Niamh Mc Goldrick Risk Manager HSE Dublin Mid-Leinster

1. Risk Management Niamh Mc Goldrick Risk Manager HSE Dublin Mid-Leinster

2. Outline of Presentation • Introduction to Risk Management • History and Drivers of Risk Management • Overview of Risk Management within HSE • Applications for Private Nursing Homes

3. Introduction to Risk Management

4. Introduction Definition The culture, processes and structures that are directed towards realizing potential opportunities whilst managing adverse effects Aim is to eliminate hazards or reduce associated risks with a consequent improvement in patient, staff and visitor safety, and service quality.

5. What is Risk Management? Work out what can go wrong and plan for the eventuality….Spot a problem in the making and do something about it in advance Upmarket version of Murphy’s Law with a plan of action!!!

6. Why Risk Management is Important

7. History and Drivers of Risk Management

8. History and Drivers Patient safety incidents cost the NHS an estimated £2 billion a year in extra bed days, In addition hospital acquired infections add a further £1 billion to these costs. The cost of settled clinical negligence claims in 2003-04 was £423 million and provisions for outstanding clinical negligence claims as at end of 2003-04 were in excess of £2 billion.

9. History and Drivers A retrospective study of patient records in two English hospitals found 10.8 per cent of patients experienced an adverse incident; Half (5.2 per cent) were judged to have been preventable. These adverse incidents caused permanent impairment in 6 per cent and contributed to death in 8 per cent of cases.

10. High Profile Cases • Lourdes Inquiry • Leas Cross • Portlaoise Breast Cancer Services • Individual cases of service failure e.g. Rebecca O’Malley, Francis Sheridan, Kidney Operation - Crumlin etc

11. Overview of Risk Management within HSE

12. Risk management within HSE Services • Risk Management Systems consist of two Parts • - Proactive Risk Management • - ReactiveRisk Management

13. Proactive Risk Management • Risk Registers • Hazard identification • Risk assessment • Control development and implementation • Evaluation and monitoring

14. Risk Registers : what are they? A register of risks which threaten the organisation, its staff and service users The risks are rated and intended actions recorded

15. Its evolutionary ……

16. Risk Management Standard AS/NZS 4360:2004 Risk Register Monitor and review Establish the context Communicate and consult Identify risks Analyse the risks Risk Assessment Evaluate the risks Treat the risks

17. Sources of Risk Information

18. Describing Risk – ICC Approach • Risk is often viewed as negative implying the possibility of • adverse impactsbut positive risk taking can allow for the • achievement of potential if the risks are accurately • identified and managed. • Describe the potential Impact if the risk were to materialise. • Describe the Causal Factors that could result in the risk materialising. • 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.)

19. Risk Assessment Almost Certain ? Likely ? Possible ? Unlikely ? Remote ? Extreme ? Major ? Moderate ? Minor ? Negligible ? Impact Likelihood

20. Rating the Impact

21. Likelihood Scoring

22. Likelihood and Impact Likelihood: Likely Impact: Extreme

23. HSE Risk Matrix

24. Control Development and Implementation 1. Base on risk assessment 2. Agree control 3. Implement Controls 4. Assign responsibility 5. Agree time frame 6. Review

26. Points to Consider in the Analysis • What control measures are already in place (what are we doing about it?) • How effective are the control measures (is it working to reduce the risk?) • Is there a ‘risk treatment plan’ in existence? • How well is the implementation going • Is it being monitored?

27. Reactive Risk Management Incident Reporting and Incident Review / Investigation

28. Incident Reporting Incident Any event that causes or has the potential to cause harm Near Miss An event that could have resulted in an incident, but did not, either by chance or through timely intervention

29. Reviewing or investigating incidents: the aim of the Investigation • The key result should be to prevent a recurrence of the same incident/complaint. • Fact finding: • What happened? • What were the systems failures? • What should be done to prevent recurrence? • Can prevent simular Incident from ever happening • Can act as an early warning system • Helps to prioritize resources

30. Key Principles of Investigation: What Happened The Sharp Edge of the Wedge It is always easy to identify a particular action or omission as the immediate cause of an incident However it is usually a series of events that ultimately lead to an adverse outcome

31. 15% 98% 85% 2% Causes of Incident Individual Failure Organisational Failure Remedial Action

32. Accident Causation

33. Investigation Strategy - Gather information - Search for & establish facts - Isolate essential contributing factors - Find systems failures - Determine corrective actions - Implement corrective actions

34. Contributory Factors (1) PATIENT (2) TASK (3) INDIVIDUAL (staff) (4) TEAM (5) WORK ENVIRONMENT (6) ORGANISATIONAL & MANAGEMENT (7) INSTITUTIONAL CONTEXT

35. Applications Applications for Private Nursing Homes

36. Applications • - Risk Registers • Incident Reporting • Incident Investigation

37. Thank You Questions?