healthcare RM proactively, while hospitals F and C can manage only corporate and business risks proactively. The connection with strategic planning deserves attention. This was brought up in the interviews as an essential factor in the evaluation of ERM. The importance of autonomy and the relationship between ERM and senior management were mentioned. Without a close relationship, the value given to ERM is easily lost in the routine of teams, which must be multidisciplinary in nature to meet the demands of ERM. For this bond to exist, it is necessary to establish risk owners who may be inspired through goals. The economic risk assessment module emphasizes the difficulty of knowing the real costs for all hospitals. In this regard, six of the interviewees mentioned the goal of implementing the ABC method in the upcoming years to improve the allocation and management of costs. Migration to ABC requires mapping of processes, which is a starting point for the establishment of management by processes. With regard to this aspect, only the hospitals that direct strategic ERM according to processes are able to assign variability to costs. The others consider the economic risk assessment only from the perspective of variable income. Contextualization of ERM Strategic and A departmental ERM D Strategic ERM by processes Autonomy and decision power Below the executive management and with CRO Related to Compliance and Auditing Motivate d by the improve ment of processes x x x x x x Includes the healthcare risk management Works in parallel with the healthcare Risk Management Valued by the institution x x C x x x x x x F x x x x x X G x x x x x B x x x x E x x x x Figure 6. Comparison of hospitals with the contextualization of risk. x x JOURNAL OF RISK RESEARCH ERM identification and technical analysis Strategic and departmental ERM Strategic by processes ERM Linked to Strategic planning Spread in the hospital culture Use of risk committees by the hospital and risk owners Encourag ed by JCI, Anvisa or OMS x x A x D x C x x x x Proactive Risk identification with the use of COSO Corrective Risk identification with the use of COSO 13 Involveme nt of multidisci plinary profession als x x x x x x x x F x x x x x x G x x x x x x x B x x x x x E x x x x Downloaded by [Fundacao Getulio Vargas] at 05:13 09 January 2018 Figure 7. Relation of hospitals with the technical risk analysis module. Another relevant point is the relationship between the economic assessment and the dissemination of ERM. Some interviewees (F, C, G, B and E) noticed that the ERM can only receive universal attention from everyone when its monetary parameters are widely known. Knowledge of economic variation by all those involved offers an incentive for the streamlining of processes and makes the hospital more efficient. Finally, the increase in financial transparency is mentioned as an objective for all hospitals when adopting ERM practices. The implementation of ERM models generates multiple strategic factors for those interested in contributing to the corporate governance of health organizations. With regard to this aspect, the treatment and monitoring of risk modules investigated how the hospitals achieved continuous improvement on the basis of the information generated by ERM. Figure 9 presents some specific aspects examined in each study. The wealth of information provided by the ERM must justify the action plans aimed at continuous improvement. Some hospitals mentioned the need to establish a budget (F, D, C, and G) and timescale (F, C, and G) on the basis of which these plans can be discussed at a strategic level and effectively carried out in future exercises. Considering the need for the administrative board’s approval to implement the projected actions, hospitals recommend the allocation of operational owners to risks and actions. The existence of multidisciplinary groups distributed throughout the hospital contributes to the feasibility of treatment actions and improvement. These groups commonly take the form of committees. Finally, the importance of education and dissemination of ERM culture in the organization’s routine was mentioned. For this reason, information about the improvements achieved and handouts explaining concepts and risk mapping on intranets and notice boards within easy reach of the relevant professionals were cited as illustrations of success in hospitals A, C, G, and B. Thus, the ERM cycle is completed, linking monitoring to strategic management and guiding decisions directed at continuous improvement of healthcare processes. Furthermore, the information generated can be translated into monetary values that can then be fed into analysis by interested parties and are also important for successful corporate governance in the hospital. 3.3.3. Review of the proposed model Through these case studies, a model of ERM for health care organizations was consolidated, reviewed by experts, and given a firm theoretical base. As shown in Figure 10, the ERM structure should be situated below strategic management, together with areas of compliance and auditing. This positioning in the hierarchical structure became clear after the interviews (Figure 6). In hospitals that are actively developing ERM, this governance model has made possible the autonomy necessary for ERM because it plays a role in managing operational information and provides competitive differentials for senior management. Downloaded by [Fundacao Getulio Vargas] at 05:13 09 January 2018 14 A. P. B. DA SILVA ETGES ET AL. In the economic assessment module, a number of issues were raised. The first refers to the inclusion of variable revenue, where the main information that managers want to receive is an estimate of the variability of the results in terms of the difference between revenues and costs. Therefore, the use of ABC was seen as making a positive contribution to the organization of health care by all respondents, who were aware that, in current cost center structures, there is a lack of precise information (Figure 8). Thus, study of the variability of costs was validated and encouraged by the case studies. To deliver results on variability, the variability of revenue was added to the costs. This approach was inspired by the practice in those hospitals in which ERM models related to both strategic and departmental management, because these identify risks associated with the revenue from the strategic objectives. The proposed model examines what has been sought and done by organizations to provide complete management with regard to a health organization’s enterprise risks. As products of economic assessments, the following indicators are delivered: the indicator cost at risk (CaR), which enables identification of the processes that most influence the variability of total costs; the revenue at risk (RaR), indicating the value placed on risk with regard to revenue; and, finally, the result, cash flow at risk (CFaR), which represents the organization’s cash flow under risk, defined as the difference between revenues and costs. For this reason, an evaluation was made of how much the working capital can either compromise or contribute to the result of an organization in a given period. This evaluation can be done using Monte Carlo simulation, which considers the information on risk variability in the cash flow. As additional information and relevant to strategic decision-making, at the end of the economic assessment, the calculated CFaR must be compared with the CFaR strategy defined by the organization, which represents the appetite for risk. The appetite for risk was emphasized in the case studies because it was considered the definitive strategic factor in the ERM results. The appetite for risk also has an impact on the value that ERM represents in the hospital. From the case studies, it was possible to identify that the organizations that take more risks are looking first for new methodologies that can help them be more competitive and can enhance their ability to deliver good patient experience. The way to assess risks, the level of detail, the proportion of employees that will be involved, the investment, and the risk education that will be incorporated into the organizational structure are all related to the hospital’s appetite for risk. When this is higher, the tendency is to believe in the value of ERM and to try to incorporate it into the hospital culture as rapidly and as sustainably as possible. If the appetite for risk is smaller, then, although managers still believe that it is important, they are waiting for some benchmarking and further inspiration to decide on how much can be invested and on the proportion of professionals’ involvement. At the same time, given that this topic is new for this business environment, it remains a challenge to find ERM in health organizations for benchmarking and to identify the main risks involved in health care, and this is a topic that deserves further exploration by researchers and health managers. ERM Economic Assessment Strategic and departmental ERM Strategic by processes ERM Difficulty of knowing the real costs Designed as a variability and revenue function A x x D x x C x F x x Essential for the existence and disseminati on of ERM x Rises the Encourages financial the processes transparency rationalization x x Linked to the strategic deployment and goals x x x x x x x x x x x x x x x x x x G x x B x x E x x Figure 8. Economic risk assessment. Essential for the value creation of the health organization x x x JOURNAL OF RISK RESEARCH Generates a budget for the Treatment and Monitoring of improvements ERM Strategic A and department D x al ERM Downloaded by [Fundacao Getulio Vargas] at 05:13 09 January 2018 Strategic by processes ERM Generates plans for the short, medium and long term Assign goals to committees and owners of risks Generates information for corporate governance Must be documented and allow easy access to all Present in educationa l and training programs Should feed strategic goals for the organizati on x x x x x x x x x x x x C x x x x F x x x x G x x x x x x B x x x E x x Figure 9. Treatment and monitoring of risk. Figure 10. Reviewed ERM model for health organizations. x x x x 15 Downloaded by [Fundacao Getulio Vargas] at 05:13 09 January 2018 16 A. P. B. DA SILVA ETGES ET AL. Once again, it is possible to see the connection between ERM and strategic management, which can take advantage of operational information from the model to better guide actions for improvement. Trotta et al. (2013) emphasized this by proposing the construction of a balanced scorecard (BSC) to evaluate the performance of educational programs in hospitals. The need to assess aspects that are subjective and also related to the quality of teaching and processes led these researchers to recommend the use of methodologies such as the BSC to evaluate performance focused toward continuous improvement of the educational system in the health sector. The budget complements the plans, which must be structured in such a way as to produce an appropriate design for the required actions. The final module concerns monitoring. In this regard, the interviews revealed the importance of integrating ERM, the operational managers involved in each process, and the strategic management. The definition of risk owners is essential so that the CRO only follows and monitors the implementation of the actions by the risk owners. The latter must be professionals with leadership roles in the processes for which the risks are being analyzed. To establish the relationship with control, there should be structured agreements between each process and ERM. Finally, ERM should be disseminated throughout the hospital culture. The case studies have reinforced this perception, since the interviewees mentioned the need to ensure that employees are wedded to the use of ERM. For this reason, training, documentation, and periodic dissemination of results should be established to help integrate the model into the organization. Is important to highlight that the model described here was constructed based on results described in the health literature and results of case studies and is oriented to application in health organizations, where tacit knowledge and the involvement of many professionals ensure successful care of patients. However, the main concepts and phases involved, the position of ERM in the organizational structure, and the techniques for implementation of ERM that are described here could also be applied to similar business environments in which a variety of professionals with high tacit knowledge are involved, such as universities and innovation companies. 3.3.4. Tools, techniques and methods applied to ERM As a second product of the case studies, the main tools, techniques, and methods that health organizations have used in their RM practices were examined. Figure 11 shows the tools, techniques, and methods used in each phase of the proposed ERM model, together with the phases suggested by ISO 31000. The operationalization of this conceptual model essentially concerns how, to what purpose, and by whom the techniques illustrated in Figure 11 are used. Analysis of Figure 11 also reveals how little the tools and methods of economic assessment are used. In spite of the organizations’ emphasis on the need for better management and sustainability of financial health, the metrics of control and management practices do not target this. When the interviewees were asked about this, their responses unanimously mentioned the difficulty of establishing economic parameters for the processes involved. With regard to motivational factors, among the seven case studies, only one showed no interest in being the subject of a study to validate the preliminary model through implementation in its corporate governance structures. The gains in financial transparency, procedural management, and visualization of flaws and opportunities in a proactive way were mentioned by managers of the other six hospitals involved. Nonetheless, among private organizations, a greater commitment and dedication to this issue can be noted in their declarations of the need for financial sustainability provided by effective processes in their structures. 4. Conclusions Motivated by the application of ERM to health environments, this study has proposed a conceptual model of ERM for health organizations. The current literature on the subject has been analyzed and managers of a number of hospitals in Brazil have been interviewed. The need for health institutions to seek value from quality assurance is clear from both the literature and the interviews, which justifies the proposed establishment of an ERM model that integrates the JOURNAL OF RISK RESEARCH Phases of ERM - ISO 31000 Phases Models ERM – health organizations Tools, techniques, and methods Downloaded by [Fundacao Getulio Vargas] at 05:13 09 January 2018 Brainstorming Enterprise Risk Strategic planning analysis Contextualization Management and Matrix Strengths, Weaknesses, Contextualization Opportunities and Threats Risk identification and analysis Identification and technical analysis A B C D E F G x x x x x x x x x x x x x x x x Matrix Severity Urgency and Trend x Brainstorming London Protocol x x x x Ishikawa x x x 5-why x Failure Mode and Effect Analysis (FMEA) Matrix rank Severity Levels Definition Root cause analysis x x x x x x x x x x x x x x x x x x x x x x x x x x x x What if Layer of Protection Analysis (LOPA) Process Mapping AS IS - TO BE Risk Assessment Treatment Monitoring Economic Assessment Treatment Monitoring Cost analysis in occasional events Revenue Analysis x x x Appetite for risk - acceptable variability Analysis of criticality from an estimation of financial impact Action Plans Definition Preparation of budget for the action plans Definition of Risk Owners in each process Risk Maps Metrics links to strategic goals and objectives Dissemination of results and education 17 x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x Figure 11. Techniques, tools and methods applied to operationalize the risk management. technical and economic management of health care processes. ERM is applied across the board and is subjected to the strategic positioning of the organization and with autonomy to manage on the basis of processes, providing informational support to corporate governance. Opportunities and gaps are identified proactively, and the multiple disciplines and inter-relations involved in the routine of health organizations are taken into account. The quest for economic sustainability and financial transparency is identified as an essential and motivational factor for investment in ERM. By contrast, the difficulty in establishing better economic parameters for the organization, again emphasizing the importance and appropriateness of the suggested model, is also noted. Although this study has a theoretical foundation, the proposed model is aimed at applications in real health care environments. In this context, the interest from six out of seven interviewees in the practical validation of the model through analysis and operationalization of its application in participating hospitals is gratifying. The main techniques for implementation of ERM in health care have been explored and documented in the framework of this study. On the basis of the results presented here, risk managers from different 18 A. P. B. DA SILVA ETGES ET AL. Downloaded by [Fundacao Getulio Vargas] at 05:13 09 January 2018 hospitals can look for appropriate techniques that enable them to conduct ERM in their organizational structures, depending on the level of detail and complexity that a hospital is ready to accept. In terms of application of the model, one thing that could be explored further with regard to complementing the implementation of ERM in a health environment is to define the main risks involved in this business market. The identification of enterprise risks is a starting point for RM. 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