Surplus Safety: A New Way to Understand Risk

On September 12-13, I had the pleasure of participating in a national symposium hosted by the Erickson School at the University of Maryland to explore the topic of surplus safety. This gathering, made possible through funding from the Rothschild Foundation, brought together key stakeholders to explore important perspectives on this topic.

So what exactly is “surplus safety”? According to Dr. Judah Ronch, PhD, dean of the Erickson School, there are three primary definitions to consider:

1. Risk: concerns the deviation of a result from the benchmark
2. Downside risk: describes the probability of an outcome that is worse than the benchmark.
3. Upside risk: describes the probability of an outcome that is better than the benchmark.

I was first introduced to the concept of surplus safety at a Pioneer Network conference where Dr. Ronch and Dr. Bill Thomas shared their thinking on this topic, which they have been working on together. These two experts in aging said:

In the current concept of risk, only the downside risk — in which harm may come to elders if they are allowed to attempt certain activities such as getting out of bed — are considered, leading to restrictive policies in care settings. Many safety measures, such as bed alarms or dining practices, are designed with downside risk management in mind. The result of these downside-risk-only policies has been called Surplus Safety. There is a strong need to look at upside risk management in addition to the traditional focus on managing downside risk.

This framework offers an exciting new way to consider supporting elders to achieve their optimal level of health and wellbeing as required by OBRA regulations. Consider physical restraints. It used to be a standard practice to physically restrain, or “tie,” elders in chairs or beds, with the intent of keeping them safe from falling. Over time, we learned that these restraints were actually causing more harm than good. They cause decline, loss of ambulation, pressure ulcers, incontinence, and loss of dignity, to name a few negative effects.

In that example, restraints were used solely to manage the downside risk: that is, to manage or attempt to eliminate injury from falls. Unfortunately, the use of the restraints virtually eliminated any opportunity for the elder to experience the benefits associated with the upside of risk. In this case, the upside includes such things as the ability to ambulate, the ability to remain continent, the ability to sustain independence, good circulation, etc.

The objectives of the symposium were to:

• Identify strategies to promote an evaluation of the full spectrum of risk and related outcomes in long-term care, both positive and negative.
• Reframe a current concept of safety that is exclusively about downside risk management, which is negative and potentially harmful to an elder’s quality of life.
• Identify the specific sets of national regulations, guidelines, standards and/or legal statutes/practices which need to be addressed in order to change the current regulatory environment from its near-exclusive focus on managing downside risk.
• Identify appropriate stakeholder groups to work with us to make the necessary changes.

Surplus safety offers us a new and thoughtful way to understand safety and risk. There is no question that the current OBRA regulations, interpretive guidelines, and scope and severity scale heavily influence our current obsession with managing downside risk. Through a multi-stakeholder approach, infused with the expertise each stakeholder brings, I feel hopeful that we will move toward a vastly improved approach to risk and safety in long-term care.

I look forward to continuing to support the dialogue, learning, and policy changes that will need to happen to make it possible for elders to enjoy the benefits of upside risk!

By Susan R. Misiorski, Director of PHI Coaching and Consulting Services