1. INTRODUCTION TO RISK MANAGEMENT IN HEALTHCARE Stuart Emslie

2. What is risk?

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

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

11. Low MediumHigh RISK Almost certain - 5 Likely - 4 Possible - 3 Unlikely - 2 Remote - 1 Likelihood Minor 2 Moderate 3 Major 4 Extreme 5 Consequence Insignificant 1 RISK QUANTIFICATION MATRIX

12. Low MediumHigh RISK Almost certain - 5 Likely - 4 Possible - 3 Unlikely - 2 Remote - 1 Likelihood 510152025 48121620 3691215 246810 12345 Minor 2 Moderate 3 Major 4 Extreme 5 Consequence Insignificant 1 RISK QUANTIFICATION MATRIX

17. Risk perception

21. The healthcare risk ‘universe’ Financial Human Resource IT Integrity Patient care and safety Occupational safety & health Physical resources Information for decision making etc. Legal Environment

22. INTERNAL EXTERNAL PROACTIVE REACTIVE Risk Register General risk assessments Patient adverse incidents Staff consultation Internal audits and inspections Complaints Claims Specialist risk assessments Patient consultation Staff adverse incidents Other adverse incidents Hazard warnings Safety alerts Incidents etc. occurring ‘elsewhere’ Coroners reports Inquiry reports Benchmarking Accreditation standards External stakeholder consultation External audits, reviews etc. Some common sources of information used to populate a healthcare risk register Facilitated workshops Books Root cause analyses Conferences, Seminars, etc. Suggestion scheme FMEA

23. INTERNAL EXTERNAL PROACTIVE REACTIVE Risk Register General risk assessments Patient adverse incidents Staff consultation Internal audits and inspections Complaints Claims Specialist risk assessments Patient consultation Staff adverse incidents Other adverse incidents Hazard warnings Safety alerts Incidents etc. occurring ‘elsewhere’ Coroners reports Inquiry reports Benchmarking Accreditation standards External stakeholder consultation External audits, reviews etc. Some common sources of information used to populate a healthcare risk register Facilitated workshops Books Root cause analyses Conferences, Seminars, etc. Suggestion scheme FMEA

24. Environment risk Empowerment risk A common risk language Patient Care and Safety Risk Human resource risk Physical resource risk Integrity risk Financial risk Legal risk Information for decision making 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 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 Purpose. Structure. Leadership. Accountability. Authority. Boundary. Compliance. Resource allocation. Communication. Rate of change. Performance measurement Fraud Corruption Unauthorised use Unethical practice Illegal acts Reputation Conflict of interest Facilities / Equipment Capacity Availability Breakdown / Interruption Utilisation Performance Efficiency / Economy Compatibility Misuse / Impairment Loss Operator Technology Utilities failure Environment Environmental Impact Conservation Waste Regulatory compliance Litigation Contractual Cash flow Budget control Cash collection Bad debts Payment Investment Insurance Currency Misappropriation Value for money Clinical. Operational. Financial. Strategic Staff capabilities and education Qualifications /registration Proficiency Professional development Maintaining a quality workforce Loss of key staff Turnover Recruitment Remuneration Industrial relations Workforce planning 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 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 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 Access. Availability. Accuracy. Timeliness. Completeness. Usability. Utilisation IT risk: System failure / Availability Technology Integrity Unauth. access/use Loss of data Cost / time overruns User needs not met Process risk P.15

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 HFMEA TM 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… 1.Select a process (topic) 2.Assemble your team 3.Describe the process steps

36. 1 2a 2b 4b3b 3c 5 4a 3a

37. FMEA Steps… 1.Select a process (topic) 2.Assemble your team 3.Describe the process steps 4.Identify the ways in which each process step can fail (failure modes – e.g. drug maladministration; performing wrong site surgery; clinical mis-diagnosis; etc.) 5.Identify the root cause(s) of failure (Why?) 6.Identify the most likely effect(s) (i.e. consequence of failure) of each identified failure mode 7.Assess risk associated with each failure mode (consequence and likelihood – from risk matrix) 8.Identify additional controls required (actions to effect improvement) 9.Implement additional controls 10.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 1.Infection control 2.OSH 3.Medication error 4.Resuscitation 5.Transfer of patients 6.Documentation of medical records, including consent 7.Patient identification (during consultation, blood sampling, operation & for investigations) 8.Wrong site surgery 9.Proper use of infusion pumps 10.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. Depts. HORMC Cluster Hospital Aggregation ‘Front line’ Information Resources/Action/Improvement Filtering/ Escalation

50. Low MediumHigh RISK Almost certain - 5 Likely - 4 Possible - 3 Unlikely - 2 Remote - 1 Likelihood Minor 2 Moderate 3 Major 4 Extreme 5 Consequence Insignificant 1 RISK QUANTIFICATION MATRIX

54. 1. Risk type: 2. Risk description: 4. Initial consequences: 5. Initial likelihood: 6. Additional controls: 7. Residual consequences: 8. Residual likelihood: 3. Existing controls:

55. Describing risk – the ‘3 C’s’ 1.Risk is inherently negative, implying the possibility of adverse consequences. Describe the potential consequences if the risk were to materialise 2.Describe the causal factors that could make the risk materialise 3.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.)

56. Which of the following are adequate descriptions of risk? Risk to patients due to errors and unsafe clinical practice caused by reduced skill base and competence of junior and middle grade medical staff Needlestick injury OSH Reduced staff retention and increased sickness absence due to reduction in morale caused by increased workload, pressure and stress to achieve targets Inadequate patient transfer Budget overrun and financial deficit due to cost of introducing new technologies/medicines as required by NICE guidance Medication error Loss of use of ICU due to fire

57. 1. Risk type: 2. Risk description: 4. Initial consequences: 5. Initial likelihood: 6. Additional controls: 7. Residual consequences: 8. Residual likelihood: 3. Existing controls: Patient falling off a trolley causing harm to patient or a member of staff. Patient care and safety. Occasional maintenance work carried out, but very inadequate. AIRS figures show that this type of incident happens at least once per week. There Have been some reports of staff injury when a trolley breaks down.

58. Low MediumHigh RISK Almost certain - 5 Likely - 4 Possible - 3 Unlikely - 2 Remote - 1 Likelihood Minor 2 Moderate 3 Major 4 Extreme 5 Consequence Insignificant 1 RISK QUANTIFICATION MATRIX

59. 1. Risk type: 2. Risk description: 4. Initial consequences: 5. Initial likelihood: 6. Additional controls: 7. Residual consequences: 8. Residual likelihood: 3. Existing controls: Patient falling off a trolley causing harm to patient or a member of staff. Patient care and safety. Occasional maintenance work carried out, but very inadequate. AIRS figures show that this type of incident happens at least once per week. There Have been some reports of staff injury when a trolley breaks down. Major (4) Almost certain (5) Need a proper system of planned maintenance carried out on the trolleys to ensure they don’t break down and accidentally harm patients or staff. Major (4) Unlikely (2)

60. GROUP WORK - Brainstorming risks…..what are the issues or concerns that ‘keep you awake at night’? 1.Think about yourself and your colleagues – list 3 issues or concerns you have at work. 2.Now think about patients – list 3 issues or concerns you might have in relation to the safety or quality of care provided to patients in your department, hospital etc. 3.Finally, think about your organisation– list 3 issues or concerns………..

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