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Improving Improvement

A toolkit for Engineering Better Care

 

Assessing Risk

A risk perspective ensures that system threats and opportunities are identified and their consequent risks are managed in accordance with stakeholder expectations.

Contents

 

Introduction

Engineering risk and safety management methods, such as Failure Mode and Effects Analysis, Hazards and Operability Analysis and Fault Tree Analysis, are used to identify potential threats and opportunities within a system and to manage their likelihood and/or impact on people, property, progress or profit. The role of risk management is to identify, assess and control the level of known risk, accepting the inherent threat or opportunity that may be present within the system, in particular with complex medical interventions and in the distributed system of social care.

It is useful to consider the process of risk management to be made up of a series of iterative examine, assess / seek and improve cycles that enable a team to progress from understanding what is known about the system through to developing interventions to manage the risk presented by the system. Active risk management is appropriate at all stages of a product or service lifecycle, from early conception, through use to disposal.

Risk can be referenced to a system’s ability to deliver high-quality, cost-effective care, where quality is defined as the combination of clinical and cost effectiveness, patient safety and patient experience1. Risk management is commonly used as a clinical tool for the prospective analysis of an individual patient’s risk, with or without a particular intervention. However, it may also be used to evaluate the risk in sustaining or not achieving the desired outcomes for a population of patients, the efficiency of a care process or the finances of a care provider2. Different stakeholders may have different risk priorities within the same system and risk tolerance levels will vary with time and be dependent upon the context of each specific care delivery system or process. Risk may also be attributed to uncertainty in performance where mitigation will likely focus on the identification of the sources of such variation and their reduction.

The identification and exploitation of opportunities to learn from exceptional performance represents the alternative face of risk management. This view has gained much traction in recent years as a complementary activity alongside traditional methods of risk management1. In practice, both approaches should be used to be able to take an holistic approach to proactive risk management.

Footnotes

  1. From Safety-I to Safety-II: A White Paper. Hollnagel, Wears and Braithwaite, The Resilient Health Care Net, 2015.
  2. Design for patient safety: a system-wide, design-led approach to tackling patient safety in the NHS. Department of Health and Design Council, London, UK, 2003.

Questions

Examine

What is going on?

The examine phase asks the question ‘What is going on?’ and leads to an understanding of the system architecture and details of the interfaces between the elements, which takes account of the range of stakeholders and their needs. It is likely to include a variety of activities that can help build this understanding, for example:

  • Outline the goals of the risk assessment
  • Describe the system and identify critical risk stakeholders
  • Agree acceptable levels of system risk

Assess

What could go wrong?

The assess phase asks the question ‘What could go wrong?’ and leads to a systematic assessment of the likelihood and potential impact of threats within a system, which takes account of the nature, frequency and source of the threats. It is likely to include a variety of activities that enable this assessment, for example:

  • Identify threats to the sustained performance of the system
  • Evaluate risks associated with the threats and their detectability
  • Specify mitigation needs to reduce unacceptable risks

Seek

What are we doing well?

The seek phase asks the question ‘What are we doing well?’ and leads to a systematic assessment of the likelihood and potential impact of opportunities within a system, which takes account of the nature and source of the opportunities. It is likely to include a variety of activities that enable this assessment, for example:

  • Identify opportunities to enhance the performance of the system
  • Evaluate benefits linked to the opportunities and their achievability
  • Specify improvement needs to exploit the opportunities

Improve

How can we make it better?

The improve phase asks the question ‘How can we make it better?’ and leads to range of possible solutions that would help mitigate the threats or exploit the opportunities, which takes account of the stakeholders’ appetite of such risk. It is likely to include a variety of activities that enable this implementation, for example:

  • Propose actions to manage the risk within the system
  • Implement potential actions within the system
  • Review the assessment in a timely manner

Process

Tools

Literature

British Standards (2009). BS ISO 31000:2009 Risk management — principles and guidelines. British Standards, London, UK.

DH and Design Council (2003). Design for patient safety: a system-wide, design-led approach to tackling patient safety in the NHS. Design Council and Department of Health, London, UK.

Hollnagel E, Wears R and Braithwaite J (2015). From Safety-I to Safety-II: A White Paper. The Resilient Health Care Net: Published simultaneously by the University of Southern Denmark, University of Florida, USA, and Macquarie University, Australia.

HSE (2014). Risk assessment — A brief guide to controlling risks in the workplace. INDG163 (rev4), Health and Safety Executive, London, UK.

Lewis H, Allan N, Ellinas C and Godfrey P (2014). Engaging with risk. CIRIA, London, UK.

NPSA (2007). Healthcare Risk Assessment Made Easy. NPSA, London, UK.

Spear SJ (2005). Fixing Healthcare from the Inside, Today. Harvard Business Review, R0509D.

Vincent C and Amalberti R (2016). Safer Healthcare: Strategies for the real world. Springer International Publishing, Switzerland.

Yu A, Flott K, Chainani N, Fontana G and Darzi A (2016). Patient safety 2030. NIHR Imperial Patient Safety Translational Research Centre, London, UK.

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