Originally published in RMFInteractive, Issue 5, October 2004

By RMF Staff

When we say "Risk", we mean uncertainty about future events that may threaten the safety of patients and the assets and reputations of providers. Generally, assets fall into several categories.¹

• People—patients, clinicians, boards of directors, volunteers, employees.
• Property—buildings, facilities, equipment, materials, copyrights, and trademarks.
• Financial—revenue, reserves, reimbursement, grants, and research.
• Goodwill—health and well-being, reputation, stature in the community, and the ability to raise funds and appeal to prospective audiences.

What is risk management?

Risk management is a discipline for dealing with the possibility that some future event will cause harm. It provides strategies, techniques, and an approach to recognizing and confronting any threat faced by an organization in fulfilling its mission. Risk management may be as uncomplicated as asking and answering three basic questions:

• What can go wrong?
• What will we do (both to prevent the harm from occurring and in the aftermath of an "incident")?
• If something happens, how will we pay for it?

Large organizations may have a risk management department responsible for answering the three basic questions. In addition, the department may manage litigation, coordinate patient safety programs, and undertake the complex analyses required to set monetary reserves for future claims. In small, community-based nonprofits, the risk management function is more likely to focus on issues such as:

• Screening volunteers, credentialing employees, meeting continuing education requirements;
• Developing board orientation programs and training materials;
• Coordinating the development and consistent use of employment practices; and
• Negotiating the availability of bank credit and purchasing liability insurance.
• Developing a Risk Management Program

To establish a risk management program, first determine your organization's purpose for creating and maintaining one. The program's purpose may be to reduce the cost of insurance or to reduce the number of patient injuries or malpractice lawsuits. Next, assign responsibility for the risk management plan to a designated individual or team. This group will be responsible for developing and implementing your organization's program. While the team is principally responsible for the risk management plan, a successful program requires the integration of risk management within all levels of your organization. Operations staff and board members should assist the risk management committee in identifying risks and developing suitable loss control and intervention strategies.

Insurance and Risk Management

For most professionals and organizations, insurance is a valuable risk financing tool. Purchasing insurance, however, is not synonymous with risk management. Practicing risk management is living the commitment to prevent harm. In addition, risk management addresses many risks that are not insurable—such as, the potential loss of accreditation, tax exempt status, public goodwill, and continuing donor support.

Defining the Purpose of Your Risk Management Program

Optimal patient safety is more cultural than programmatic; it stems from the organizational mission and is consistent across all interactions the patient has with a health care entity. In the ideal setting, the patient safety culture is deliberate, well-defined, and universally understood. This program can help leaders and individuals within an organization assess the prevailing patient safety culture and work on directing it toward the ideal.

The mission of medical care is to improve patient health or, at the very least, prevent avoidable patient harm. Despite these truisms, statistics say hundreds of people are harmed each day in the health care system. The organizational culture underlying attitudes and commitments regarding patient safety are key to instituting and sustaining meaningful improvements. Since an organization’s culture is an amalgam of individual attitudes and practices, those individuals and the institution as a whole have an obligation to define and promote the cultural components that make optimal patient safety "the way we do things here."

• Is your organization safe for you and your patients?
• What makes it safe, or unsafe?

Even if you cannot document it, you know the answer. Even in their first few days, your new colleagues will get a sense of where this workplace falls on the safety spectrum. Even the sickest patients will observe it. And even in the safest settings, it can always be pushed toward improvement.

The institutional attitude toward patient safety—and toward improving patient safety—is often called the "culture of safety." Most organizations are striving to improve patient safety, to move toward an optimal culture of safety. Such goals are not easily achieved, they cannot be achieved by mandate. Even the best designed safety programs have to work within the local culture.

What is the local culture? Simply put, organizational culture is "the way we do things here." It is the combination of institutional history, leadership, budget reality, and staff experience: the underlying sense of appropriate behavior and practice that prevails throughout the workplace. It is what helps you decide:

• This clamp is almost obsolete, should I restock it?
• Should I listen to this patient for five more minutes or keep on schedule with others who are waiting?
• Who do I tell about what just happened?

A health care organization's culture of safety is a subset of the overall organizational culture. The triumph of patient safety improvement is directly linked to that culture. Getting clinicians who are inundated with competing time demands to show up for safety-related meetings means you are attempting to change the culture. Asking the time-pressed OR staff to take three minutes for pre-procedure briefings is attempting to change the culture. Extolling residents used to being told to "figure it out yourself" to call their supervisor whenever they're unsure is attempting to change the culture.

Successful patient safety improvement efforts always need to have one foot in the way things are and the other foot in the way you want them to be. Ignoring the existing culture will doom virtually any new idea. Postponing improvements because "nothing will ever change" is a self-fulfilling prophecy. Introducing change in alignment with the current culture can bring about significant patient safety improvement.

Step one is assessing the current culture. Step two is determining the basic components of an optimal culture of safety for your workplace. What do you and your colleagues want patients and caregivers to see, hear, smell, and feel as they move through the health care process. Step three is figuring out who can lead your organization to that goal. Step four is to start making improvements.

Step five is to ask yourself again:

• Is this organization safe for me and our patients?
• What makes it safe, or unsafe?

Notes & References

1. http://www.eriskcenter.org/knowledge/normac/basics.html