RISK Management: Q & A with Peggy Martin

RISK Management: Q & A with Peggy Martin

By Jennifer Schraag

Q: Can you explain why root cause analysis is so important to an effective risk management program?

A: Root cause analysis (RCA) is important to an effective risk management program because it provides opportunities to design and implement risk reduction strategies based on lessons learned. An important aspect of risk management is loss prevention. RCAs, properly done, can uncover systems problems that will cause harm again if they are not recognized and addressed. Some of those systems issues may be unintended consequences of policies and procedures that were created because of other risk situations.

Q: What can be learned from documenting ALL near misses?

A: Risk managers must be proactive, not just reactive. To that end, the study of all near misses can provide early — and possibly unexpected — clues into potentially dangerous situations that can be addressed before they compromise patient safety. In addition, encouraging staff to report all near misses can help them understand and recognize system issues that could (and often do) lead to patient harm. Analyzing all near misses can indicate areas in which a more extensive failure mode and effects analysis (FMEA) may need to be done. ASHRM defines FMEA as an in-depth analysis of a system’s process in order to assess and modify it to reduce the potential for harm.

Q: How can an organization foster a strong risk management program? Do you have pointers on how they can implement a safe-guarded “focus on prevention, not punishment” element to the program?

A: An organization can foster a strong risk management program with a focus on prevention by creating an organizational “culture of safety.” This must be done through the commitment of senior leadership of the organization who communicate safety as a priority in daily practice. Leadership must actively reward reporting of adverse events and near misses. Human resource departments must work with leadership and front-line managers to define the difference between individual accountability for patient safety and punishment for mistakes. Unions may create special challenges and their leadership should be included in these discussions.

Q: How does risk management play into the growing requirements of adverse event and patient safety reporting systems?

A: Risk management is a critical component of effective adverse event and patient safety reporting systems through our expertise in analyzing the data that are collected by these systems and then recommending corrective actions to prevent future losses. Risk managers are frequently the keepers of potential and actual claims data that, combined with other institutional data, can give leadership a clearer picture of the risk of patient harm.

Q: What are the key aspects to developing a safety culture?

A: The key aspects to developing a safety culture include, but are not limited to:

• Organizational commitment 
• Accountability 
• Effective communication among providers and with patients 
• Staff and consumer education 
• Creating an environment of openness and collaboration 
• Rewarding patient safety efforts at all levels of the organization

Q: How regularly should training programs be conducted on risk management?

A: Training schedules and priorities are determined according to the needs and priorities of the organization. Risk managers analyze incident and claims data to determine which areas, or which health care providers, need risk management education. In academic medical centers, it is important to plan periodic programs for all levels of residents and medical students throughout their stay in the organization. Continuing medical education credits for attending physicians and continuing education units for nurses may be helpful in getting the maximum attendance at risk management programs. Risk management training can also occur when the risk manager attends and participates in Grand Rounds, departmental quality improvement committees and M&M rounds.

Q: If there was one thing you could convey to all healthcare workers concerning risk management and patient safety, what would it be?

A: Patient safety is part of good patient care and has always been a vital part of risk management. All health care workers need to remember that patient safety is everyone’s job. Good patient care, properly documented, is the best loss prevention strategy for patients, health care providers and health care organizations.

Peggy B. Martin, ARM, MEd, DFASHRM, CPHRM, is president of Lifespan Risk Services based in Providence, RI. Martin served as the 2006 president of the American Society for Healthcare Risk Management (ASHRM).