Risk Management Program Overview

1. Risk Management
Vision in Action

2. “The world is not dangerous because
of those who do harm but because of
those who look at it without doing
anything”
Albert Einstein
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3. Overview
 What is Your role in Risk Management
 Unusual Occurrences
 Risk Management Framework
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4. Your Role in Risk Management
 Employees are first line of defense
 Eyes and ears of the organization
Dispelling the Myth
• Risk Management is not a department
• Risk Management is all of our Jobs – It starts with You
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5. The Role of the Risk Coordinator
◦ Facilitate Risk questions and concerns
 Reporting and Learning
◦ Support and work with departments to investigate Risk
concerns
◦ Help identify areas for quality improvement and
communication
◦ Conduct education and training on risk management topics
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6. High-
High-Level Organizational Risk
 Strategic
 Financial

Examples:
Operational Preventable barriers to timely
treatment of the patients
Unresolved Staff & Patient safety
 Hazard issues
Potential litigation due to unusual
occurrences
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7. Vision for - Risk Management Program
 Decentralized Risk Management Program (i.e. everyone is
involved) – fostering a culture that values reporting and
capturing of Risks / occurrences
 Shared understanding of what Risk means to the
Organization
 Linkage of a common understanding of Risk to timely
Decisions / Planning / Actions
 Targeted supporting processes and tools
 Ability to predict / mitigate Risks using a wide variety of
related data and tools
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8. Unusual Occurrences
 One of the existing methods to capture Agency Risks
 Goal: Reporting and Learning
 Definition: Anything that happens (or almost happens) that
is unexpected or outside of normal operation.
◦ Also Known As: Accidents, Incidents, Adverse Events
◦ Actual or Near Miss
◦ No Harm → Death
◦ Involved parties: patients, staff, visitors, volunteers, students
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9. Unusual Occurrences
 Reporting an Unusual Occurrence
◦ Objective - Reporting and Learning
◦ Anyone can report
◦ The person closest or most aware of the occurrence to complete the
appropriate form
 Your first priority is always the patient or person injured / hurt
 What do I document?
◦ Just the Facts are documented on the unusual occurrence form (or
other form) and the patient’s medical record
◦ Do not document in the medical record that an occurrence form was
completed
◦ Do not make copies of the form
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10. Critical Incidents
 Saskatchewan is 1 of 3 provinces in Canada with mandatory
reporting of critical incidents, with specific guidelines for
management and reporting to the Ministry of Health
 Critical Incident - Definition
◦ “…we mean a serious adverse health event including, but not
limited to, the actual or potential loss of life, limb or function
related to a health service provided by, or a program by, a regional
health authority (RHA) or a heath care organization (HCO)”
Source: Saskatchewan Critical Incident Reporting Guidelines, 2004
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11. Critical Incidents
 Critical Incident Reporting Categories
◦ Surgical Events
◦ Product or Device Events
◦ Patient Protection Events
◦ Care Management Events
◦ Environmental Events
◦ Criminal Events
 What do I do if a Critical Incident Happens?
◦ Take care of the patient first
◦ Notify the attending physician or oncologist
◦ Notify your immediate supervisor
◦ Contact Risk Manager via telephone (supervisor)
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12. ALERTS – Risk Identification Method
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13. Risk Mitigation Tools
 Risk Matrix
◦ Risk Likelihood & Risk Severity
 Human Factor Analysis
 Barrier Analysis
 Root Cause Analysis
 Failure Mode and Effect Analysis
 Process Decision Program Chart
 Fault Tree Analysis
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14. Risk Program – Visual Construct
Risk Mitigation
Agency Risk
(Prospective and Retrospective) Decision Planning Implementation
Risk Event Risk Profile
Internal Risk Trigger
External Risk Trigger
Outcome / End Result / Risk Reduction
Evaluation
Risk Evaluation Prediction
(Secondary)
Trend & Track
Broader
Organizational Level Organizational Risk
Evaluation Profile
Risk Network
• Engages all levels of staff and leadership
• Links strategies to reduce risk
Risk • Supports timely decision making and creation of action plans
Assessment • Strategically evaluates and monitors Risks (local and external)
• Evaluation and Feedback of Risk Mitigation Plan / Strategies
Facilitation
Prioritization
Assign Risk position Trend & Track
on the Risk Matrix
Change Management
Use Organization’s
Strategy & Prior data Communication
Risk Consequences
Shared understanding
What the UO / Risk / Event / Information means to the
Organization?
Working profile based on all available data
Pull the trending profile based on the data entered at earlier stages
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15. Step 1 Risk Capture
(Prospective and Retrospective)
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16. Retrospective Risk Capture: Unusual
Occurrences
 One of the key existing methods to capture Risks
 Goal: Reporting and Learning
 Definition: Anything that happens (or almost happens) that is unexpected or
outside of normal operation.
◦ Also Known As: Accidents, Incidents, Adverse Events
◦ Actual or Near Miss
◦ No Harm → Death
◦ Involved parties: patients, staff, visitors, volunteers, students
 Provides a good basis for what has taken place (Limitation – Backward
looking)
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17. Prospective Risk Capture: Risk Alerts
 There are many sources of information that can
(and need!) use to help and anticipate or
prospectively capture / Prevent Risk
◦ Active Environmental Scanning
◦ Provincial Risk Management Forum
◦ Ministry of Health Alerts
◦ ISMP Alerts
◦ FDA Alerts
◦ Health Canada Alerts
◦ Insurance providers Alerts
◦ And many Others….
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18. Step 2 - Risk Assessment
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19. Scope
 Applying Risk Matrix to New categories and
subcategories
Busy Busy
Frontline Manager
staff
member
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20. Scope
Staff: OOOps! I have
an unusual What a busy
occurrence to report day!
I need a day
off
Busy
Frontline
Busy
staff
member
Manager
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21. Thank Goodness
that we have an
electronic
system. Now what!
…….Another
I don’t need to occurrence!
waste any time Staff: Wow! I can
now searching for Do I need to act
the right form!
select from the drop
on it today?
downs. And I don’t
need to chase anyone
for sign off or
anything!
Reportin
g
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22. This is 60th
Scope occurrence of the
month!
QSR – we hate you!
Why did you
developed such an
easy reporting
system!
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23. Scope
I wish there was a way
to identify which one of
these reports I should
tackle first!
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24. Prioritization of the Risk!
 Adding “Risk” to the discussion
◦ Assessment of Severity / Likelihood for the event in
question at that time
Busy
Frontline
staff Busy
member Manager
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25. Prioritization of the Risk! There is no
consistency
in
reporting…..
Everyone
uses different
Please tell me words in
precisely how bad their
this event was? description….
Help me prioritize
it.
Busy
Frontline
staff
member
Busy
Manager
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26. Prioritization of the Risk!
There must
I can rank be a way to
What!
consistently if I captured the
get the
I don’t know
…. occurrence and explained information
anything about what went wrong? to rank the
Risk How else can I help? risks
Reportin
g
Busy
Frontline
staff
member
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27. Which Risk Matrix?
Risk Matrix
hmm…..
• Used by the staff when initially
completing the occurrence report
What if I
get this
wrong? • Helps prioritize and screen the
occurrence based on the perception
of the person completing the
occurrence.
• Severity or the Risk will be very
much dependent on the occurrence
being reported.
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28. Which Risk Matrix?
Well,
during
review I
can
discuss
and
reprioritize
..
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29. Which Risk Matrix?
Well,
Risk Matrix during
review I
• Used by the manager at the end of can
the initial review of the occurrence. discuss
and
reprioritize
• Helps prioritize and position the
..
Risk using the additional information
and knowledge from previous
occurrences
•Severity or the Risk will be very
much dependent on the occurrence What does this mean?
being reported.
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30. What do you mean by Occurrence
Dependent Risk Severity?
Should these occurrence
have same Risk
Severity?
What are the
similarities?
What are the
differences?
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31. Linking occurrence events with severity
I wish there
would be
drop downs Please don’t forget me! You
and guide for always say that healthcare
Risk Severity. should be patient centered!
…
Are you reporting something
which relates back to patient-
safety or risk?
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32. Risk Matrix!
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33. Step 3 - Risk Consequences
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34. Sample Consequence Table
 Based on a shared understanding, definitions represent what
a consequence means for a particular risk (i.e. presented here
for a patient safety impact)
 Consequence tables should be developed for other
overarching organizational risk areas
Consequence Category Patient Safety Impact
Critical Service resulting in Patient death. Significant impact on patient care.
Major Service affecting patient care. Patient may experience permanent loss
of body function
Moderate Service affecting patient care. Patient may require additional
treatments and/or experiences temporary loss of body function
Some threat to patient service. Patient may experience delay ( < 15
Minor
days) or experiences minor pain / discomfort (Scale: 3/ 10 ?)
Patient may not experience any noticeable impact
Negligible
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35. Step 4 - Risk Profiling
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36. What does our risk data tell us?
 Understand Current Capacity
 Use Pareto Charts to analyze and review the organizational
Risk Profile.
 Identify vital few area – which can result in BIG gains
 Create Risk Profile for all organizational services and areas
“There's a way to do it better - find it.” - Thomas Alva Edison
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37. Expanding Capability with Risk
Management Program
 With a shared understanding of risk, and tools
such as the Risk Matrix, Risk Profiling can be
nurtured for multiple benefits:
◦ What does risk X mean in regards to risk Y
◦ Alert generation based on the statistical analysis
◦ Risk understanding becomes a driver for making
system improvements / decisions / strategy
◦ Helps focus patient and staff safety improvements
◦ Allows more informed benchmarking
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38. Step 5 Risk Mitigation
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39. Risk Mitigation
 Risk that has been quantified and profiled, needs
to also lead to effective mitigation (i.e. Action!)
 The RM program should be used in the decision
and planning process
 Tools such as following can be developed that
specifically address the following areas:
◦ Roles and responsibilities in mitigation
◦ Levels of authority and decision making
◦ Development and actioning of implementation plans
◦ Monitoring and Evaluation of risk mitigation efforts
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40. Central Hub - Risk Network
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41. Goal:
A shared infrastructure to enhance support, understanding and
Communication of Risk
 The ‘Glue’ that brings all of the processes together
 Formalizes a mechanism that enables staff to contribute
their local knowledge and expertise to the
organizational risk program
 Links and engages all levels of the organization together
 Specifically designed to overcome the common
challenge faced at all levels by being designed to be
conscious of staff time and limited resources
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42. Risk Program – Visual Construct
Risk Mitigation
Agency Risk
(Prospective and Retrospective) Decision Planning Implementation
Risk Event Risk Profile
Internal Risk Trigger
External Risk Trigger
Outcome / End Result / Risk Reduction
Evaluation
Risk Evaluation Prediction
(Secondary)
Trend & Track
Broader
Organizational Level Organizational Risk
Evaluation Profile
Risk Network
• Engages all levels of staff and leadership
• Links strategies to reduce risk
Risk • Supports timely decision making and creation of action plans
Assessment • Strategically evaluates and monitors Risks (local and external)
• Evaluation and Feedback of Risk Mitigation Plan / Strategies
Facilitation
Prioritization
Assign Risk position Trend & Track
on the Risk Matrix
Change Management
Use Organization’s
Strategy & Prior data Communication Risk Consequences
Shared understanding
What the UO / Risk / Event / Information means to the
organization?
Working profile based on all available data
Pull the trending profile based on the data entered at earlier stages
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43. Keeping Perspective
 * Mary Insert Pictures Here *

44.  Questions ……
 Additional Information
◦ Telephone: (306) 791-2777
◦ Email: Jignesh_padia@yahoo.com
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