Understanding and managing clinical risk

Clinical risk management is an approach towards identifying circumstances that put patient at risks and acting to prevent those risks, writes Sheenu Jhawar

With changing healthcare needs and thus consumer expectations, many new models of management are emerging to compete for best practice. Within this remit, clinical risk management in healthcare is an up and coming phenomenon and needs adequate attention within all areas in a hospital.

Some of us may query, what has clinical risk got to do with management? Is it not something for the patient to be concerned about? The answer, interestingly, is both yes and no. Clinical risk definitely falls within the umbrella of patient safety, but involves both the provider and the user of healthcare. Putting it this way may explain the concept a bit further. If taken proactively, management of clinical risk can not only save a hospital from litigation and thus financial risk, but also add a boost through value addition to the money paid by the patient.

Management ensures better patient care by brick-walling its organisation for any possible adverse incidents that could take place. Clinical risk management is an approach to improving the quality of health care by identifying circumstances that put patient at risk and acting to prevent or control those risks.

Evidence suggests that in the USA, 3.7 per cent of patients admitted to hospital are injured by the treatment they receive. Of these 1 per cent is due to negligence, 13 per cent of these result in death and 7 per cent in permanent disability. Extrapolating these results to England, suggest 325,000 injuries per annum, including 42,000 deaths and 22,750 permanent disability cases.

Can we begin to assess the financial cost and opportunity costs of these numbers?

Needless to say, with the evolution of best practices around the world, many parallel issues for concern are heading up too. Models of management and terminology may be different across the globe, but problems essentially remain the same. Litigation suits, once considered a phenomenon of the west, have descended down at large in India too. With this in mind, adverse events and medical error in healthcare should form a priority on the management agenda, and tools should be established to address them.

These tools should cater not only to patient safety but also to the staff, since during the administration of clinical care both staff and patient can be at risk by negligent procedures. As literature points out, four categories of risk management can be identified, risks relating to clinical care, non-clinical risks such as security and fire hazards, avoidable falls, risks to the health of the workforce, and organisational risks. Given the complexity of the health care system, preventing these adverse events and improving patient safety requires a multi-faceted approach. To that effect, two strategies can be adopted simultaneously are

Pro-active

This would entail establishing operational protocols for different sectors, areas, and systems within the hospital to guard against and address possible clinical risk issues by ensuring that:

• line of control and responsibility is made clear
• levels of decision making are well understood and do not over-lap, but are approached as a multidisciplinary team effort
  
• there is practical and applicable education and training policy for the staff
  
• at the time of joining the hospital, it should be ensured that staff are aware of, and trained in handling of relevant medical equipment
  
• equipment maintenance policies are in place and are adhered to
  
• there are adequate policies on fire safety, infectious and non-infectious waste management, infection control as well as occupational health
• regular clinical audits must be done to ensure that these practices follow the laid out standards in order to point out to the gaps if any
  
• there is provision for documentation, archiving and timely retrieval of the medical records
  
• there is an accurate record tracking system in place
  
• communication between junior and senior members of the medical team, the nursing team and other health care professional is well maintained
  
• there is adequate hand-over
  
• there is provision of documenting pertinent communication between staff and patient/relative, regarding treatment decisions
  
• specific medical documentation like that of allergies, is readily and promptly accessible on medical records
  
• notes are legible and signed

Re-active

This is by ensuring:

• patient and staff complaints are treated with adequate and timely attention and are resolved with the consent of the parties involved
  
• periodical morbidity and mortality reviews are done to identify preventable factors if any, as well as to ensure that best care has been provided
  
• reasons for the litigation actions if any, are approached at the root cause level and addressed with a blame free culture
  
• there is a reporting mechanism in place for any clinical or non clinical adverse incidents that take place. This should ideally also include the ’near-misses’
  
• all such incidents should also be maintained on a ’risk register’ for periodical analysis, and audit.

Even if all adverse events could be avoided, still the cost of malpractice litigation can not be eliminated. As The Harvard Medical Practice Study found that while less than 2 per cent of negligent injuries led to claims, over 80 per cent of negligence claims were in cases where there was no injury and no negligence. This means that, if the right risk management processes and systems are in place, hospitals and doctors should be able to rebut allegations of negligence in 80 per cent of cases and successfully argue that no compensation payment should be made. While this cannot be generalised with absolute confidence but at the same time the results of the study and their implication cannot be ignored.

Although the implementation of risk management activities in hospitals is the immediate responsibility of hospital management, not doctors, yet to accomplish this as part of an ongoing organisational strategy, heads of managerial as well as clinical departments have to be taken on board. The drivers of change would be: 1. understanding the importance of the concept and 2. devising a practical, phased out approach to incorporate the various management features and tools. Henceforth, practices that are essential to the creation of an integrated proactive risk management programme can be covered.

The author is clinical auditor, Mid Stafford General Hospital, UK. Email:sheenujhawar@yahoo.com