How improving your hospital s risk management program reduce cost and provide better value

How improving your hospital’s
Risk Management Program
reduces cost and provides
better value
Jose M Acuin, MD


Outline of presentation
• What is risk?
• What is risk management?
• How is risk management related to quality
and safety?
• How do you start a risk management
program?
• How do you know if your risk management
program is effective?


What is risk?
Webster’s Definition of “Risk”
• A dangerous element or factor
• Possibility of loss or injury
• The degree of probability of such loss
5 elements of risk
• Identification
• Permanence
• Timing
• Probability
• Value (subjective badness)

Asians and risk management
•
•
•
•
•
•
•

Risk perception
Risk communication
Physician – patient relationships
Technological management
Public accountability
Medical care financing
Legal protection


Risk management
Ensuring patient and staff safety through
•

Detecting risks
– patient care, medical staff, employee, property, financial

•

Analyzing risks

•

Controlling risks
– Exposure avoidance, loss frequency reduction prevention, loss
severity reduction, loss exposure segregation


Risk management, quality and
safety
Quality
design

Quality:
Quality
function
deployment

“Fitness for use” – Juran
Failure
mode and
effects
analysis

“Conformance to requirements” – Crosby

Quality
planning

Process
capability

studies

Statistical
process
control

Audit
and
review


The scope of a RCA of a
medication error
• Patient identification
• Staff
levels, orientation/training, compete
ncy
assessment, credentialing, supervisi
on, communication
• Information access
• Tech support
• Equipment maintenance
• Physical environment
• Medication management

Any or all of
these system
components
can be the
root cause of

a medication
error


How to Deal with a Sentinel
Event / Adverse Event
SENTINEL
EVENT

Unit heads /
dept chairs

Immediate
Containment
Action

AP, Unit
heads / dept
chairs +
Customer
Service

Reporting and
Notification

Persons
accountable
Unit heads /
dept
chairs, AP, Team

+ Risk
Management
Office

Investigation
and Review

Unit heads /
dept
chairs, SQD +
MQIO

Action Plan
& Monitoring


Errors can occur at
any stage of human
performance.
Information reception
Information processing
Decision-making
Mistakes

Slips and lapses

Actions
Receiving and
interpreting feedback
on result of actions

Human factors engineering in
risk management
•
•
•

•
•
•
•

Crew resource management
Device procurement
In-house product / service development
– Avoid reliance on memory
– Use forcing functions
– Avoid reliance on vigilance
– Simplify
– Standardize
Surveillance activities
Staff training
Root cause analyses
Corrective action formulation


Hierarchy of Barriers
for Error Reduction
Most Effective

Physical (Forcing, Simplification)
Knowledge
Natural (Distance, Time)
in the
Information (Labels, Signs)
World
Measures (Tests, Inspections)
Knowledge (Training, Coaching)
Knowledge
Administrative (Checklists, Policies) in my Head
Least Effective


Building an error proof culture
•
•
•
•
•
•
•
•

Set a clear example
Publish a quality and safety policy
Monitor performance
Use rewards and sanctions to reinforce correct
behavior
Recruit and retain safe people
Train

Create a system for reporting safety concerns
Build openness into the workplace


Communication – the ultimate
loss reduction technique
•
•
•
•
•
•
•

Informed consent
Unexpected outcomes
Advance directives
Medication reconciliation
Read back
Checklists
Universal protocol


Eight steps to respond to
unexpected outcomes
1. Care for the patient
2. Preserve the evidence
3. Document in the medical record
4. Report the event
5. Disclose factual information

6. Analyze the event to prevent
recurrence and/or improve outcome
7. Follow Through with subsequent
disclosure discussion(s)
8. Heal the Health Care Team


Some organization
prerequisites for effective risk
management
1.
2.
3.
4.
5.

Top level and staff commitment
Culture change
Resources
Information systems
Incentives and sanctions


Conducting case-based review
Clinical data for one patient

Apply case-based criteria

Does care meet criterion?
Yes

No

STOP

Perform case-based review

Does case meet standard of care?

Yes

No

STOP

Conduct intervention if needed


Applying medical review criteria to cases
to construct a performance rate
Clinical data for one patient

Apply medical review criteria derived from a TA/guideline

Does case meet criterion?
Yes

No

Criterion status = "met"

Criterion status = "not met"

Aggregate with criterion status of many
cases and divide by total number of cases

Performance rate


Applying standards of quality to a
performance rate
Performance rate

Apply comparative standard

Apply prescripive standard

Analysis

Does rate meet standard?

Quality improvement
intervention if needed

Re-assess periodically

Yes

No

Analysis

Quality improvement
intervention if needed


Summary of presentation
• The key to improving
safety lies not in changing
the human condition, but in
changing the conditions
under which humans work.
• Effectively managing risks
posed by health care
require executive
commitment, hospital staff
buy-in and data-driven
pursuit of quality.


A Surgical Safety Checklist to Reduce Morbidity
and Mortality in a Global Population
Safe Surgery Saves Lives Study Group. N Engl J Med 2009;360:491-9.


May

March

January '09

November

September

July

May

March

January '08

November

300

12

200
10

150
8

MArch

6

100

4

50
2

0
0

22

Infection Rates per 1000 pt days

Infection rates

September

July

May

March

January '07

November

Admissions

September

July

May

March

January '06

November

September

July

May

March

January '05

No. of Admissions

Overall Nosocomial Infection Rates
Intensive Care Unit
per 1000 patient-days care
2005 – 2006 – 2007 – 2008 - 2009
Linear (Infection rates)
16

250

14


Needle Stick Injury
June 2009
Needle Stick Rates 2008-2009
14
12

11

11

11

10
8

8

8

7

7
6

6

5

5

6

5

5

4

4

3
2

2

2
0
Series2

1

Jan '08Feb '08Mar '08Apr '08May'08Jun'08Jul '08Aug'08Sep '08Oct '08Nov '08Dec'08Jan'09Feb'09Mar'09Apr'09May'09
June'09
8

4

5

11

11

8

7

5

11

5

6

Frequency per Month

6

3

5

7

2

2

1


2

Jun '09

3

May '09

3

Apr '09

2

Mar '09

2

Feb '09

1

Jan '09

2

Dec '08

2

Nov'08

0

Oct'08

3

Sept'08

Aug'08

Jul '08

1

Jun '08

3

May '08

Apr '08

Mar '08

Feb '08

Jan '08

Staff Accident Data
June 2009
Frequency Per Month 2008-2009

6
5

5
4

4
3

3
2
FREQ.

2
1

1
Linear
(FREQ.
)

0

0


ICU Standardized Mortality Rates
45

0.6

Standardized Mortality Ratio (ICU)
40
0.5
35

30

0.4

25

20
SMR

Mortality (%)

0.3

15

0.2

10
0.1
5

0

0

Oct 2007- Feb 2009

Average Pred
Mort
Actual Mort
SMR