RM

1. RISK MANAGEMENT
Presented by
Bonney son
Shangdiar (QM)

2. CONTENTS
• Introduction to Risk
• Risk Management framework
• Categories/types of Risk in Hospitals
• Approach to risk management
• Risk Management process

3. NQAS Area of Concern –G
STANDARD G8 Facility has de defined, approved and communicated Risk Management framework for existing and potential risks.
ME G8.1 Risk Management framework has been defined including context, scope, objectives and criteria
ME G8.2 Risk Management framework defines the responsibilities for identifying and managing risk at each level of functions
ME G8.3 Risk Management Framework includes process of reporting incidents and potential risk to all stakeholders
ME G8.4 A compressive list of current and potential risk including potential strategic, regulatory, operational, financial, environmental risks has been prepared
ME G8.5 Modality for staff training on risk management is defined
ME G8.6 Risk Management Framework is reviewed periodically
STANDARD G9 Facility has established procedures for assessing, reporting, evaluating and managing risk as per Risk Management Plan
ME G9.1 Risk management plan has been prepared and approved by the designated authority and there is a system of its updating at least once in a year
ME G9.2 Risk Management Plan has been effectively communicated to all the staff, and as well as relevant external stakeholders
ME G9.2 Risk assessment criteria and checklist for assessment have been defined and communicated to relevant stakeholders
ME G9.4 Periodic assessment for Physical and Electrical risks is done as per defined criteria
ME G9.5 Periodic assessment for potential disasters including re is done as per de defined criteria
ME G9.6 Periodic assessment for Medication and Patient care safety risks is done as per defined criteria.
ME G9.7 Periodic assessment for potential risk regarding safety and security of staff including violence against service providers is done as per defined criteria
ME G9.8 Risks identified are analyzed evaluated and rated for severity
ME G9.9 Identified risks are treated based on severity and resources available
ME G9.10 A risk register is maintained and updated regularly to risk records identify risks, there severity and action to be taken

4. RISK MANAGEMENT ORGANIZATIONAL FRAMEWORK
HOSPITAL QUALITY COMMITTEE
QUALITY TEAM
QUALITY CIRCLE
WARD

6. WHAT IS RISK
As per ISO 31000:
 Risk is "The effect of uncertainty on objectives"
 Risk in healthcare refers to the potential for harm or loss that can
affect patients, staff, and the organization, encompassing various
categories such as operational, financial, compliance, patient
handling risk, Environmental risks, behaviour etc.
 Risk management is "coordinated activities to direct and control an
organization with regard to risk".

7. Examples of Risk in Hospitals

8. APPROCAH TO RISK MANAGEMENT

9. RISK MANAGEMENT PROCESS

13. Brain storming:
Group/ team exercise
1. Defer judgement
2. Encourage out of the box or
new ideas
3. One conversation at a time
4. Build on ideas of others
5. Encourage members for
listing as many risk as
possible
6. Stay relevant ad focused on
the topic

14. Root cause analysis:
1. Helps the team to reach
beyond the evident reason for
cause of the hazard
2. The staff member performing
the hazard should continue
asking the question ‘why’ until
he/she reaches the most logical
and explanatory cause of the
hazard
3. One must ensure that only
relevant reasons should be
kept in the process and ones
with less probability of causing
the hazard should be

15. Peer review technique:
1. Peer are people belonging to the
same level and having a similar
work and practising in a similar
way
2. Peer review procedure is mostly
executed for risks cause under
the ambit of ‘patient and clinical
safety’

16. Analogy  Analogy in risk
management means having
a reference from the past
in order to avoid certain
risk and to predict
potential risk

17. FMEA
FMEA (Failure mode effect
analysis) is a systematic,
proactive method for
evaluating a process to identify
where and how it might fail
and to assess the relative
impact of different failures, in
order to identify the parts of
the process that are most in
need of change

18. Surveys  Systematic feedback from
the patients, staff, and
visitors.
 The objectives of not only
achieving patient
satisfaction but to optimize
the procedure and
increasing patient safety

19. Audits  Independent, systematic, and
documented procedure to gather
information about an event
 It can be inter-departmental,
intradepartmental, or can be a
facility audit
 E.g. Prescription audit

20.  Risk score is calculated by multiplying the likelihood score with severity of impact
score as below:

21. Example of Risk score calculations

26. Risk identified for medication system/HIC Likelihoo
d
severit
y
Risk
score
Risk
categor
y
Mitigation plan
Drug contraindications 1 2 2 low CME-Continuous Medical Education
improper Storage of drugs/high alert drugs 3 3 9 Medium Policy for Storage of high alert drug,
Stock calculation( buffer stock & reorder
level)
Medication administration error 4 4 16 High Staff training, change SOP/policy, follow
7R technique
HAI 3 3 9 Medium Hand hygiene- 6 steps & 5 moments,
Infection control policy
Spill management(Blood spill) 3 5 15 High PPE, Decontamination & environmental
cleaning
CAUTI(catheter associated urinary tract infection) 4 2 8 Medium Maintain a closed, sterile drainage
system to prevent contamination.
Examples

27. Risk register: document maintain by all the departments
Date of
identificatio
n
Risk
title
Risk
descriptio
n
Possible
cause
Likelihoo
d of risk
Severity
of risk
Impact
factor
Risk
category
Risk
owner
Date of
assessment
Date of
resolve
Residual
risk
Date of
surveill
ance
Risk
avoidanc
e
/mitigati
on

28. THANK YOU