Risk Management
Sanjeev Sharma
Clinical Governance
Clinical Governance (NeLH- Health Management)
What is Clinical Governance? (1)
Clinical Governance is:
• “A framework through which NHS
organisations are accountable for continously
improving the quality of their services and
safeguarding high standards of care by
creating an environment in which clinical care
will flourish” (DoH, 1999)
Clinical Governance (NeLH- Health
Management)
What is Clinical Governance? (2)
The foundations of clinical governance are:
• The setting of realistic and evidence-based standards
of care
• The monitoring of performance against these
standards
• The implementation of change to ensure that these
standards are reached and, if possible, exceeded
Clinical Governance (NeLH- Health
Management)
What is Clinical Governance? (3)
•
•
•
•
•
•
•
•
•
•
The tools to achieve these foundations include:
Multidisciplinary clinical audit
Clinical effectiveness
Research & development
Lifelong learning
Risk management & critical incident reporting
Evidence-based medicine/ practice
Guidelines, pathways and protocols
Service accreditation
Individual appraisal and assessment
Information management
Clinical Governance (NeLH- Health
Management)
Why is it important?
• Clinical governance is explicitly reflected in the
responsibilities and management of NHS Trusts
• Chief Executives have the ultimate responsibility for
assuring the quality of the services provided by their
NHS Trust (Health Act, 1999)
• The Health Act also established the Commission for
Health Improvement (CHI) to help improve the
quality of health care in the NHS by investigating the
quality of healthcare in Trusts and by providing
advice on quality health care
Clinical Governance (NeLH- Health
Management)
What are the benefits?
• Clinical governance improves not only the
quality of patient care, but also efficiency and
procedures
• It can therefore both enhance patient
satisfaction and reduce costs
Clinical Governance (NeLH- Health
Management)
Risk Management
What is risk?
A risk is the likelihood of a hazard happening and the impact it
could have.
Risk is defined as “ the possibility of incurring misfortune or
loss” and can be associated with people ( patients, visitors
and staff ), buildings and estate, equipment and consumables,
systems and management.
Risk Management
Risk
The likelihood of a hazard happening and the impact
it could have.
Hazard
The potential for harm.
Hazard ?
• Something with the potential
to cause harm
Risk ?
The Likelihood of harm occurring
Risk Management
What is risk Management?
It is the process of assessing risks and taking steps to either
eliminate or to reduce them ( as far as is reasonably
practicable) by introducing control measures.
Risk Management
• Providing health is a risky
business.
• Risks are associated with
environment, procedures,
interventions and
treatments.
• Risks can be to
• Patients
• The health care staff
• The health care provider
organization
• Risk management is about
providing care safely.
• It aims to develop good
practice and reduce the
likelihood of harmful
incidents happening.
• All risks need to be
minimized as a part of
quality and safety agenda.
Risk Management
Why do risk management?
• A number of widely publicised high profile cases.
• 850,000 adverse incidents per year – 1/3 leading to disability or
death1.
• 50% avoidable according to US studies.
• £2 billion/year in additional in-patient stays.
• £400 million in compensation.
1 Vincent
C, BMA conference, March 2000
Risk management
Why do things go wrong?
Organisational
Cultural
Weak leadership
Education and research
not valued
Cliques and factions
No strategies
Poor management
Poor communication
Sparse infrastructure
Individual
External
Defensive
Fortress mentality
Little collaboration
Poor motivation
Poor team working
Poor attitude
Lack of skills
Risk Management
What is Risk Management Strategy?
The risk management strategy integrates all aspects of
governance and risk to ensure quality and safety of NHS
organizations.
Each NHS Trust must have a strategy for governance and risk.
Risk Management
What is Risk Management Strategy?
• Focus on the system rather than the individual incident.
• It is anticipatory not reactive in emphasis.
• Significant event audit and adverse incident reporting
therefore supports risk management by monitoring it.
Risk Management
Care Quality Commission
It is responsible for health and social care in
England.
NHS Litigation Authority ( NHSLA )
It is responsible for all clinical and non clinical
negligence claims against NHS bodies in England.
National Patient Safety agency ( NPSA )
It is responsible for for improvement of patient
safety.
All patients safety incidents are reported to NPSA.
Risk Management
The Risk Register
A risk register is a log or database that lists every type of risk
that has occurred within the Trust.
Risk Management
Principal areas of concern
•
•
•
•
Diagnosis
Prescribing
Communications
Organisational change
Risk Management
Incident Reporting
All NHS staff have a professional and ethical responsibility to
complete a Trust Incident Form after any and every incident
that occurs that potentially compromises patient safety, or
safety of the staff.
It is to understand what happened, why it happened, learn
from the incident to prevent future events.
Risk Management
Possible reportable incidents
Non-clinical
•
•
•
•
•
•
•
•
•
Maintenance of equipment/ buildings
The hostile patient
Waste management
Infection control
Fire safety
Employers liability
Message handling
Staff turn-over
Security of information
Risk management
Benefits of Incident reporting
• Better allocation of resources.
• More informed decision-making.
• Greater compliance with legislation.
• Greater transparency and accessibility to external review.
Risk management
Benefits of Incident reporting
• Better outcomes and patient satisfaction (improved
quality of service).
• Ability to learn from mistakes.
• Reduced costs of litigation and compensation.
• Better public image.
Incident Reporting
Risk Management
Incident Report
What information to be included in the incident form?
–
–
–
–
Date of incident.
Time and place of incident.
Personal details of those involved.
A brief description of the nature of the event.
Three copies
Nine Sections
(1) Date/Time/Location
(2) Person Affected
(3) Injury/Outcome
(4) Type of incident & Severity
(5) Details of Occurrence
(6) Action taken at the time of
incident
(7) Who completed the report
(8) Subsequent action
Risk Management
Record Keeping
What is a record?
A record is recorded information in any format that is created,
received, or maintained by the Trust and kept as evidence of
healthcare treatment for a patient.
Risk Management
Good Record keeping
•
•
•
•
Gives accurate accounts of treatment.
Allows better communication between team members.
Has ability to detect changing situations early.
Guarantee of safe and quality care,
Risk Management
Good Record Keeping
Well organised and Easily
Located
Contain Factual
Information Only
Written Within 24 hours
Additions/Changes clearly
marked and signed
A Good Patient Record
System
Shows the Correct Date
and Time
Written Clearly and Cannot
be Erased
Patient Understands
Language
Easy to Read and Make
Copies
Risk Management
Bad Record Keeping
Staff not Trained Properly
Record not saved Properly
Details not Checked before
being Processed
Bad Patient Record System
Records not Produced
Quickly Enough
Key Information Missing
Risk Management
How is risk Calculated?
It is measured in terms of likelihood and consequences and
modified by the frequency of the activity that may lead to
risk.
Risk Management
Calculation of Risk
Existing level of risk = Severity ( as a measure of magnitude) X
Likelihood (as a measure of frequency )
Risk Assessment
Management of Health and Safety at Work Regulations
These regulations set legal requirements for which Directors and
Managers can be held personally responsible
Risk Assessment is basically a 5-stage process which consists of the following steps:
Identify Hazards
Evaluate the Risks
Eliminate the Hazards if possible
Minimise (control) the risk
Monitor/review periodically
Risk Management
Establish
Likelihood
Multiply
Likelihood X
Impact
Rating
Establish
Impact
Category
ALARP PRINCIPLE
INTOLERABLE
REGION
Risk cannot be
justified
Smoking
Driving a car
ALARP REGION
Risk is undertaken only if a
benefit is desired) and steps
must be taken to reduce the risk
is “As Low As Reasonably
Practical (ALARP)
Taking the contraceptive pill
Being struck by lightning
ACCEPTABLE REGION
Risk reduction not
likely to be required
Being struck by a meteorite
Risk Management
The components of quality
Attitude
Audit
Risk Management
Patient focus
Life-time learning
Systematic care
Valuing practitioners
Supporting innovation
From the NHS Plan
Relationship to critical event audit
Significant event
audit
Risk Management
Three Types of Risk
Uncertaintybased risk
Opportunitybased risk
Hazard-based
risk
Error Types
Basic error types
Intended
actions
Violations
Mistakes
Routine, reasoned,
reckless and
malicious: we always
break that rule
Rule or knowledge
based errors: don’t know
something is wrong
Unsafe
acts
Unintended
actions
Lapses
Slips
Skill based errors,
memory failures:
forgetful
Skill based errors
attention failures:
distracted, tired
Adapted from NPSA and Reason