Preliminary Risk Analysis : a french experience

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Preliminary Risk Analysis a french experience
Quality and Safety in Health Care

• Patrice BLONDEL, Centre Hospitalier de
  Saint-Denis
• Annick MACREZ, Hopital Bichat-Claude Bernard
  AP-HP
• Benjamin MEYER, CNEH

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Speakers

• Patrice BLONDEL
• Hygienist Physician
• CH Saint-Denis (93) 800 beds, 1300 profs.
• Ecole Centrale Paris
• Missions promote hygienic politics, training,
  studies
• AFGRIS President
• Annick MACREZ
• Risk manager since 2002
• Education Ecole Centrale Paris
• Hopital Bichat-Claude Bernard APHP- Paris
• Missions to animate and coordonate risk and
  quality management training and application of
  risk methodologies, meetings, monitoring of
  hospital accreditation
• AFGRIS Vice-president
• Benjamin MEYER
• Quality and risk management engineer, consultant
  at the CNEH
• Education Ecole Centrale Paris
• Missions training, project management, audit in
  french public and for-profit hospitals about
  quality and risk management
• Member of AFGRIS since 2007

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• AFGRIS French Risk Managers Association
• Founded in 2001
• 200 members hospitals and healthcare
  institutions (public/for-profit/non-profit
  general/specialized/teaching hospitals)
• Missions
• Experience feedback
• Methods and tools mutualisation
• Professional meetings and workshops
• Annual congress october (next one 10/16 17
  PARIS  Safety care Management )
• 2 think tanks nosocomial infection control
  risks mapping
• Linked to the Portuguese and Spanish RM
  Association
• http//www.afgris.asso.univ-paris7.fr/

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How can we reduce risk in health care ? A
methodand a tool Preliminary Risk Analysis
(PRA)(APR Analyse Préliminaire des Risques)
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Preliminary Risk Analysis

• Method developped in the 60s military and
  aeronautic fields
• An  a priori  method promoted by Ecole Centrale
  Paris
• Why using the PRA ?
• To prevent probability and severity of
  critical/adverse events during an healthcare
  process (ex. nursing, medication preparation,
  hospital waste)
• To give a comprehensive vision of a process by
  identifying and managing its risks
• How to build the PRA ?
• Identify all the potential risks in the process
  and their consequences
• Score and classify each of them
• Develop prevention measures and implement safety
  parameters  paramètres de sécurité 

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Concepts-definitions

• Chain of events? Root Cause Analysis

Daprès A. Desroches, École Centrale Paris-CNES
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5
Dangerous situation  Situation dangereuse 
ACCIDENT

?

?
4
6
Triggering Event  Évènement Amorce 
Damages  Conséquences 
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Concepts-definitions
Example
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Secondary Infection (legionnellose)
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1
Legionnella
Legionnella in room patient

?
2

?
Obstructed filter
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Immuno-depressed Patient (inhalation)
Death
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Concepts-definitions
Daprès A. Desroches, École Centrale Paris-CNES
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Contact Event
1
System/process
3
Dangerous situation
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Triggering Event
4
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Concepts-definitions

• Danger/threat
• The potential of damages on persons, goods or
  environment
• Substance gas, toxic product
• Object virus, equipment, tool
• Phenomenon fire, flood
• Process organisation failure, medical error,
  treatment error
• Dangerous situation
• state of the system facing a danger or a threat

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The PRAs methodology

• Describe the system/process
• Build the PRA
• List of all the dangers/threats (generic and
  specific)
• Dangerous situations mapping
• Building of scales severity, probability,
  criticality, effort
• Making of the PRA chain of events
• Analyse the results
• Determine and organise risk reducing actions
  Manage residual risks

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1.Building the PRA system/process

• Who are the actors ?
• What are the limits ?
• What are the steps ?
• What are the fonctions/missions ?

• Describe the system/process
• Build the PRA
• List of all the dangers/threats
• Dangerous situations mapping
• Building of scales
• PRA of the chain of events
• Present the results
• Risk reduction and residual risk

• Example
• Study made by Evelyne JOFFRION,
• consultante CNEH, 2007
• Patient care process in an emergency department
  (ED)

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Patient satisfaction rate
Room occupancy rate
Performances
Hospitalisation rate
Waiting time
Macro Process
Patient
care in the ED

Primary cares
Continuity in patient care
Admission

Medical care
Registration and Patient medical record
Nursing care
Orientation and transfer
Diagnostic
Continuity of care and patient release
Patient medical record closure
Exams rooms
Triage
Patient monitoring
Identification of the patient
Archiving
Elementary tasks
Care beds availability outside the hospital
Regulation
Patient Flow variability
Specific units availability
Human resources
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Micro process pattern (7 logical diagrams)
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2.1 Building the PRA list of dangers

• Describe the system/process
• Build the PRA
• List of all the dangers/threats
• Dangerous situations mapping
• Building of scales
• PRA of the chain of events
• Present the results
• Risk reduction and residual risk

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2.1 Building the PRA list of dangers
Example Patient care process in an emergency
department ? 4 generic dangers

• Describe the system/process
• Build the PRA
• List of all the dangers/threats
• Dangerous situations mapping
• Building of scales
• PRA of the chain of events
• Present the results
• Risk reduction and residual risk

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2.2 Building the PRA mapping

• Goals
• Determine feared/adverse events  évènements
  rédoutés  for each specific danger
• Crosscheck these feared/adverse events with each
  step of the studied process/system
• Score from the most vulnerable dangerous
  situations to less vulnerable
• 1 extremly vulnerable
• 2 vulnerable

• Describe the system/process
• Build the PRA
• List of all the dangers/threats
• Dangerous situations mapping
• Building of scales
• PRA of the chain of events
• Present the results
• Risk reduction and residual risk

dangerous situation mapping
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Ex 1 Dangerous situations mapping
subsystem
Step 1
Step
Dangerous situations
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Ex. 2 Dangerous situation mapping
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(No Transcript)
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Ex. 3 Dangeroussituation mappingPatient care
in the ED
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Step I patient admission
Step
Transfer and settle patient
Open patient record
Patient Reception
subsystem
Complete or create electronic patient record
Complete or create paper Patient record
Complete or create paper Patient record
Look after anterior record
Identify patient reasons
Identify nursing needs
Check patient identity
Decid patient transfer
Monitoring patient
Transfer patient
Prepare stetcher
Settle patient
GENERIC DANGERS
SPECIFIC DANGERS
CRITICAL EVENTS
Health complication
2
1
1
Non detection of a criticial behavior
2
1
1
Patient
No identification of patient or his need
2
2
2
1
Aggresive behavior / violence
2
1
1
HUMAN FACTORS
STAFF MEMBER
No staff involvment
2
2
Individual behavior
Bad hard skills
2
2
2
Bad relationships within the team
2
2
2
2
2
1
STAFF MEMBER
Bad relationships with the other hospital teams
2
2
2
Interaction
Soft skills absence
2
2
1
2
MANAGEMENT
INADAPTED HUMAN RESOURCES
Not enough
2
1
2
2
1
No tutoring
2
2
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2.3 Building the PRA scales

• Team project must build their own
• Scale of severity damages
• Scale of probability (occurency)
• Criticity matrix (risk acceptability)
• Scale action level (effort)

• Describe the system/process
• Build the PRA
• List of all the dangers/threats
• Dangerous situations mapping
• Building of scales
• PRA of the chain of events
• Present the results
• Risk reduction and residual risk

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Severity Scale / Echelle Gravité G
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Probability Scale / Echelle probabilité P
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Criticity matrix
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Example in Patient care in the ED
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Performance
Safety
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2.4 PRA of chain of events

• Goals
• Analyse each dangerous situation and find
• what are the contact event ?
• what are the triggering event ?
• are treatment yet existing ?
• Score each chain of event (P G C)
• For C2 and C3 determine risk reducing actions
  with their efforts (protection/prevention)
• Score again each residual C2 and preview safety
  parameters ( paramètres de sécurité ).
• This is the residual risk management.

• Describe the system/process
• Build the PRA
• List of all the dangers/threats
• Dangerous situations mapping
• Building of scales
• PRA of the chain of events
• Present the results
• Risk reduction and residual risk

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2.4 score the initial risk
Initial risk
Feared event consequences (severity scale)
Risk assessment
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Example
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2.4 score the residual risk
Initial risks
Residual risks
Resolution actions (prevention/protection)
Risk measurement
Assurance of resolution action
Effort
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Example
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2.4 PRA results
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3.Global Results

• Statistic treatment of the risk assessment
• Dangerous situation mapping (ED process)

1
2

• Describe the system/process
• Build the PRA
• List of all the dangers/threats
• Dangerous situations mapping
• Building of scales
• PRA of the chain of events
• Present the results
• Risk reduction and residual risk

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3.Global Results

• PRA Results by specific dangers

1
2
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3.Global Results

• Criticity Repartition by dangers

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3.Global Results

• Result of critical steps for Logistic danger

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3.Global Results

• Result of critical steps for Human danger

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Farmer Diagram
3. Results of ED Process
Inacceptable
Acceptable
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Kiviat Diagram
3. Results of ED Process
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4. Risk reduction residual risk

• Action Plans (CHANGE)
• Training (good practice, sandards and regulation)
• Writing nursing transmissions during cares
• Improvment of patient waiting conditions (room,
  decoration, equipment, delay, triage)
• Creation of an identity vigilance unit managed by
  a physician coordinator
• Implementation of electronic patient record
• Writing organisational procedures (use of patient
  rooms patient transfer)
• Residual risk Management (FOLLOW)
• Creation of a safety parameters listing
  containing indicators, evaluation measures
  (audit, studies, Assessment of Professional
  Practice)

• Describe the system/process
• Build the PRA
• List of all the dangers/threats
• Dangerous situations mapping
• Building of scales
• PRA of the chain of events
• Present the results
• Risk reduction and residual risk

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4. ED process

• 6 major risks identified
• Lack of patient monitoring
• Lack of professional pratice writing
• Care delays
• Nursing cares needs identification failures
• Patient violence
• 38 action plans
• Management (13)
• Professional practice (12)
• Equipement/resources management (8)
• Management process and traceability (3)
• Training/information (2)
• 13 safety parameters listing
• Examples
• Care delay between patient admission and patient
  triage

• Describe the system/process
• Build the PRA
• List of all the dangers/threats
• Dangerous situations mapping
• Building of scales
• PRA of the chain of events
• Present the results
• Risk reduction and residual risk

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Conclusion

• PRA
• comprehensive risks analysis method
• technical tool of identification, priorization
  and risks handling
• PRA Strenghts
• A communicative, interactive and dynamic time
  for a team/unit/establishment
• Involve the whole staff in a dynamic improvment
  with realistic action plans
• True decision making tool for managers

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Conclusion

• PRA Weaknesses
• Training needed before using it (score, scales,
  method) ? time-consuming
• Technical method with a specific vocabulary which
  forces users to translate or adapt the PRA to the
  professionals
• Assessment professional culture is needed. Teams
  must take time to anticipate and think about
  preventive improvment actions
• Success Keys Factors
• Designate a trained project manager supported by
  top management
• Involvment of the team project (concerned
  professionals active in the process)
• Most of all adapt the PRA to the level and goals
  of the team project

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• Thank you very much
• for your attention

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Contact

• Patrice BLONDEL
• pabl_at_club-internet.fr
• Annick MACREZ
• annick.macrez_at_bch.aph.fr
• Benjamin MEYER
• benjamin.meyer_at_cneh.fr