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Semelhante a Enterprise Risk Management in Healthcare Organisations “Going Beyond Patient Safety”
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Enterprise Risk Management in Healthcare Organisations “Going Beyond Patient Safety”
- 1. Enterprise Risk Management in HealthcareOrganisations “Going Beyond PatientSafety” Hossam Elamir MSc.HCM, TQMD, MBBCh, CPHQ, CPHRM
- 3. “A ship in harbor is safe, but that is not what ships are built for” John Augustus Shedd (1859 – 1928)
- 4. "any uncertainty that, if it occurs, could have a positive or negative effect on achievement of one or more organizational aims and objectives and is assessed through the combination of magnitude of potential injury (impact) and the probability (likelihood) that the uncertainty will occur". Hillson, D. (2005). When is a risk not a risk? International Project Management Association. Central Board of Accreditation for Healthcare Institutions. (2011). Hospital Standards (2nd ed.). Jeddah, Saudi Arabia: CBAHI Accreditation Dept.
- 5. “Any uncertainty which can affect achievement of objectives either positively or negatively” Key point: Link risks to organisational objectives… Objectives Uncertainty versus What must happen What might happen Hillson, D. (2005).When is a risk not a risk? International Project Management Association.
- 7. “The only alternative to risk management is crisis management JAMES LAM Enterprise Risk Management: From Incentives to Controls, 2003 --- and crisis management is much more expensive, time consuming and embarrassing”
- 8. Delivering safe care of high quality is the professional, legal and ethical duty of all healthcare professionals
- 9. Accreditation Requirement: Organizations must have a documented risk management plan
- 10. “The whole process of initiation, risk identification, evaluation, response development, implementation, continuous monitoring & review to reduce the risk of injury to patients, staff and visitors and the risk of loss to the organization itself". Feeney, L. & Murphy D. (2013), CBAHI guide to risk management. Jeddah, Saudi Arabia: CBAHI Accreditation Dept. Its is an anticipatory (proactive) process
- 11. TheTraditional Risk Management (TRM) was established in the early 70s focusing on the acute care settings, these programs stayed reactive and generated in response to incidents that were ultimately patient safety-centred. The process was fragemented into silos of resposiblities and accountabilities with no overlap or relationship between different business units.
- 12. ERM in healthcare promotes a Comprehensive framework for making risk management decisions which maximize value protection and creation by managing risk and uncertainty and their connections to total value. ASHRM ERM Pearl, p.7
- 13. Managing UncertaintyValue CreationValue Protection Comprehensive Framework •Reduce risks •Eliminate loss •Promote standardization •Use evidence-based practice •Decrease variability •View the impact of risk holistically not in silos (eliminate silo mentality) •Understand chaos theory •Eliminate/minimize lost opportunities •Captures the positive or upside •Increased market share •Competitive edge •Financial strength •Improved ROI •Increased margins •Enhanced reputation •Improved satisfaction scores •Quality outcomes •Credible •Respected •Reduce uncertainty •Reduce variability •Duplication •Separation •Shield assets •Efficient use of resources •Quality outcomes •Safe practices •Organizationwide •Holistic •Broad perspective •Synergistic effect •Comprehensive •Strategic •Thorough •Robust •Structured
- 14. ERM: A framework of activities that helps an organization identify and manage risk holistically by considering all forms of risk across the organization. An integrated approach to risk management that connects silos so that the organization understands all risks facing the organization and enables the organization to be more strategic Process that supports concept that risks do not exist or behave in “isolation” but can be identified, grouped and catalogued in risk domains v. 1 pp. 7-8; ASHRM ERM Pearl, pp. 7-8
- 15. ContrastingTraditional RM with Enterprise RM ERMTRM ProactiveFocusReactive Value creationOutcomeAsset preservation Organizational-wideBreadth/ DepthDepartmental/silos Risk preventionActivitiesRisk mitigation Clinician/staffEngagementBoard/C-Suite
- 16. Source: J. Conway, F. Federico, K. Stewart and M. Campbell, Respectful Management of Serious Clinical Adverse Events, Institute for Healthcare Improvement (IHI), IHI Innovation Series White Paper, Cambridge, MA, 2010, citing N. Augustine, “Managing the CrisisYouTried to Prevent,” Harvard Business Review, Vol. 73, No. 6, 1995, pp. 147-158.
- 17. Medicine used to be simple, ineffective & relatively safe… now it is complex, effective & potentially dangerous! Chantler, C. (1999),The role and education of doctors in the delivery of healthcare, Lancet, 53(9159), 1178–1181. Medicine used to be simple, ineffective & relatively safe… Chantler, C. (1999),The role and education of doctors in the delivery of healthcare, Lancet, 53(9159), 1178–1181.
- 18. Change in patient demographics Enhanced expectations by variety of stakeholders Increased use of internet Movement towards a paperless environment Changing line of authority Market share competition Variability in clinical care Changing reimbursement methodologies Enterprise Risk Management For Health Care Entities, 3rd Edition, PP 23
- 19. Operational Patient Safety Holistic Approach Value Protection andValue Creation
- 20. Clinical Operational Patient Safety Holistic Approach Value Protection andValue Creation
- 21. Strategic Clinical Operational Patient Safety Holistic Approach Value Protection andValue Creation
- 22. Financial Strategic Clinical Operational Patient Safety Holistic Approach Value Protection andValue Creation
- 23. Financial Human Capital Strategic Clinical Operational Patient Safety Holistic Approach Value Protection andValue Creation
- 24. Financial Human Capital Strategic Clinical Operational Legal/ Regulatory Patient Safety Holistic Approach Value Protection andValue Creation
- 25. Financial Human Capital Strategic Clinical Operational Legal/ Regulatory Technology Patient Safety Holistic Approach Value Protection andValue Creation
- 26. Financial Human Capital Strategic Clinical Operational Legal/ Regulatory Technology Hazard Patient Safety Holistic Approach Value Protection andValue Creation
- 29. v. 1 pp. 108, 223, ASHRM ERM Pearl, pp. 19-27 Identifying and analyzing loss exposures Identification Analysis Types of exposures Mothods of identifying exposures Organizational objectives Significance
- 30. v. 1 pp. 108, 223, ASHRM ERM Pearl, pp. 19-27 Examining feasibility of alternative techniques Risk control to stop losses Risk financing to pay for losses Retention Transfer
- 31. v. 1 pp. 108, 223, ASHRM ERM Pearl, pp. 19-27 Selecting apparently best techniques Choosing selection criteria Decision rules applying criteria
- 32. v. 1 pp. 108, 223, ASHRM ERM Pearl, pp. 19-27 Implementing the selected risk techniques
- 33. v. 1 pp. 108, 223, ASHRM ERM Pearl, pp. 19-27 Monitoring & improving the RM program Purposes Control program
- 34. v. 1 p. 223 The Risk Management Process Identification and Analysis of Exposures Treatment of Exposures Risk Control Risk Financing Retention Transfer
- 35. Risk Ranking Overview Provide an initial means of prioritizing assessed risks based upon assessments of Impact and Likelihood. ▪ Risks were assessed assuming the effectiveness of existing risk management activities. Used to identify a risk’s position on a Risk Map. Risk Ranking Calculation Steps Multiply the Impact assessment and the Likelihood assessment for each risk. Reference the product against a range of values. Assign one of four risk rankings (very high, high, medium or low) based upon referenced range. RangeRank Greater than 17.0Very high Greater than 10.0, but less than 17.0High Greater than 5, but less than 10.0Medium Less than 5.0Low Risk Ranking Matrix Critical Impact InsignificantModerate Potential LikelyUnlikely Likelihood RiskRanking
- 36. Risk = Likelihood of risk occurring (Frequency) x Impact of risk occurring (Severity, Consequences)
- 37. Likelihood x Impact = Risk Score (a value 1 to 5)(a value 1 to 5) 1 x 1 = 1 (lowest possible score) 5 x 5 = 25 (highest possible score) (Likelihood + Velocity) x Impact = Risk Score (a value 1 to 5) (a value 1 to 3) (a value 1 to 5) (1 + 1) x 1 = 2 (lowest possible score) (5 + 3) x 5 = 40 (highest possible score)
- 39. Risk ID Description of Risk Risk Assessment Risk Rating (I x L)Impact (I) Likelihood (L)
- 43. Provide the right level of detail to facilitate understanding and risk based decision making, without oversimplifying. The right level of details depends on your goal.
- 45. Fault tree Event tree
- 46. Fault tree Event tree
- 51. Barrier Name Apply wristband upon admission to the ward (Haz.) Operating a patient / Applying incorrect procedure // (Tht.) Wrong patient // (Br.) Apply wristband upon admission to the ward Apply wristband upon admission to the ward At admission on the ward: Check the patient's identity by nurse together with patient through open questions (Haz.) Operating a patient / Applying incorrect procedure // (Tht.) Wrong patient // (Br.) At admission on the ward: Check the patient's identity by nurse together with patient through open questions At admission on the ward: Check the patient's identity by nurse together with patient through open questions At preoperative screening: Check the anethesia tecnique by anesthesiologist together with patient in accordance with the planned procedure (Haz.) Operating a patient / Applying incorrect procedure // (Tht.) Wrong anethesia technique // (Br.) At preoperative screening: Check the anethesia tecnique by anesthesiologist together with patient in accordance with the planned procedure At preoperative screening: Check the anethesia tecnique by anesthesiologist together with patient in accordance with the planned procedure At preoperative screening: Check the diagnosis and procedure by anesthesiologist together with patient twith electronic medical record (Haz.) Operating a patient / Applying incorrect procedure // (Tht.) Wrong procedure // (Br.) At preoperative screening: Check the diagnosis and procedure by anesthesiologist together with patient twith electronic medical record At preoperative screening: Check the diagnosis and procedure by anesthesiologist together with patient twith electronic medical record At preoperative screening: Check the operating site and side by anesthesiologist together with patient twith electronic medical record (Haz.) Operating a patient / Applying incorrect procedure // (Tht.) Wrong site /side // (Br.) At preoperative screening: Check the operating site and side by anesthesiologist together with patient twith electronic medical record At preoperative screening: Check the operating site and side by anesthesiologist together with patient twith electronic medical record At preoperative screening: Check the patient's identity by anesthesiologist together with patient through open questions (Haz.) Operating a patient / Applying incorrect procedure // (Tht.) Wrong patient // (Br.) At preoperative screening: Check the patient's identity by anesthesiologist together with patient through open questions At preoperative screening: Check the patient's identity by anesthesiologist together with patient through open questions At surgery preparation room, check perioperative marking and completeness elecronic medical record by nurse and staff member with awake patient (Haz.) Operating a patient / Applying incorrect procedure // (Tht.) Wrong procedure // (Br.) At surgery preparation room, check perioperative marking and completeness elecronic medical record by nurse and staff member with awake patient At surgery preparation room, check perioperative marking and completeness elecronic medical record by nurse and staff member with awake patient (Haz.) Operating a patient / Applying incorrect procedure // (Tht.) Wrong site /side // (Br.) At surgery preparation room, check perioperative marking and completeness elecronic medical record by nurse and staff member with awake patient At surgery preparation room, check perioperative marking and completeness elecronic medical record by nurse and staff member with awake patient At surgery preparation room, check the patient's identity by anesthesiologist and staff member with awake patient through open questions (Haz.) Operating a patient / Applying incorrect procedure // (Tht.) Wrong patient // (Br.) At surgery preparation room, check the patient's identity by anesthesiologist and staff member with awake patient through open questions At surgery preparation room, check the patient's identity by anesthesiologist and staff member with awake patient through open questions At surgery preparation room, check the patient's identity by nurse and staff member with awake patient through open questions (Haz.) Operating a patient / Applying incorrect procedure // (Tht.) Wrong patient // (Br.) At surgery preparation room, check the patient's identity by nurse and staff member with awake patient through open questions At surgery preparation room, check the patient's identity by nurse and staff member with awake patient through open questions At the start of the surgey the surgeon, anaesthesiologist, operating assistant and nurse anesthetist and awake patient - check on the basis of the electronic medical record / - whether it is the: right patient; right site and side; appropriate intervention; adequate supplies (Haz.) Operating a patient / Applying incorrect procedure // (Tht.) Wrong anethesia technique // (Br.) At the start of the surgey the surgeon, anaesthesiologist, operating assistant and nurse anesthetist and awake patient - check on the basis of the electronic medical record / - whether it is the: right patient; right site and side; appropriate intervention; adequate supplies At the start of the surgey the surgeon, anaesthesiologist, operating assistant and nurse anesthetist and awake patient - check on the basis of the electronic medical record / - whether it is the: right patient; right site and side; appropriate intervention; adequate supplies
- 52. ! 2 Do you have enough barriers to be (enough) in control?
- 53. 3 ! ! ! What if the Engineering Manager is fatigued? Or when you have a power blackout?
- 55. The barrier functioned as planned and stopped the next event in the incident scenario. e.g.: High level trip operated correctly stopped the overfill The barrier stopped the incident sequence, but there is uncertain if it will do so in the future. e.g.: High level trip stopped the overfill but there is evidence that it is left in defeated state at times The barrier functioned as intended by its design, but was unable to stop the sequence of events. e.g. High level trip operated but inflow was via another route that could not be shutoff, i.e. no trip valve The barrier was implemented, but did not function according to its intended design. e.g. High level trip did not operate as its was broken/defeated etc. The barrier was described in the organization’s SMS or was considered an industry standard, but it was not successfully implemented. e.g. High level trip is required, but was not installed.
- 57. The success of the risk management program depends on the cooperation of all employees.
Notas do Editor
- So lets watch this 18 secs video. Do u think this incident caused by a safety issue! Or it happened because the astronaut had failed to explore and prepare 4 all risks?
- In 1928 John A. Shedd an American author and a professor released a collection of sayings titled “Salt from My Attic”, and the following popular aphorism was included: So risks r parts of doing business.
- Failure to manage risks effectively can lead to harm or injury to persons as well as organizational financial losses and loss of reputation – Crises Management It is a key part to improving the organization services aiming at achieving best practice in managing risks. “Quality comes from Sufficient Risk Management - William E. Deming”
- The organization should acknowledge its legal duty to safe Gard staff, patients, and members of the public.
- The organization should acknowledge its legal duty to safe gard staff, patients,and members of the public.
- Ongoing business decision-making process Instituted & supported by Board of Directors, Executive administration and medical staff leadership Recognises the synergistic effect of risks Goal is to reduce uncertainty & process variability, promot patient safety, & maximize the ROI Through asset preservation, value creation
- Diversity of pateints, staff, & physicians. Aging of the population Patients/residents, families, medical staff, BOD, Executive leadership, Professional caregivers, community As a source for health knowlwdge, exchange, & social interaction Promotion of electronic health/medical records, integration Staff empowerment Local, Regional, & National Hesitancy to follow EBBP (GL, Algo, Pathways, Protocols) P4P, Bundled payment
- Operational: Risks resulting from inadequate or failed internal processes, people, or systems that affect business operations.
- Clinical: Risks associated with the delivery of care to residents, patients and other healthcare customers, professional liability.
- Strategic: Risks associated with the focus and direction of the organization—brand, reputation, competition, failure to adapt to changing times, health reform or customer priorities
- Financial: Decisions that affect the financial sustainability of the organization, access to capital or external financial ratings through business relationships or the timing and recognition of revenue and expenses, and other lines of liability make up this domain
- Human Capital: This domain refers to the organization’s workforce. This is an important issue in today’s tight labor and economic markets
- Legal/ Regulatory: Risks are generally associated with fraud and abuse, licensure, accreditation, product liability, management liability, Conditions of Participation (CoPs) and Conditions for Coverage (CfC), as well as issues related to intellectual property.
- Technology: This domain covers machines, hardware, equipment, devices and tools, but can also include techniques, systems and methods of organization.
- Hazard: This ERM domain covers assets and their value. Traditionally, insurable hazard risk has related to natural exposure and business interruption. Specific risks can also include risk related to: facility management, plant age, parking (lighting, location, and security), valuables, construction/renovation, earthquakes, windstorms, tornadoes, floods, fires.
- Operational: Risks resulting from inadequate or failed internal processes, people, or systems that affect business operations. Clinical: Risks associated with the delivery of care to residents, patients and other healthcare customers, professional liability. Strategic: Risks associated with the focus and direction of the organization—brand, reputation, competition, failure to adapt to changing times, health reform or customer priorities Financial: Decisions that affect the financial sustainability of the organization, access to capital or external financial ratings through business relationships or the timing and recognition of revenue and expenses, and other lines of liability make up this domain Human Capital: This domain refers to the organization’s workforce. This is an important issue in today’s tight labor and economic markets Legal/ Regulatory: Risks are generally associated with fraud and abuse, licensure, accreditation, product liability, management liability, Conditions of Participation (CoPs) and Conditions for Coverage (CfC), as well as issues related to intellectual property. Technology: This domain covers machines, hardware, equipment, devices and tools, but can also include techniques, systems and methods of organization. Hazard: This ERM domain covers assets and their value. Traditionally, insurable hazard risk has related to natural exposure and business interruption. Specific risks can also include risk related to: facility management, plant age, parking (lighting, location, and security), valuables, construction/renovation, earthquakes, windstorms, tornadoes, floods, fires.
- The organization should acknoledge its legal duty to safe gard staff, patients,and members of the public.
- It’s a systematic application of management polices, procedures and practices to the tasks of establishing the context, identifying, analyzing, evaluating, treating, monitoring and communicating risk. Communicating risks: Any purposeful exchange of information about risks between interested parties. (WHO) Risk Management is a Proactive Strategy involving 5 steps: Risk Management is a Proactive Strategy involving 5 steps: Establish the Context Risk identification Risk analysis Risk treatment: Risk control Risk financing Monitoring and evaluation
- Property, Liability, Personnel, Net income Loss histories, Financial statements, Records & files, Personal inspections, Flowcharts, Standardised surveys/questionnaires, Experts Profit, Continuous operation, Stable Earnings, Growth, Legal requirements, Humanitarian concerns Loss Frequency, Loss severity
- Exposure avoidance, Loss prevention, Loss reduction, Segregation of exposures (separation/duplication), Contractual transfer for risk control (nonisurance) Current expensing of losses, Unfunded reserve, Funded reserve, Borrowing, Captive Insurer Contractual transfer for risk financing (noninsurer hold harmless agreements), Commercial insurer, Hedging (for business risk only)
- Financial criteria, Criteria related to other objectives Risk control, Risk Financing
- Technical Decisions Managerial Decisions
- To ensure proper implementation, To detect & adapt to changes Results standards, Activities standards
- There are four risk treatment activities stated in ISO 27005:2008. A) Risk Reduction - The level of risk should be reduced through the selection of controls so that the residual risk can be re-assessed. B) Risk Retention - The decision on retaining the risk without further action should be taken depending on risk evaluation. C) Risk Avoidance - The activity or condition that gives rise to the particular risk should be avoided. D) Risk Transfer - The risk should be transferred to another party that can most effectively manage the particular risk
- Map of London Underground (1865) - a raw diagram
- Map of London Underground today Truth is often complex and unfathomable Models of the truth are more comprehensible
- A Bowtie is like the map – a representation of the truth that enables risks to be understood, with the risk treatment strategies
- It is said that the first ‘real’ Bowtie diagrams appeared in the (Imperial Chemistry Industry) course notes of a lecture on HAZAN (Hazard Analysis) given at The University of Queensland, Australia (in 1979), but how and when the method found its exact origin is not completely clear. The catastrophic incident on the Piper Alpha platform in 1988 awoke the oil & gas industry. After the report of Lord Cullen, who concluded that there was far too little understanding of Hazards and their accompanying risks that are part of operations, the urge rose to gain more insight in the causality of seemingly independent events and conditions and to develop a systematic/systemic way of assuring Barrier over these Hazards. In the early nineties the Royal Dutch / Shell Group adopted the Bowtie method as company standard for analysing and managing risks. Shell facilitated extensive research in the application of the Bowtie method and developed a strict rule set for the definition of all parts, based on their ideas of best practice. The primary motivation of Shell was the necessity of assurance that appropriate risk Barriers are consistently in place throughout all worldwide operations. Following Shell, the Bowtie method rapidly gained support throughout the industry, as Bowtie diagrams appeared to be a suitable visual tool to keep overview of risk management practices, rather than replacing any of the commonly used systems. In the last decade the Bowtie method also spread outside of the oil & gas industry to include aviation, mining, maritime, chemical and health care to name a few.
- Bowtie was created by mixing two existing risk analysis tools, namely Fault trees and Event trees. Fault trees flow from bottom to top and show all the ways in which the Top Event, the event at the top, can happen. Fault trees have AND/OR gauges to model whether Barriers are parallel or sequential. Event trees work the other way around. They start with a single event, and model what consequences can result from that. They do that by having combinations of conditions, and based on a particular combination, a certain consequence occurs. Often Event trees also have calculated frequencies for their consequences.
- Bowtie adds the two together, and forms one diagram.
- One way of doing so is by introducing the barrier concept. This concept was popularized in the 80s with the introduction of the Swiss Cheese metaphore by James Reason.
- A BowTie is like the map – a representation of the truth that enables risks to be understood, with the risk treatment strategies
- The Coordination of all risk management functions is important to eliminate fragmentation, duplication and resource waste. In Hospitals this is typically the function of the risk manager or the quality manager (if well trained on risk management functions). If centralization is not possible, the administrative team (e.g. Director, Deputy Director and all department heads) should be assigned the responsibility for the appropriate functions.