RISK

MANAGEMENT
QUALITY IMPROVEMENT TRAINING FOR
FILE HOLDERS

M.T.MAREMA
PRINCIPAL TECH OFFICER (E.H)
08 JUNE 2022
SHUMBA LODGE, TUTUME,BOTSWANA
 PURPOSE OF TRAINING

 Raise awareness on Risk Management

 Equip file holders with skills for core risk management practices
 Establish a risk management process known to all
 Strengthen quality assurance in a proactive manner
 To help FH know their roles with regard to RM and what is expected of them

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 LEARNING OBJECTIVES

At the end of training, participants should be able:

 to understand what is healthcare risk management
 to describe the risk management process
 associate risk management with quality improvement
 To understand the role of FH in the accreditation system with regard to risk management process
 To understand the importance of risk management in accreditation

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 RISK?

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What is Risk?

The chance of something happening that will have an impact on objectives .

Outcome or Probability or
impact of an Frequency of an
event event
(qualitatively or
quantitatively)

Risk = Consequence X Likelihood

 Hazard?

 Anything with the potential to cause harm

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 Hazard vs. Risk

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 What is risk management?

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What is Risk Management?

The culture, the processes, and the structures that are directed towards realizing set objectives whilst managing
adverse effects.
HEALTHCARE RISK MANAGEMENT GOALS

The goal of risk management in health care is to:

1. Minimise the likelihood of possible events that have negative consequences for patients, staff & the
organisation
2. Minimise the risk of death, injury &/or disease for patients, employees & others as a result of services
provided
3. Enhance patient outcomes
4. Manage resources effectively
5. Support legislative compliance & to ensure organisational viability & development.
Risk Management as Organization wide
Performance Improvement Process

 RM is a key component of the quality management process

 Good quality management = good RM outcomes
 The aim of this collaboration is to manage risks at all levels whilst ensuring quality of care & services
 RM and QI are not isolated processes.
 Provide a framework for identifying ways to improve healthcare service delivery before problems are
identified.
 RM & QI emphasize “Harm prevention”,
 QM & RM are designed to gather information on undesirable events or trends
 N.B-Longer the length of stay for a patient in a hospital, the higher the risk of a healthcare associated event.
QUALITY INDICATORS

What is an indicator?
 A measure for monitoring and evaluation of the quality of health care
What is the Purpose of the use of indicators?
 Document the quality of care
 Make comparisons over time
 Make judgments and set priorities
 Support accountability, regulation, and accreditation
 Support quality improvement
EXAMPLES
Generic indicators which monitor organisation-wide patient safety characteristics
 Indicators monitoring hospital-acquired infections
 Indicators monitoring preventable surgical complications
 Indicators monitoring medication safety
 condition specific areas (e.g. bedsores, falls)
 Fraction of patients experiencing adverse events
 Surgical wound infections rate
 Ventilator pneumonia rate
 Catheter based UTI rate
 rate of consumption of hand disinfectants per 1000 bed days
 Rate of adverse drug events
 Patients understanding of purpose for taking medications.
Assessment of quality

Quantitative
Uses indicators to quantify
Identify priority clinical areas for review of processes
It enables comparisons over time, between providers, and of effectiveness of interventions.
Qualitative
Rich source of detailed information,
Increased knowledge on causation, preventability, & safe practices.
 ACCREDITATION

Compliant (C) – if the condition is met

Partially compliant (PC) – if partially met
Non compliant (NC) – if there is no observable progress towards complying with the required condition
SERVICE ELEMENTS
FILE HOLDERS
QUALITY MANAGEMENT,RISK
MANAGEMENT, IPC

 Quantitative
 Uses indicators to quantify
 Identify priority clinical areas for review of processes
 It enables comparisons over time, between providers, and of effectiveness of interventions
QUALITY MANAGEMENT,RISK
MANAGEMENT, IPC

Generic SEs
Cut across
Found in every SE
Cant be accredited without compliance to all
SE,STANDARD, CRITERIA,CRITERION
COHSASA ACCREDITATION STANDARDS (VERSION 6.8)

SERVICE ELEMENTS SE 5

PERFORMANCE INDICATOR (P.I) 5.5

STANDARDS 5.5.1

CRITERIA 5.5.1

CRITERION 5.5.1.5
RISK MANAGEMENT IN DIFFERENT SEs
BASIC GENERIC REQUIREMENTS FOR MOST SEs
 Incident reporting procedure/reporting of incidents
 Fire fighting equipment
 Proper handling of waste management
 Occupational health (ergonomics, PPE, screening, vaccinations)
 Security of staff/patients belongings & their persons
 Safety from harm/injury/adverse events for staff and patients
 Free from the risk of fire (flammable materials)
 PPE
 HIRA
 RISK MANAGEMENT IN DIFFERENT SEs
ACCESS TO
CARE/PATIENT RADIOLOGY
ADMIN/MANAGEMENT PHARMACY
RIGHTS  Radiation exposure
 Policies approved  Lookalike sound alike
 Patient  Disposal of xray films/
medications
 Funds availed safety/education processing chemicals
 Storage of spirit
 People appointed to  Consent
positions  Concentrated
 Telephonic verbal
electrolytes
 Staff trained/competent orders
FOOD SERVICES
LABORATORY SERVICES MAINTENANCE LINEN MANAGEMENT
 Food safety SERVICES
 Accuracy of lab results  Fire safety
 Medical exams for food for diagnosis  Security measures
handlers  Occupational
 Waste management  Control Hazards health/safety
 Waste management
 Expiries  Fire safety  Chemical
 Expiries
 Fire safety  Fire safety management