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Enterprise Risk Management in Healthcare Organisations “Going Beyond Patient Safety”

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This presentation was given at the 10th Canadian Quality Congress, Vancouver, September 2018. The author suggests the applicability and usefulness of enterprise risk management to healthcare and proposes the bow tie methodology as a proactive barrier-based risk management tool valid for enterprise risk management implementation in healthcare.

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Enterprise Risk Management in Healthcare Organisations “Going Beyond Patient Safety”

  1. 1. Enterprise Risk Management in HealthcareOrganisations “Going Beyond PatientSafety” Hossam Elamir MSc.HCM, TQMD, MBBCh, CPHQ, CPHRM
  2. 2.  “A ship in harbor is safe, but that is not what ships are built for” John Augustus Shedd (1859 – 1928)
  3. 3.  "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.
  4. 4.  “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.
  5. 5. “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”
  6. 6. Delivering safe care of high quality is the professional, legal and ethical duty of all healthcare professionals
  7. 7.  Accreditation Requirement: Organizations must have a documented risk management plan
  8. 8.  “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
  9. 9.  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.
  10. 10. 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
  11. 11. 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
  12. 12.  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
  13. 13. ContrastingTraditional RM with Enterprise RM ERMTRM ProactiveFocusReactive Value creationOutcomeAsset preservation Organizational-wideBreadth/ DepthDepartmental/silos Risk preventionActivitiesRisk mitigation Clinician/staffEngagementBoard/C-Suite
  14. 14. 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.
  15. 15.  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.
  16. 16.  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
  17. 17. Operational Patient Safety Holistic Approach Value Protection andValue Creation
  18. 18. Clinical Operational Patient Safety Holistic Approach Value Protection andValue Creation
  19. 19. Strategic Clinical Operational Patient Safety Holistic Approach Value Protection andValue Creation
  20. 20. Financial Strategic Clinical Operational Patient Safety Holistic Approach Value Protection andValue Creation
  21. 21. Financial Human Capital Strategic Clinical Operational Patient Safety Holistic Approach Value Protection andValue Creation
  22. 22. Financial Human Capital Strategic Clinical Operational Legal/ Regulatory Patient Safety Holistic Approach Value Protection andValue Creation
  23. 23. Financial Human Capital Strategic Clinical Operational Legal/ Regulatory Technology Patient Safety Holistic Approach Value Protection andValue Creation
  24. 24. Financial Human Capital Strategic Clinical Operational Legal/ Regulatory Technology Hazard Patient Safety Holistic Approach Value Protection andValue Creation
  25. 25. 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
  26. 26. 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
  27. 27. v. 1 pp. 108, 223, ASHRM ERM Pearl, pp. 19-27 Selecting apparently best techniques Choosing selection criteria Decision rules applying criteria
  28. 28. v. 1 pp. 108, 223, ASHRM ERM Pearl, pp. 19-27 Implementing the selected risk techniques
  29. 29. v. 1 pp. 108, 223, ASHRM ERM Pearl, pp. 19-27 Monitoring & improving the RM program Purposes Control program
  30. 30. v. 1 p. 223 The Risk Management Process Identification and Analysis of Exposures Treatment of Exposures Risk Control Risk Financing Retention Transfer
  31. 31. 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
  32. 32. Risk = Likelihood of risk occurring (Frequency) x Impact of risk occurring (Severity, Consequences)
  33. 33. 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)
  34. 34. Threats (negative) Opportunities (positive) Proactive control Prevent Reduce Accept Contingency Transfer Share Exploit Enhance Reject
  35. 35. Risk ID Description of Risk Risk Assessment Risk Rating (I x L)Impact (I) Likelihood (L)
  36. 36. 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.
  37. 37. 1979 1988 90’s 00’s
  38. 38. Fault tree Event tree
  39. 39. Fault tree Event tree
  40. 40. Oil & Gas Aviation Energy Chemical Mining Medical Financial Government Construction Cyber risk
  41. 41. 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
  42. 42. ! 2 Do you have enough barriers to be (enough) in control?
  43. 43. 3 ! ! ! What if the Engineering Manager is fatigued? Or when you have a power blackout?
  44. 44. 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.
  45. 45. The success of the risk management program depends on the cooperation of all employees.
  46. 46. Dr. Hossam Elamir dr_hossam_elamir@hotmail.com 67767083

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