SCHOOL OF BUSINESS AND ECONOMICS

DIPLOMA IN HEALTH SYSTEMS MANAGEMENT

INDIVIDUAL ASSIGNMENT
TAKE HOME

HSM 212: PROJECT MANAGEMENT FUNDAMENTALS FOR HEALTHCARE SYSTEMS.

BY: PROF. PHILEMON YUGI.

15/07/2021

NAME: HOSEA KIBET RUTTO

STUDENT NO:200682 DHSM

 RISK ANALYSIS AND RISK MANAGEMENT PLAN FOR MY HEALTH FACILITY
1. RISK ANALYSIS
Risk is defined as the uncertainty of an event or an action that might lead to an adverse impact on the objectives, processes
or the organization as a whole. Hospitals are complex organizations dealing with a sensitive and dangerous business that
touches upon human lives. Now more than ever before, hospitals are bound to face a multitude of risks ranging from
financial to operational and other physical hazards. We in hospital management need to be cognizant of such risks and try to
identify and mitigate them in a safe manner. For this purpose, it is imperative to implement an active risk management
program.
Consequence score
Risk Low risk Minor risk Moderate risk Major risk Catastrophic risk
1 2 3 4 5
Operational Adverse event Minor injury or illness, Significant injury requiring Major injuries/long term Incident leading to death or major
/ Clinical leading to minor first aid treatment is medical treatment e.g. fracture incapacity or disability (loss of permanent incapacity.
injury not required. < 3 days and/or counselling. >3 Days limb) requiring medical Event which impacts on large
requiring first aid. extended hospital stay. absence or 3-8 Days extended treatment and/ or counselling. number of patients or members of
No impaired Impaired functions. hospital stay. Impaired Impaired functions greater the public.
functions Greater than 3 days functions greater than one than six months Sustained loss Permanent impairment of functions
month but less than six months of service which has serious or incapacity Permanent loss of core
Some disruption in service with impact on overall delivery of service or facility.
unacceptable impact on overall services. Requires Major
services. Temporary loss of contingency plans
ability to provide services
Financial Interruption in a Short term disruption to Significant injury requiring Major injuries/long term Incident leading to death or major
Business service which service with minor medical treatment e.g. fracture incapacity or disability (loss of permanent incapacity. Event which
does not impact impact on overall and/or counselling. >3 Days limb) requiring medical impacts on large number of patients
Continuity on the overall services of the hospital absence or 3-8 Days extended treatment and/ or counselling. or members of the public.
delivery of hospital stay. Impaired Impaired functions greater Disruption of overall hospital
services. functions greater than one than six months Sustained loss services. May lead to significant
Improvement month but less than six months of service which has serious ‘knock on’ effect
actions required Some disruption in service with impact on overall delivery of
 unacceptable impact on overall services. Requires Major
services. Temporary loss of contingency plans
ability to provide services
Strategic / Rumors, no media Local media interest Local media –adverse publicity. Local media – long term National/ International media/
Reputation coverage. No possible but short term Significant effect on staff adverse publicity. Public calls adverse publicity, > than 3 days.
public concerns coverage Single failure morale & public perception. for specific remedial action. Public confidence undermined.
voiced to meet internal Public calls (at local level) for Comprehensive review/ Hospital performance questioned.
standards or follow specific remedial action. investigation necessary Government intervention. Court
protocol. Minor Review/ investigation necessary Repeated failure to meet action. Gross failure to meet
recommendations Repeated failure to meet external standards. Failure to external standards. Repeated failure
which can be easily internal standards or follow meet national norms and to meet national norms and
addressed by hospital protocols. Important standards / regulations. Critical standards / regulations. Severely
management recommendations that can be report or significant findings critical report with possible major
addressed with an appropriate and/ or lack of adherence to reputational or financial
management action plan 10% regulations 10-25% over implications >25% over budget.
over budget. Some delay in budget. Major delay in Major delay in scheduled activities.
scheduled activities. Reduction scheduled activities. Failure to
in scope/quality Moderate meet secondary objectives
effect of the facility. May affect Damage to the facility
some hospital services requiring external assistance
(civil defense, radiation
protection service etc.)
Legal / Minor non- Local media interest Local media –adverse publicity. Local media – long term National/ International media/
Regulatory compliance with possible but short term Significant effect on staff adverse publicity. Public calls adverse publicity, > than 3 days.
internal standards. coverage Single failure morale & public perception. for specific remedial action. Public confidence undermined.
Minor issues to meet internal Public calls (at local level) for Critical report or significant Hospital performance questioned.
requiring standards or follow specific remedial action. findings and/ or lack of Government intervention. Court
improvement protocol. Minor Review/ investigation necessary adherence to regulations 10- action. Gross failure to meet
recommendations Repeated failure to meet 25% over budget. Major delay external standards. Repeated failure
which can be easily internal standards or follow in scheduled activities. Failure to meet national norms and
addressed by hospital protocols. Important to meet secondary objectives standards / regulations. Severely
management recommendations that can be Damage to the facility critical report with possible major
addressed with an appropriate requiring external assistance reputational or financial
management action plan 10% (civil defense, radiation implications >25% over budget.
over budget. protection service etc.) Major delay in scheduled activities.
Technologic Insignificant cost. Local media interest Local media –adverse publicity. Local media – long term National/ International media/
al / Projects Increase / Minor possible but short term Significant effect on staff adverse publicity. Public calls adverse publicity, > than 3 days.
delay in activities. coverage Single failure morale & public perception. for specific remedial action. Public confidence undermined..
Barely noticeable to meet internal Public calls (at local level) for Comprehensive review/ Court action. Gross failure to meet
reduction in scope standards or follow specific remedial action. investigation necessary external standards. Repeated failure
or quality protocol. Minor Review/ investigation necessary Repeated failure to meet to meet national norms and
recommendations Repeated failure to meet external standards. Failure to standards / regulations. Severely
which can be easily internal standards or follow meet national norms and critical report with possible major
addressed by hospital protocols. Important standards / regulations. Critical reputational or financial
management recommendations that can be report or significant findings implications >25% over budget.
addressed with an appropriate and/ or lack of adherence to Major delay in scheduled activities.
management action plan 10% regulations 10-25% over Failure to meet primary objectives
over budget. Some delay in budget. Major delay in Many hospital services are
scheduled activities. scheduled activities. Failure to curtailed. Detrimental effect
meet secondary objectives requiring external assistance
Damage to the facility
requiring external assistance
(civil defense, radiation
protection service etc.)
Natural Negligible Local media interest Local media –adverse publicity. Local media – long term National/ International media/
Disaster / effect possible but short term Significant effect on staff adverse publicity. Public calls adverse publicity, > than 3 days.
coverage Single failure morale & public perception. for specific remedial action. Public confidence undermined.
Hazard to meet internal Public calls (at local level) for Repeated failure to meet Hospital performance questioned.
standards or follow specific remedial action. external standards. Government intervention. Court
protocol. Minor Review/ investigation necessary Critical report or significant action. Gross failure to meet
recommendations Repeated failure to meet findings and/ or lack of external standards. Repeated failure
which can be easily internal standards or follow adherence to regulations 10- to meet national norms and
addressed by hospital protocols. Important 25% over budget. standards / regulations. Severely
management recommendations that can be Major delay in scheduled critical report with possible major
addressed with an appropriate activities. Failure to meet reputational or financial
management action plan 10% secondary objectives implications >25% over budget.
over budget. Some delay in Damage to the facility Major delay in scheduled activities.
scheduled activities. Reduction requiring external assistance
in scope/quality Moderate (civil defense, radiation
effect of the facility. May affect protection service etc.)
some hospital services
2. RISK MANAGEMENT PLAN
Physician Strategy Risks associated with doctor engagement model including attracting and retaining
and Relations experienced panel of physicians for hospital operations
Medical Services Risks associated with a multidisciplinary approach to acute care, specialty care,
diagnostic and investigations and wellness program. This includes risks related to
inadequate facilities and inaccurate treatment of an ailment in each of the service
areas.
Service Risks associated with adequate infrastructure to support patient services, patient
Excellence satisfaction and care for IP, OP and International Patients
Quality and Risk associated with infection control, physician licensing and credentialing,
Accreditations medicare documentation and reporting, clinical standards and practices, emergency
procedures, clinical audits etc.
Health & Safety Risks associated with environment pollution, safety of resources and employees’
health and security at health care establishments
Nursing Risks related to the adequacy of policies and procedures related to nursing
Operations operations and maintain continuous care.
Facilities & Risks associated with inadequacy or failure of facilities and equipment for delivery
Equipment’s of care.
Pharmacy Risks associated with operation of pharmacy and delivery of pharmaceutical
products to hospital units and out patients.
Finance Risks associated with customer sources, competition, brand management & brand
licensing and reputation of the company.
Legal and Risk relating to non-compliance with legislations including direct & indirect tax
Compliance law provisions, adequacy of financial reporting & disclosures, regulations, internal
policies and procedures.

Periods for implementing the plan

Role Time implementing risk Activities Half yearly

assessment Yearly
Risk Owner Half yearly Update status of implementation
of mitigation plan for identified
component of risk
 Review and update risk register
and profiles and submit to Risk
Coordinator - Risk Coordinator

Risk Coordinator Half yearly Collate updated risk profile from

Risk Owner and submit to the
Divisional Risk Management
Committee (DRMC) for their
review  Update DRMC risk
register and report to the
Company Secretary
Divisional Risk Management Half yearly Validate assessment of risks
Committee (DRMC)  Review and approve risk
mitigation plans submitted by the
Risk Coordinator
 Review and approve risk
register
Risk Management Steering Yearly Review the risk register and  Review consolidated risk register
Committee profiles for the hospital
 Monitoring and reviewing of the
risk management activities as
approved by the Board
Review and recommend the Risk
management report for approval of
the Board
Board of Directors Yearly  Review the critical risks for the
hospital and their mitigation plans
 Approve public disclosures related
to risk management