INTRODUCTION TO RISK MANAGEMENT IN HEALTHCARE

1. INTRODUCTION TO RISK MANAGEMENT IN HEALTHCARE Stuart Emslie

2. What is risk?

8. Risk management processAS/NZS 4360:2004 - Risk management Establish Context Identify Risks Analyse Risks RISK ASSESSMENT Monitor and review Communicate and Consult Evaluate Risks Treat Risks

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

11. 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

12. 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

17. Risk perception

18. Risk perception

19. Risk perception

21. 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.

22. 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’ Conferences, Seminars, etc. External stakeholder consultation EXTERNAL Inquiry reports Books

23. 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’ Conferences, Seminars, etc. External stakeholder consultation EXTERNAL Inquiry reports Books

24. 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 Integrity risk Human resource risk Patient and family rights Information & Consent Confidentiality Security Satisfaction/complaints 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 Performance 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 Misappropriation 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 Infectious Disease Insects and rodents Contractor Facilities / Equipment Capacity Availability Breakdown / Interruption Utilisation Performance Efficiency / 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

29. Daily Telegraph 20 August 2002

32. 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

33. 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. • 1960’s – NASA and US firms • 1990’s US healthcare • ‘Product’ design • Process design or re-engineering • ‘Proactive hazard/risk analysis’

34. FMEA Steps… • Select a process (topic) • Assemble your team • Describe the process steps

36. 2a 4a 1 3a 5 2b 3c 3b 4b

37. FMEA Steps… • Select a process (topic) • Assemble your team • Describe the process steps • Identify the ways in which each process step can fail (failure modes – e.g. drug maladministration; performing wrong site surgery; clinical mis-diagnosis; etc.) • Identify the root cause(s) of failure (Why?) • Identify the most likely effect(s) (i.e. consequence of failure) of each identified failure mode • Assess risk associated with each failure mode (consequence and likelihood – from risk matrix) • Identify additional controls required (actions to effect improvement) • Implement additional controls • Test process improvements

40. Risk Management Experience Sharing from KWC Dr Joseph Lui CCC (Risk Management), KWC

41. Medical Stream Clinicians • Premature discharge of patients leading to death or poor outcome due to bed shortage

42. 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

43. 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

44. 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

45. 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

46. Operational risks identified by Clusters for 2004/05 • Infection control • OSH • Medication error • Resuscitation • Transfer of patients • Documentation of medical records, including consent • Patient identification (during consultation, blood sampling, operation & for investigations) • Wrong site surgery • Proper use of infusion pumps • Medico-legal risk (open disclosure)

47. Strategic Vs Operational risk? Strategic Operational

48. 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

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

50. 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