Checklists such as those that Dr. Atul Gawande writes about in
his book "The Checklist Manifesto" are an important first step in
managing risk. Frederick W. Taylor discussed this idea in the
1890s.
The next step for the health care services industry is to
develop and execute a robust operational risk management program.
It starts with developing a vision. The vision statement should
articulate the ideal future state of the organization. Vision
enables stakeholders to agree on a destination and the parameters
to get there.
There are five salient characteristics:
- The customer -- who is also the patient - must be the focus. It
is not the government or those that provide the services.
- The interaction of these groups and the customer define the key
point of leverage.
- There must be operational policies and standards agreed upon by
all stakeholders.
- Patient values and professional standards must be reflected in
the vision.
- The customers must actively manage their own health risks.
Risks should only be accepted if there is value in doing so,
e.g., to advance knowledge or because there is no other
professional choice.
Risks are generally future events that may negatively, perhaps
catastrophically, affect the implementation of the strategy to
execute a vision. These may change over time, be knowable or not
knowable, and are usually cumulative. Cumulative in a sense that
minor untoward events may be additive and become catastrophic.
Historical Reference
Risks are often best identified by analyzing historical data.
Certainly catastrophic events should be included. Given the fact
that risks are usually cumulative, it is important to collect
non-catastrophic events also; even if we do not initially know how
to link the data. So as our environment changes, new risks may
emerge and old ones fade.
In analyzing the data, we must seek to identify risk drivers.
Ideally we would like to address the causes of the risk. Addressing
signs, symptoms or isolated risks may compromise our ability to
achieve the vision and lead to inefficient use of resources.
Solutions that ration resources without identifying the drivers are
usually sub-optimal.
Since service is "manufactured" between the customer and those
interacting with the customer, the drivers may be behavioral. How
effectively do the parties interact? Do they act in ways that may
create risk? Do they act in a synergistic way to achieve the
vision?
Customers have a responsibility to do no harm to themselves.
They also have the responsibility to be effective co-manufacturers
of the service.
The culture of the organization must be supportive of the vision
being executed. The opinions, attitudes and beliefs of the
organization are the key enablers of a successful strategy. If the
patient isn't viewed as part of the solution-that is a problem. If
the process is viewed as more important than the customer or the
doctor-that may cause risks. If the service delivery is too
atomized-important linkages or systemic drivers may be missed.
One of the reasons to analyze historical risk data is to
estimate the value to address it. In other words, if the risk
occurred what would be the result? Would it be catastrophic? Would
it be isolated?
Wrestling with Data
Some risks may be knowable at a point in time; continuous
learning is critical. But some risks also may not be knowable. They
may be caused by unforeseeable events and/or have a low probability
of occurring.
There are generally four sources of this type of data:
proprietary clinical, insurance and loss data; customer feedback;
data from other health care organizations (public or private); and
data from other service organization - including lessons learned
from other sectors that apply to health care.
The data is often overwhelming. It may be best to focus first on
the catastrophic events. Where there is experience that suggests
certain risks are not likely to be catastrophic, perhaps you should
initially defer the analysis.
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