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R ISK AND Q UALITY M ANAGEMENT A DAPTED B Y : R USSEL JANSEN VAN R ENSBURG.

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Presentation on theme: "R ISK AND Q UALITY M ANAGEMENT A DAPTED B Y : R USSEL JANSEN VAN R ENSBURG."— Presentation transcript:

1 R ISK AND Q UALITY M ANAGEMENT A DAPTED B Y : R USSEL JANSEN VAN R ENSBURG

2 F LOW D IAGRAM OF PROCESSES (1) Strategic Plan (SWOT) (2) Committee & Identification of Risks (3) Assessing the Risks (4) Formulating a Risk Management Plan (5) Committee & Identification of Quality Improvement Opportunities (6) Formulating a Quality Improvement Plan (7) Documenting these Quality Improvement Actions(QIPs)

3 P ROCESS 1: S TRATEGIC P LAN : Mission, vision and objectives of the organisation Core business of the organisation SWOT Analysis: Weaknesses & Strengths

4 P ROCESS 2: C OMMITTEE & I DENTIFICATION OF R ISKS : Form Risk Committee representing all service areas/departments. Job descriptions Meetings: 1-3/12. Agenda & minutes In-service Training documented in training register & personnel files:

5 P ROCESS 2: I DENTIFICATION OF R ISKS : What is a Risk ? Anything that causes or has the potential to cause harm or injury to persons (patients, employees, volunteers, visitors or contractors), the organisation (physical, legal, financial, operational) or the environmen t Many risks cannot be eliminated but need to be managed

6 P ROCESS 3 : A SSESSING THE R ISKS : a) Start with a detailed assessment of each area of service/department: - Governance - Human Resources - Administrative Support : financial management, information management, MER, facilities, OHS, security, fire & emergency planning, equipment, provisioning & supplies, vehicles, waste management etc - Patient Care : Clinical & Non-clinical: incl. IDT, pt. access & rights, pt care, infection control, medication management. In Patient Unit & Home Based Care - Support Services : Food, laundry & housekeeping - Education & Research: CPLs - Fundraising: donor id & maintenance

7 P ROCESS 3 : A SSESSING THE R ISKS ( CONT.) b) Assign a severity rating and prioritise the risks: Weighing Key : Probability : 1 = LOW (may not occur at all) 5 = VERY HIGH ( already present or occurring) Impact: 1 = MILD (may not have any visible effect) 5 = CATASTROPHIC (will result in loss of life, function etc) To get the actual risk factor/severity: Multiply the probability with the impact

8 P ROCESS 3 : A SSESSING THE R ISKS ( CONT.) b) Assign a severity rating and prioritise the risks Probability on a 1 – 5 scale x (multiplied Impact on a 1 – 5 scale = Severity Rating Example: Bomb explodes: Probability 1 x Impact 5 = 5 Difficulty in finding staff: Probability 4 x Impact 5 = 20

9 P ROCESS 3 : A SSESSING THE R ISKS ( CONT.) c) Document Severity Rating of all risks across all Service Areas/Departments: Example: Service area RiskProba- bility ImpactTotal risk Com- ments

10 P ROCESS 3 : A SSESSING THE R ISKS ( CONT.) Key to Determine the Severity Rating : Severity of Impact: Proba- bility Insign 1 Minor 2 Mod. 3 Serious 4 Very Serious 5 Very High High Medium Low Very Low

11 P ROCESS 3 : A SSESSING THE R ISKS ( CONT.) Prioritise the Risks identified: On basis of: * High Risk * High Volume * High Cost

12 P ROCESS 4 : F ORMULATE A R ISK P LAN : How? Start with an overview: - Organisation - What Risk Management entails Get each department to id own risks

13 P ROCESS 4 : F ORMULATING A R ISK M ANAGEMENT P LAN Develop an overall risk management plan Service Area/ Depart. Risk Ident. Object.Action plans Resp. Person Time Frame Pro- gress Gov. HR Admin Support

14 P ROCESS 4 : F ORMULATING A R ISK M ANAGEMENT P LAN A DDITIONAL T ASKS : Develop a tool/instrument for monitoring risks (could also be progress if updated 1/12) Record all near miss/adverse events (negative incidents) Take and record remedial action Report on progress to the H & S Committee, Management and Board ( NB: Occupational Health & Safety Act no 85 of 1993)

15 P ROCESS 5 : C OMMITTEE & I DENTIFICATION OF Q UALITY I MPROVEMENT OPPORTUNITIES Form Quality Improvement Committee representing all service areas/departments. Job descriptions Meetings: 1-3/12. Agenda & minutes In-service Training documented in training register & personnel files:

16 P ROCESS 5 : I DENTIFICATION OF Q UALITY I MPROVEMENT OPPORTUNITIES How? Quality Improvement Activities are based on the Evidence from Assessments: Evidence from: Reports of near miss/adverse events (negative incidents) Inspections, audits IOD Risk assessments

17 P ROCESS 5 : I DENTIFICATION OF Q UALITY I MPROVEMENT OPPORTUNITIES How? 1. High Risk – where there is the risk of serious consequences when care is not provided correctly pain management infection control medication 2. High Volume – where the service is occurring frequently and affecting a large number of people patient assessment record keeping communication pain management medication patient/family education

18 P ROCESS 5 : I DENTIFICATION OF Q UALITY I MPROVEMENT OPPORTUNITIES How? 3. High Cost – where there are areas with costs that could escalate and put the organization at risk transport salaries communication donor fatigue/overload

19 P ROCESS 6 : F ORMULATING A Q UALITY I MPROVEMENT P LAN : How? Start with an overview: - Organisation - What Quality Improvement Culture and Activities involve Get each department to id own opportunities for QI based on the id, assessment and prioritising of their risks

20 P ROCESS 6 : F ORMULATING A Q UALITY I MPROVEMENT P LAN Develop an overall quality improvement plan Service Area/ Depart. QIP Ident. Stan- dard Req. Action plans Resp. Person Time Frame Pro- gress Gov. HR Admin Support

21 P ROCESS 7 : D OCUMENTING THE Q UALITY I MPROVEMENT A CTIONS : = Q UALITY I MPROVEMENT P ROJECTS 1. Identifying and Stating the Problem/Need 2.Stating the expected Standard/Norm/Intended Outcome 3.Choosing a possible solution: What will you do to improve the situation? 4.Choosing a measuring tool: questionnaire, check sheet, tick list, audit 5.Choosing the right indicator: is a measurement which will show (indicate) that improvement has taken place. Indicators must be achievable and measurable, i.e. a number or % (SMART)

22 P ROCESS 7 : D OCUMENTING THE Q UALITY I MPROVEMENT A CTIONS : = Q UALITY I MPROVEMENT P ROJECTS 6.Deciding on a time frame: How long do you think it will take to achieve 7. How will you display the results e.g. graph 8. What will you do with the results? 9. How will you do on-going monitoring? e.g. spot checks and how often? Report on progress to the H & S Committee, Management and Board and at 1-3/12 QI meetings

23 Q UESTIONS ??? Acknowledging all previous work done on this subject matter by HPCA Staff Members


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