R ISK AND Q UALITY M ANAGEMENT A DAPTED B Y : R USSEL JANSEN VAN R ENSBURG.

RISK AND QUALITY MANAGEMENT ADAPTED BY: RUSSEL JANSEN VAN RENSBURG

FLOW DIAGRAM OF PROCESSES

(1) Strategic Plan (SWOT)

(2) Committee & Identification of Risks

(3) Assessing the Risks

(4) Formulating a Risk Management Plan

(5) Committee & Identification of Quality Improvement Opportunities

(6) Formulating a Quality Improvement Plan

(7) Documenting these Quality Improvement Actions(QIP’s)

PROCESS 1: STRATEGIC PLAN:

Mission, vision and objectives of the organisation

Core business of the organisation

SWOT Analysis: Weaknesses & Strengths

PROCESS 2: COMMITTEE & IDENTIFICATION OF RISKS:

Form Risk Committee representing all service areas/departments. Job

descriptions

Meetings: 1-3/12 . Agenda & minutes In-service Training documented in

training register & personnel files:

PROCESS 2: IDENTIFICATION OF RISKS:

What is a Risk?Anything that causes or has the potential to

causeharm or injury to persons (patients, employees,volunteers, visitors or contractors), the organisation (physical, legal, financial,operational) or the environment

Many risks cannot be eliminated but need to

be managed

PROCESS 3: ASSESSING THE RISKS:

a) Start with a detailed assessment of each area of service/department: - Governance

- Human Resources - Administrative Support: financial management,

information management, MER, facilities, OHS, security, fire & emergency planning, equipment, provisioning & supplies, vehicles, waste management etc

- Patient Care: Clinical & Non-clinical: incl. IDT, pt.

access & rights, pt care, infection control, medication management. In Patient Unit & Home Based Care

- Support Services : Food, laundry & housekeeping - Education & Research: CPL’s

- Fundraising: donor id & maintenance

PROCESS 3: ASSESSING THE RISKS (CONT.)

b) Assign a severity rating and prioritise the

risks: Weighing Key:Probability: 1 = LOW (may not occur at all) 5 = VERY HIGH ( already present or

occurring)

Impact: 1 = MILD (may not have any visible effect) 5 = CATASTROPHIC (will result in loss of

life, function etc)To get the actual risk factor/severity:Multiply the probability with the impact

PROCESS 3: ASSESSING THE RISKS (CONT.)

b) Assign a severity rating and prioritise the risks Probability on a 1 – 5 scale x (multiplied Impact on a 1 – 5 scale = Severity Rating

Example:Bomb explodes: Probability 1 x Impact 5 = 5Difficulty in finding staff: Probability 4 x

Impact 5= 20

PROCESS 3: ASSESSING THE RISKS (CONT.)

c) Document Severity Rating of all risks across all

Service Areas/Departments:

Example:Servicearea

Risk Proba-bility

Impact Totalrisk

Com-ments

1 2 3 4 5 1 2 3 4 5

PROCESS 3: ASSESSING THE RISKS (CONT.)

Key to Determine the Severity Rating:

Severity of Impact:

Proba-bility

Insign

1

Minor

2

Mod.

3

Serious

4

VerySerious5

Very High5

5 10 15 20 25

High4

4 8 12 16 20

Medium3

3 6 9 12 15

Low2

2 4 6 8 10

Very Low1

1 2 3 4 5

PROCESS 3: ASSESSING THE RISKS (CONT.)

Prioritise the Risks identified:

On basis of: * High Risk * High Volume * High Cost

PROCESS 4: FORMULATE A RISK PLAN:

How?• Start with an overview: - Organisation - What Risk Management entails

• Get each department to id own risks

PROCESS 4: FORMULATING A RISK MANAGEMENT PLAN Develop an overall risk management

plan

ServiceArea/Depart.

Risk Ident.

Object. Actionplans

Resp.Person

TimeFrame

Pro-gress

Gov.

HR

Admin Support

PROCESS 4: FORMULATING A RISK MANAGEMENT PLAN ADDITIONAL TASKS:

Develop a tool/instrument for monitoring

risks (could also be progress if updated 1/12)

Record all near miss/adverse events (negative incidents)

Take and record remedial action

Report on progress to the H & S Committee, Management and Board (NB: Occupational Health & Safety Act no 85 of 1993)

PROCESS 5: COMMITTEE & IDENTIFICATION OF QUALITY IMPROVEMENT OPPORTUNITIES Form Quality Improvement Committee

representing all service areas/departments.

Job descriptions

Meetings: 1-3/12 . Agenda & minutes In-service Training documented in

training register & personnel files:

PROCESS 5: IDENTIFICATION OF QUALITY IMPROVEMENT OPPORTUNITIES

How?

Quality Improvement Activities are based on

the Evidence from Assessments:

Evidence from: Reports of near miss/adverse events (negative

incidents) Inspections, audits IOD Risk assessments

PROCESS 5: IDENTIFICATION OF QUALITY IMPROVEMENT OPPORTUNITIES

How?

1. High Risk – where there is the risk of serious consequences when care is not provided correctly

pain managementinfection controlmedication

2. High Volume – where the service is occurring frequently and affecting a large number of people

patient assessmentrecord keepingcommunicationpain managementmedicationpatient/family education

PROCESS 5: IDENTIFICATION OF QUALITY IMPROVEMENT OPPORTUNITIES

How?

3. High Cost – where there are areas with costs that could escalate and put the

organization at risk

transport

salaries

communication

donor fatigue/overload

PROCESS 6: FORMULATING A QUALITY IMPROVEMENT PLAN:

How?

• Start with an overview: - Organisation - What Quality Improvement Culture and Activities involve

• Get each department to id own opportunities for QI based on the id, assessment and prioritising of their risks

PROCESS 6: FORMULATING A QUALITY IMPROVEMENT PLAN Develop an overall quality improvement plan

ServiceArea/Depart.

QIPIdent.

Stan-dardReq.

Actionplans

Resp.Person

TimeFrame

Pro-gress

Gov.

HR

Admin Support

PROCESS 7: DOCUMENTING THE QUALITY IMPROVEMENT ACTIONS: = QUALITY IMPROVEMENT PROJECTS 1. Identifying and Stating the Problem/Need

2. Stating the expected Standard/Norm/Intended Outcome

3. Choosing a possible solution: What will you do to improve the situation?

4. Choosing a measuring tool: questionnaire, check sheet, tick list, audit

5. Choosing the right indicator: is a measurement which will show (indicate) that improvement has taken place. Indicators must be achievable and measurable, i.e. a number or % (SMART)

PROCESS 7: DOCUMENTING THE QUALITY IMPROVEMENT ACTIONS: = QUALITY IMPROVEMENT PROJECTS 6. Deciding on a time frame: How long do you think it will take

to achieve 7. How will you display the results e.g. graph

8. What will you do with the results?

9. How will you do on-going monitoring? e.g. spot checks and how often?

Report on progress to the H & S Committee, Management

and Board and at 1-3/12 QI meetings

QUESTIONS???

Acknowledging all previous work done on this subject

matter by HPCA Staff Members