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 you start a risk management program? • How 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 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 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 Care for the patient Preserve the evidence Document in the medical record Report the event Disclose factual information Analyze the event to prevent recurrence and/or improve outcome Follow Through with subsequent disclosure discussion(s) Heal the Health Care Team Some organization prerequisites for effective risk management 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 MArch 100 50 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 7 6 5 5 4 2 Series2 Jan '08Feb '08Mar '08Apr '08May'08Jun'08Jul '08Aug'08Sep '08Oct '08Nov '08Dec'08Jan'09Feb'09Mar'09Apr'09May'09 June'09 11 11 11 Frequency per Month 2 Jun '09 May '09 Apr '09 Mar '09 Feb '09 Jan '09 Dec '08 Nov'08 Oct'08 Sept'08 Aug'08 Jul '08 Jun '08 May '08 Apr '08 Mar '08 Feb '08 Jan '08 Staff Accident Data June 2009 Frequency Per Month 2008-2009 5 4 3 FREQ 1 Linear (FREQ ) 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 0 Oct 2007- Feb 2009 Average Pred Mort Actual Mort SMR [...]... 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... 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. .. 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... 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... 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 =...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,... 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... 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 –... 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 ... 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