INTRODUCTION TO RISK MANAGEMENT IN HEALTHCARE

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INTRODUCTION TO RISK MANAGEMENT IN HEALTHCARE
Stuart Emslie
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What is risk?
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Risk management processAS/NZS 43602004 - Risk
management
Establish Context
Identify Risks
Analyse Risks
RISK ASSESSMENT
Communicate and Consult
Monitor and review
Evaluate Risks
Treat Risks
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HORMC
Aggregation
Cluster
Filtering/ Escalation
Aggregation
Information
Resources/Action/Improvement
Hospital
Aggregation
Depts.
Front line
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RISK QUANTIFICATION MATRIX
Consequence
Insignificant 1
Minor 2
Moderate 3
Major 4
Extreme 5
Likelihood
Almost certain - 5
Likely - 4
Possible - 3
Unlikely - 2
Remote - 1
RISK
Low
Medium
High
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RISK QUANTIFICATION MATRIX
Consequence
Insignificant 1
Minor 2
Moderate 3
Major 4
Extreme 5
Likelihood
5
10
15
20
25
Almost certain - 5
4
8
12
16
20
Likely - 4
3
6
9
12
15
Possible - 3
2
4
6
8
10
Unlikely - 2
1
2
3
4
5
Remote - 1
RISK
Low
Medium
High
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Risk perception
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Risk perception
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Risk perception
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The healthcare risk universe
Environment
Patient care and safety
Financial
Occupational safety health
Legal
Human Resource
Physical resources
IT
Integrity
Information for decision making
etc.
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Some common sources of information used to
populate a healthcare risk register
INTERNAL
Internal audits and inspections
Patient adverse incidents
Patient consultation
Staff consultation
General risk assessments
Staff adverse incidents
Other adverse incidents
Suggestion scheme
Complaints
Specialist risk assessments
Facilitated workshops
Claims
Risk Register
PROACTIVE
REACTIVE
Root cause analyses
FMEA
External audits, reviews etc.
Hazard warnings
Safety alerts
Accreditation standards
Benchmarking
Coroners reports
Incidents etc. occurring elsewhere
External stakeholder consultation
Conferences, Seminars, etc.
EXTERNAL
Inquiry reports
Books
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Some common sources of information used to
populate a healthcare risk register
INTERNAL
Internal audits and inspections
Patient adverse incidents
Patient consultation
Staff consultation
General risk assessments
Staff adverse incidents
Other adverse incidents
Suggestion scheme
Complaints
Specialist risk assessments
Facilitated workshops
Claims
Risk Register
PROACTIVE
REACTIVE
Root cause analyses
FMEA
External audits, reviews etc.
Hazard warnings
Accreditation standards
Safety alerts
Benchmarking
Coroners reports
Incidents etc. occurring elsewhere
External stakeholder consultation
Conferences, Seminars, etc.
EXTERNAL
Inquiry reports
Books
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A common risk language
Environment risk
Government funding / policy . Laws and
Regulations . Economy . Demographics .
Technology. Market share . Other providers .
Customer needs and expectations . Public
awareness . Suppliers . External disasters .
External relations . Labour market
Process risk
Empowerment risk
Purpose . Structure . Leadership . Accountability
. Authority . Boundary . Compliance . Resource
allocation . Communication . Rate of change .
Performance measurement
Patient Care and Safety Risk
Human resource risk
Integrity risk
Patient and family rights Information
Consent Confidentiality Security Satisfaction/comp
laints Privacy Participation Comfort /
Convenience Access and continuity Availability /
Access Appropriateness Timeliness /
delay Continuity Over / under utilisation Volume
/ capacity Interfaces Assessment of
patients Adequacy of assessment Error (laboratory
/ reporting / interpretation) Appropriateness
Fraud Corruption Unauthorised use Unethical
practice Illegal acts Reputation Conflict of
interest
Staff capabilities and education Qualifications
/registration Proficiency Professional
development Maintaining a quality workforce Loss
of key staff Turnover Recruitment
Remuneration Industrial relations Workforce
planning
Care planning Care of patients Standard of
care/Bolam Competence Safety Care/Treatment
accident Prescribing accident Drug admin.
accident Efficacy Nosocomial Infection Clinical
trial / new treatment Patient /family
Educ. Clear Communication Patient
compliance Other Documentation
/ recording Service development
Legal risk
Regulatory compliance Litigation Contractual
Performance Productivity Efficiency Teamwork Perf
ormance Incentives Coverage / skill-mix Absence
/ attendance Staff morale Occupational safety
and health Safe systems of work Instructions /
training /supervision Security /
Violence Stress Hazardous exposure
Financial risk
Cash flow Budget control Cash collection Bad
debts Payment Investment Insurance Currency Misapp
ropriation Value for money
Physical resource risk
Supplies Defective products Product /service
failure Economy Supplier Stock-out Obsolescence
/shrinkage Health and safety Act of God
Buildings / Equipment / Grounds Fire / Explosion
/Flooding Hazardous substances/ Radiation Medical
equipment and supplies Food hygiene Security Infec
tious Disease Insects and rodents Contractor
Facilities / Equipment Capacity Availability Break
down / Interruption Utilisation Performance Effici
ency / Economy Compatibility Misuse /
Impairment Loss Operator Technology Utilities
failure Environment Environmental Impact
Conservation Waste
IT risk
System failure / Availability Technology Integrity
Unauth. access/use Loss of data Cost / time
overruns User needs not met
Information for decision making risk
Clinical . Operational . Financial . Strategic
P.15
Access . Availability . Accuracy . Timeliness .
Completeness . Usability . Utilisation
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Daily Telegraph 20 August 2002
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Failure Mode and Effects Analysis (in the
context of wider risk management and quality
improvement activity)

• FMEA
• FMECA
• HFMEATM
• SFMEA
• Failure Mode and Effect Analysis
• Failure Modes and Effects Analysis
• Failure Modes, Effects and Criticality Analysis

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FMEA history and application..

• first developed by the U.S. military in 1949 to
  evaluate the reliability of systems and equipment
  and the consequences of their failure.
• 1960s NASA and US firms
• 1990s US healthcare
• Product design
• Process design or re-engineering
• Proactive hazard/risk analysis

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FMEA Steps

1. Select a process (topic)
2. Assemble your team
3. Describe the process steps

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2a
4a
1
5
3a
2b
3c
4b
3b
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FMEA Steps

1. Select a process (topic)
2. Assemble your team
3. Describe the process steps
4. Identify the ways in which each process step can
   fail (failure modes e.g. drug
   maladministration performing wrong site surgery
   clinical mis-diagnosis etc.)
5. Identify the root cause(s) of failure (Why?)
6. Identify the most likely effect(s) (i.e.
   consequence of failure) of each identified
   failure mode
7. Assess risk associated with each failure mode
   (consequence and likelihood from risk matrix)
8. Identify additional controls required (actions to
   effect improvement)
9. Implement additional controls
10. Test process improvements

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Risk Management Experience Sharing from KWC

• Dr Joseph Lui
• CCC (Risk Management), KWC

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Medical Stream Clinicians

• Premature discharge of patients leading to death
  or poor outcome due to bed shortage

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Surgeons

• Delay or missed diagnosis/treatment resulting in
  increased mortality morbidity
• Risk of harming patients associated with invasive
  procedures
• Long waiting lists resulting in increased
  morbidity complaints
• Medication error
• Harm to staff due to violent patients

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Anaesthetists (1)

• Risk associated with equipment failure
• Risk associated with inadequate supervision of
  trainees
• Risk of giving the wrong drug to patient due to
  mislabeling
• Risk of overdosing patient due to malfunctioning
  of PCA
• Risk of making unsound judgement after long hours
  of duty

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Anaesthetists (2)

• Risk of malfunctioning of resuscitation equipment
  due to lack of maintenance
• Risk of improper use of Level I rapid transfuser
  in emergency due to inadequate training
• Risk of staff injury and equipment failure due to
  cables power cords lying on the OT floor
• Risk of injury to staff
• Bumping of head against theatre light
• Slip fall after mopping of OR

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Radiology/Pathology

• Risk associated with missing specimen or X ray
  films
• Patient Identification
• Medication, Xray Path reports
• Miss labeling of specimen
• Risk associated with Equipment Maintenance
  Validation
• Risk associated with Manual handling
• Risk associated with chemical waste handling
• Risk associated with understaffing

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Operational risks identified by Clusters for
2004/05

1. Infection control
2. OSH
3. Medication error
4. Resuscitation
5. Transfer of patients
6. Documentation of medical records, including
   consent
7. Patient identification (during consultation,
   blood sampling, operation for investigations)
8. Wrong site surgery
9. Proper use of infusion pumps
10. Medico-legal risk (open disclosure)

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Strategic Vs Operational risk?
Strategic
Operational
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Strategic challenges for Hospital Authority
2004/05

• SARS and review reports
• Resources availability
• Funding
• Beds
• Staffing
• People capacity
• Service expansion/demand
• New technology
• Evolution of cluster management

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HORMC
Aggregation
Cluster
Filtering/ Escalation
Aggregation
Information
Resources/Action/Improvement
Hospital
Aggregation
Depts.
Front line
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RISK QUANTIFICATION MATRIX
Consequence
Insignificant 1
Minor 2
Moderate 3
Major 4
Extreme 5
Likelihood
Almost certain - 5
Likely - 4
Possible - 3
Unlikely - 2
Remote - 1
RISK
Low
Medium
High
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1. Risk type
2. Risk description
3. Existing controls
4. Initial consequences
5. Initial likelihood
6. Additional controls
7. Residual consequences
8. Residual likelihood
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Describing risk the 3 Cs

1. Risk is inherently negative, implying the
   possibility of adverse consequences. Describe the
   potential consequences if the risk were to
   materialise
2. Describe the causal factors that could make the
   risk materialise
3. Ensure that the context of the risk is clear,
   e.g. is the risk target well defined (e.g.
   staff, patient, department, hospital, etc.) and
   is the nature of the risk clear (e.g.
   financial, safety, physical loss, perception,
   etc.)

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Which of the following are adequate descriptions
of risk?

• Risk to patients due to errors and unsafe
  clinical practice caused by reduced skill base
  and competence of junior and middle grade medical
  staff
• Needlestick injury
• OSH
• Reduced staff retention and increased sickness
  absence due to reduction in morale caused by
  increased workload, pressure and stress to
  achieve targets
• Inadequate patient transfer
• Budget overrun and financial deficit due to cost
  of introducing new technologies/medicines as
  required by NICE guidance
• Medication error
• Loss of use of ICU due to fire

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1. Risk type
Patient care and safety.
2. Risk description
Patient falling off a trolley causing harm to
patient or a member of staff.
3. Existing controls
Occasional maintenance work carried out, but very
inadequate. AIRS figures show that this type of
incident happens at least once per week. There
Have been some reports of staff injury when a
trolley breaks down.
4. Initial consequences
5. Initial likelihood
6. Additional controls
7. Residual consequences
8. Residual likelihood
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RISK QUANTIFICATION MATRIX
Consequence
Insignificant 1
Minor 2
Moderate 3
Major 4
Extreme 5
Likelihood
Almost certain - 5
Likely - 4
Possible - 3
Unlikely - 2
Remote - 1
RISK
Low
Medium
High
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1. Risk type
Patient care and safety.
2. Risk description
Patient falling off a trolley causing harm to
patient or a member of staff.
3. Existing controls
Occasional maintenance work carried out, but very
inadequate. AIRS figures show that this type of
incident happens at least once per week. There
Have been some reports of staff injury when a
trolley breaks down.
4. Initial consequences
Major (4)
5. Initial likelihood
Almost certain (5)
6. Additional controls
Need a proper system of planned maintenance
carried out on the trolleys to ensure they dont
break down and accidentally harm patients
or staff.
7. Residual consequences
Major (4)
8. Residual likelihood
Unlikely (2)
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GROUP WORK - Brainstorming risks..what are the
issues or concerns that keep you awake at night?

1. Think about yourself and your colleagues list 3
   issues or concerns you have at work.
2. Now think about patients list 3 issues or
   concerns you might have in relation to the safety
   or quality of care provided to patients in your
   department, hospital etc.
3. Finally, think about your organisation list 3
   issues or concerns..

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HORMC
Aggregation
Cluster
Filtering/ Escalation
Aggregation
Information
Resources/Action/Improvement
Hospital
Aggregation
Depts.
Front line