Risk Associated with the Cancer Patient’s Journey

1. Risk Associated with the Cancer Patient’s Journey RISK MANAGEMENT MODULE MSc Medical Informatics Friday 12th March 2004 Bala Sridhar

2. Presentation Overview • Background • Risk Management • Risks in “The Cancer Journey” • General Issues

3. Patient - Professional Partnership Risk Management Effectiveness Communication Effectiveness Resource Effectiveness Strategic Effectiveness Patient Experiences Clinical Effectiveness Learning Effectiveness Systems Awareness Communi-cation Teamwork Ownership Leadership Strategic Fit

4. What is Risk? • Anything that poses a threat to the achievement of the Trust’s objectives, this may include damage to the reputation of the Trust which could undermine stakeholder confidence.

5. What is Risk Management? • Risk Management is having in place a corporate and systematic process for evaluating and managing risks. • Corporate Governance including Clinical, Research, Organisational and Financial Governance.

6. Why Risk Management • Risk management is not a negative concept “It is not about interfering with clinical freedom, but should be used to pinpoint deficiencies in clinical systems which needs to be improved” “We manage risks everyday, but largely on an ad-hoc basis, in an uncoordinated way”

7. RM- Why Do We Need It? • The key aim of RM is reducing the cost of risk; By-product of that is a safer. • Practices. • System of work. • Premises. • Greater staff awareness of danger and liability. • The key aim of any quality management system is conducting business to the best possible standard and providing the highest possible quality of care. • Risk management and quality of care have the same objective.

8. Role of Risk Management • Risk management is a proactive approach: • Address the various activities • Identifies the risks that exist • Assesses those risks for potential frequency and severity • Eliminates the risk that can be eliminated • Reduces the effect of those that cannot be eliminated

9. Definitions • Risk • Risk management • Adverse incident: • Error. • Near miss. • Safety

10. Principles of Risk Management • Risk identification • Risk analysis • Risk control • Risk funding

11. Risk Identification • What could go wrong? • How could it happen? • What would be the effect?

12. Risk Analysis • How often are they likely to happen? • How much are they likely to cost? • How severe would the effect be?

13. Risk Control • How can they be eliminated? • How can they be avoided? • How can they be made less likely? • How can they be made less costly?

14. Risk Funding • Full commercial insurance - transferring the risk • commercial insurance with an “excess”- sharing the risk • self insurance - retaining the risk

15. What is an acceptable risk • Acceptable risks are those assessed as being highly unlikely or having only consequences of minor loss, injury or breach of regulation which would require a disproportionate level of financial or manpower resources to further reduce the risk.

16. Uncontrollable Risk • An uncontrolled risk is an identified risk for which suitable and sufficient control measures have not been implemented or the risk has not been categorised as acceptable.

17. Clinical Risk Management • In general the risk of errors and adverse events occurring with the health system can be divided into the following five areas: • The risk of individual clinical incompetence or malpractice • The risk of systems failure • Risks imposed by cost constraints • Patients' perception of risk • Risks inherent in clinical procedures

18. Event Ensure situation is made safe Notify Ward/Departmental Manager or (out of hours) Nurse on call Determine priority of incident Complete Incident Report Form by end of same working day If incident is priority 5, initiate the Major Clinical Incident Policy immediately. If incident is priority 4, consider initiating the Major Clinical Incident Policy Give Incident Report Form to Ward/Departmental Manager who must ensure form is sent to the Operations Support Manager within 48 hours of the event Operations Support Manager logs all incidents onto DATIX and advises appropriate external bodies about the incident Category of incident reviewed by Senior Manager Incident Report form reviewed by Senior Manager and, if appropriate, an investigation is initiated. The results of this investigation, and action taken, must be reported within 1 month of the event Finalised Incident Report Form returned to Operations Support Manager Results reported to Clinical Governance Committee If necessary, further action initiated and reviewed by the Clinical Governance Committee Quarterly reports made to the Clinical and Corporate Governance Committee and Trust Board – NB Incidents classified as a major event will be reported on a case by case basis

19. RISK MANAGEMENT STRUCTURE COMMITTEE & INDIVIDUAL ACCOUNTABILITIES TRUST BOARD Chief Executive Medical Director, Director of Nursing Clinical Governance Clinical Risk Management Audit Committee Non Executive Chair Director of Finance & Performance Controls Assurance Clinical & Corporate Governance Committee Risk Management Forum Trust Risk Advisor Clinical Governance Committee Controls Assurance RESEARCH GOVERNANCE Via RESEARCH MANAGEMENT BOARD Organisational Controls Manager ADNS Governance Operations Support Manager / Health & Safety, MDA Link, Incident Reporting Quality & Audit Manager (Complaints) (PALS) Risk Management Structure

20. The Cancer Patient Journey Radio- therapy Cancer A Patient Symptoms GP Assessment Referral to Secondary Care Diagnosis Staging Surgery Follow -up Palliative Care Chemo- therapy Cancer B

21. Patient Symptoms • Patients usually present to their general practitioner with symptoms such as • cough, chest pain, haemoptosis (coughing of blood), shortness of breath, symptoms of hypercalcaemia, malaise and anorexia. • Risks: • Delay in seeking medical help. • Time lag from patient noticing symptom to seeking medical advise is approximately 3 months. Radio- therapy Patient Symptoms GP Assess Refer to 2ry Diagnosis Stage Surgery Follow -up Palliative Care Chemo- therapy

22. GP Assessment • As these symptoms mimic that of a chest infection most often patients are given antibiotics and occasionally have repeated appointment before referral. • Risks arising from delayed referral Radio- therapy Patient Symptoms GP Assess Refer to 2ry Diagnosis Stage Surgery Follow -up Palliative Care Chemo- therapy

23. Referral • GP would either request a chest x-ray or refer the patient direct to a chest physician • Risks: • Inappropriate referral • Multiple referrals - chest physician - oncologist etc. • Sometimes inappropriate tests • Inefficient referral pathway /protocol (can involve up to 10-12 steps) Radio- therapy Patient Symptoms GP Assess Refer to 2ry Diagnosis Stage Surgery Follow -up Palliative Care Chemo- therapy

24. Diagnosis and Staging • A chest physician will then carry out further investigation including taking a history, examining the patient, chest x-ray, bronchoscopy, CT scan, sputum cytology and occasionally percutaneous biopsy. • Risks: • delays after initial assessment (staffing and other associated resources) • waiting time for diagnostic procedures • delays in processing test • availability of test results Radio- therapy Patient Symptoms GP Assess Refer to 2ry Diagnosis Stage Surgery Follow -up Palliative Care Chemo- therapy

25. Treatment Modalities • Chemotherapy, • Radiotherapy, • Surgery, • Radiotherapy & Chemotherapy • Surgery & Chemotherapy • Surgery & Radiotherapy • Other combination treatments Radio- therapy Patient Symptoms GP Assess Refer to 2ry Diagnosis Stage Surgery Follow -up Palliative Care Chemo- therapy

26. Surgery • Two main categories: • Fit for surgery • Not fit for surgery • for surgical opinion but not fit for surgery due to co-morbidity • advanced disease stage ( palliative care) • Risks: • Delay in surgical appointment • Difficulty in finding bed Radio- therapy Patient Symptoms GP Assess Refer to 2ry Diagnosis Stage Surgery Follow -up Palliative Care Chemo- therapy

27. Chemotherapy • Risks: • Availability of equipment • Availability of High Cost chemotherapy drug • Administration of medication • Shelf life for preparations. Radio- therapy Patient Symptoms GP Assess Refer to 2ry Diagnosis Stage Surgery Follow -up Palliative Care Chemo- therapy

28. National Guidance

29. Publication

30. Drug administration errors • There is, on average, a 5% error rate in drug administration • 7,000 doses administered daily in average DGH • 1 in 1,000 potentially fatal • Medical error costs NHS £500 million p.a. • 20% of negligence litigation involves medication error Organisation with a Memory

31. Reported Dispensing Errors DG Hospital 1994 - 2000

32. Dispensing errors - similar names 1994 - 2000

33. Dispensing errors - similar names

35. Radiotherapy – Key staff • Clinicians - document and communicate the prescription, provide medical care to the patient and review the patients condition regularly throughout the course of radiotherapy treatment. • Radiographers - deliver the treatment and provide patient care. • Mould room technicians - manufacture treatment aids. • Physicists - provide treatment planning, dosimetry and machine quality control. • Engineers/technicians – provide machine maintenance and quality control.

36. Radiotherapy • Radiation Protection. • Ionising Radiations Regulations 1999 (IRR 1999), • Ionising Radiation (Medical Exposures) Regulations 2000 (IRMER 2000) and associated guidance for work with ionising radiation within the Christie Hospital NHS Trust.

38. Follow-up/Palliative care • Hospital System not integral • No feedback from tertiary care • Feed to and from Hospice • Links to non-NHS organisations • Separate palliative care record Radio- therapy Patient Symptoms GP Assess Refer to 2ry Diagnosis Stage Surgery Follow -up Palliative Care Chemo- therapy

39. General Issues • Communication • Number of staffs involved in the care process. • Ownership • Policies and Procedures • Notes following the patient • Clinical workflow • Availability of Resources: • Staffing • Equipment • Facilities • Finance

40. Dimensions of risk in health and healthcare • Patients’ perception of risk • The risk of individual clinical incompetence or malpractice • The risk of systems failure • Risks imposed by cost constraints • Risks inherent in clinical procedures

41. Quality of Information • The provision of healthcare services is driven to a large extent by the quality of the data that is collected and of the information which is used to make decisions that impact upon people and society. In fact, it is reasonable to state that the outcomes from healthcare are directly related to the quality, reliability, access, security,confidentiality, safety, cost-effectiveness and context of information and information technology.

42. CAN WE SIMPLIFY AND IMPROVE ALL OUR INTERACTIONS WITH PATIENTS? • SOLVE THE “MULTIPLE PERSONALITY PROBLEM” • PUT THE PATIENT BEFORE THE ORGANISATION • MAKE IT EASY TO GET THE SERVICE YOU WANT • “we’re only open from 9-10am Tuesday’s & Friday’s” • MAKE IT SAFER

43. Information Communication Technology - National and international IM&T policies and standards supports the development of risk management : • Delivering 21st century IT support for the NHS • Information for health • Building the information core • The Caldicott report • The data protection act • Modernising government 1999 – e-government • National NHS established and emerging products and standards • NHS information governance

44. References • Governance in the new NHS:CONTROLS ASSURANCE STATEMENTS 2002/2003 AND ESTABLISHMENT OF THE CONTROLS ASSURANCE SUPPORT UNIT • Control Assurance Standards 2002-2003 • Patients Safety and Clinical Risk - BMA Dec 2002 • Risk Management Manual - DoH 1992

45. “The significant problems we face today cannot be resolved at the same level of thinking that created them” Einstein