Importance Of Evidence-Based Healthcare Quality, Safety, And Governance Framework In Risk Management

The Five Criteria for Quality and Safety Governance Framework

Risk management is a critically important priority in health care compared to other industries. Mostly risk management practices and strategies are implemented in organization to address employee related issues and mitigate financial losses. However, in case of health care system, the objective of risk management is more than just preventing financial losses. Risk management in health care is more concerned with promoting patient safety (Carroll, 2009). Hence, risk management and risk evaluation in health care organizaers is influential in this aspect as they work to assess risk, develop and monitor risk management plans to minimize exposure to risk.

They work to identify risk and evaluate the severity of risk in relation to injury to patients and health care staff members. Risk management plan mainly focus on patient safety, regulating professional and health care policies, minimizing medical error and modifying existing and future policy (Bates et al., 2014, pp1123-1131). The main purpose of this report is to conduct risk management activity in relation to risk identified in Mildred’s story and discuss ways to evaluate and control the five risk related to communication, operational, environmental, clinical safety and patient dignity, and legal and ethical risk found in the scenario.

1. Importance of evidence-based healthcare quality, safety and governance framework 

Health care quality, safety and governance framework guides health care professional in improving the quality of service and providing high standard. It is an integrated system that helps to maintain the quality of care and improve patient outcomes. The five criterias for the quality and safety governance framework includes the following:

• Government and quality improvement  system to manager patient safety and quality issues.
• Clinical practice guided by best practice guidelines.
• Performance and skills management with the help of skilful clinical workforce.
• Incidents and complain management by appropriate identification, reporting and analysis of risk events.
• Respecting patients right and engagement in the care process (Governance for safety and quality :: SA Health, 2017).

 Evidence based quality, safety and governance framework is important to promote clinical effectiveness (Mannion et al.,  2015, pp 9-16). This can be done by means of collecting information and using it to monitor safety and quality of services. Sahebalzamani & Mohammady, (2014, p.295) gives insight into patient safety management by utilizing the framework of clinical governance in ICU setting.

The research was done on five areas of training, culture, environment, technology, leadership and safety items of the hospital. This helped in evaluation of safety culture at the hospital and scoring each area on the basis of safety levels. The study also emphasized that diligence of the hospital management is also critical for the improvement of safety management in clinical setting. A governed health care system embraces this approach by making up-to-date information and evidence-based practice accessible to all health care team.

This form of clinical effectiveness also supports establishing clinical standards, guidelines and indicators to monitor team and overall organization performance in health care quality and safety (Doyle et al., 2013, p.e001570). Inclusion of evidence based practice in quality and government framework ensures best patient outcome in care by means of safe and effective treatment delivery. Systematic approach is taken to develop professional guideline for health care team that helps them to implement evidence based practice. Evidence-based framework is now being developed for major health conditions to promote patient safety and improve quality.

The clinical governance framework is a combination of patient safety, clinical effectiveness and patient centered care. The importance of this framework is that it promotes effective, patient-centered centered, safe, timely, efficient and equitable delivery of care. The clinical governance framework fosters a culture of quality through continuous improvement, strategic leadership, clarity regarding safety and quality management responsibilities and well-designed system of identifying and managing risk (Colquhoun et al., 2014, p.781).

Importance of Evidence-Based Healthcare Quality, Safety, and Governance Framework

The article by Greenfield et al., (2011, p.8-19) gives evidence regarding the importance of clinical governance in guiding health professionals in safe delivery of care. It improves the nature of health care delivery.  Emergence of clinical governance has helped to improve accountability for the maintenance of quality and safety. This promotes creation of an environment where clinically excellent care can flourish.  On the other hand, the governance framework for patient safety and quality is based on the value of patient involvement, accountability, patient-centeredness, openness and including systems to maximize benefit to patients. The main role of this quality and safety framework to advocate for positive values, plan governance structure organizes data and evidence, focus on patient safety and quality (Smith et al., 2014, pp.2506-2517). 

2. The selection of best practice framework for the case study: 

The case study is based on the issues faced by Mildrel Hill, a 70 year old lady who was admitted to the hospital following a stroke. When a general practitioners assessed her in the care resident, she was found to have no movement in the right hand side and she could hardly speak. While admitting to the hospital, the staffs were made aware that she had mild stroke few years ago, however she had recovered. They were also given other patient detail such as she had mild angina. Her current symptoms included right hemiparesis with facial palsy.

Although the GP alerted the person on call that she had certain anaphylactic reactions to certain pills and she needed ciliac diet, however there staff paid little interest to the instruction and did not noted it down. Post admission, Mildred Hill faced many issues that compromised her safety at the hospital (Recognising Risk and Improving Patient Safety – Mildred’s Story, 2017). To identify different level of risk and risk control plan in the hospital, the risk management framework of American Society for Health Care Risk Management will be used in the case scenario of Mildred Hill.

ASHRM’s risk management framework has been chosen for Mildred’s case because this framework efficiently provides a structure or methodology that risk-management professionals should follow to identify risk and control them. It is a sample framework however it can be applied to address to patient safety identified in Mildred’s case. The framework effectively describes the method needed for objective setting, using different tools for risk and opportunity identification, categorizing risk, identify drivers of risk, risk evaluation and risk assessment (Carroll, 2017).

3. Risk management objectives

While proceeding with risk management practices in the organization, it is necessary to set the purpose of objective of risk management. In the context of health care, the main objective is to prevent risk to staff, patients and organizational performance. It is a means to identify all sources of risk and collaborate with staff interpret the reasons for adverse event. In some case, it is also done to maintain regulatory compliance among staff working in all department of the hospital (Okuyama et al., 2014, p.61). In case of Mildred’s case scenario, the main objective of risk management is to-

• To identify the adverse events that Mildred had to experience post admission to the hospital (Specific)
• To identify the factors exposing Mildred to risk such as negligence by staffs, lack of safety culture and others by analyzing the environment around Mildred (Measureable)
• To assess the risk on the basis of severity to patient’s health and evaluate the overall impact to patient and organization (Attainable)
• To engage in risk control process by means of evidence based patient safety, quality and government framework and promote methods to increase acceptance of new approach among health care staffs as soon as possible (Reasonable and time-bound)

The Selection of Best Practice Framework for the Case Study

The risk identification process in health care is necessary to prioritize risk within health care facility and promote patient safety. The ASHRM framework for risk identification mentions categorizing risk into different domains. This approach is influential in segregating similar risk into manageable groups and then taking action against them based on best priority (Carroll, 2017). This method of categorizing risk into different domains encourages comprehensive analysis of each risk area and supports identification of support and leaderships needed to protect the organization or patient from risk and engage in value creations (Bates et al., 2014, pp.1123-1131). 

To identify the factors that can create risk to Mildred, brainstorming approach and root cause analysis technique will be used. Both are information-gathering techniques to create a list of risk and categorize them. Brainstorming is a data gathering technique and use of each other ideas to identify risk and propose solution to the issue. On the other hand, root cause identification is based on using data related to a risk event and understands what happened and why it happened (Li et al., 2015, pp.494-AP3). On that basis, response can be taken to prevent recurrences.  With these techniques, the following risk was identified from the case study:

• Operational risk- Operational error was identified in the hospital because ideally each patient is looked after by a consultant. However, the staffs were not clear about the exact consultant for Mildred. This was also not acceptable by her daughter and she was amazed to hear that no scan was done on her before starting the treatment. This is a serious operational error as basic procedure followed for any patient while admission to the hospital was completely missing in Mildred’s case (Mans et al.,  2015, 17-26).

Another major operational risk was seen during preoperation phase when Mildred needed a surgery for femur fracture. Ideally patient’s leg which required surgery should be marked, drip should be prepared and she should be given necessary antibiotic before surgery (Rothrock 2014). However, no such procedure was followed which reflects severe case of medical negligence. Her condition went on deteriorating due to irresponsive action by the staffs and it finally resulted in the death of the patient.

• Communication risk-From the analysis of Mildred’s case, communication related risk was identified. This was observed when Mildred’s daughter called to hospital to inquire about her mother. Although she heard the news that her mother has had a stroke, however the staff reported that she had a CVI (Cerebral Vascular accident). There was also little collaboration between team as each staff were clueless about patient’s course of treatment and disease related information.
• Clinical safety and patient dignity risk-Clinical safety risk was observed in several instance after Mildred’s admission to the hospital. Firstly it was seen when the GP called up the hospital for admission of Mildred. He gave all detail about patient history and her allergy to wheat, however they did not cared to note it down. This was a case of negligence which would seriously pose risk to Mildred. Mildred’s daughter also reminded about the wheat allergy and that her mother needed a wheat free diet. However, the staff was totally confused and Mildred’s was not at all satisfied with the response of the hospital. Patient dignity risk was also prominent because staff did not cared change patients cloth or expose her body in privacy, they tend to it while others members were present. This is a risk to patient dignity in delivery of care (Faden et al.,  2013, 766-768).
• Enviornmental risk-This was seen when Mildred fell near the bathroom due to spillage of water and she sustained a fracture on the femur. Ideally a hospital environment should be safe enough to avoid fall related accident in patients. However, fall prevention was missing and Mildred suffered a lot because of this.
• Legal and ethical risk-Legal risk was also identified in the case scenario by observing the scene where Mildred’s daughter was speaking to a staff of the hospital on call. When she inquired about the status of her mother, the staff denied it and said he cannot give the information on call. This is a violation of the right to autonomy in patient and family centred care (Lindberg et al., 2014, pp.2208-2221). In patient centered care, family members play a key role in persuading patients and engaging in decision making. In such case, health care staffs have the liability to inform family member’s about patients health status and course of treatment. However, this was not done in Mildred’s case.  Patient’s or family member’s consent is necessary to proceed with any surgery, however instead of Mildred, his carer was asked to sign it.

To estimate the impact of the above identified risk, a risk inventory from the ASHRM’s framework will be used to categorize the risk into different domains and impact. The impact score is determined on the basis of impact score criteria provided in table 1 in appendix. This process of refining the risk into a manageable number of risk helps to prioritize activities and determine which area requires attention first. It is an analytical method to support risk evaluation in health care system. The use of risk estimation framework provides a practical way to understand the severity of risk and promote safety in patients (Cure Vellojin, 2011).

Risk estimation in relation to Mildred’s case scenario are presented below:

	Risk name	Risk domain	Likelihood	Impact
1	Poor process of providing handover information	Communication risk	High (4)	4
2	Negligence of health care staffs	Clinical safety risk	High (4)	4
3	Poor procedure of reviewing patient information	Clinical safety risk	Moderate (2)	3
4	Inconsistency in collaboration between health care team	Communication Risk	High (4)	4
5	Disrespect to patient and violating privacy of patients	Patient dignity risk	Moderate (2)	2
6	Poor fall related safety for patients	Environmental risk	High (4)	4
7	Violation of patient’s and family member’s autonomy	Legal risk	High (4)	5
8	Inappropriate presurgery procedure	Legal risk	Very High (5)	5

The above mentioned risk estimation has been prepared considering the damage caused to Mildred in each risk area. As negligence in surgical procedure is a critical error which even cost the life of Mildred, this area has been given the highest score of 5. Secondly, violation of the patient’s right to autonomy is a major ethical issue in health care and hence a high score is given for this area too. Evidence from literature also suggests that problem regarding patient autonomy can lead to fatal consequences for patient and violation in this area cannot be ignored.

As part of patient autonomy, informed consent is necessary before proceeding with any treatment or surgical procedure (Lindberg et al., 2014, pp.2208-2221). However, this was missing and informed consent was taken neither from Mildred nor from her daughter. The shared decision making process promotes safety in surgery. This is an approach to collaborative patient-centered care experience (Page, 2015, p.24). The violation of appropriate procedure for surgery was the major reason for death in Mildred and this would not have happened had the clinicians followed the clinical responsibility ethically.

6. Risk evaluation

The risk estimation for different categories of risk in Mildred’s case was done by the attribute of likelihood and its impact on patient safety and quality of care. The severity is defined on the basis of risk mapping procedure to evaluate risk. It is a graphical display of risk based on the dimensions of likelihood and severity of impact (Given in appendix table 4). The colour indicated in the map such as yellow, green and yellow determines the severity of risk. Red indicates critical risk areas, yellow indicates medium risk and green indicates less significant risk.

In the case scenario of Mildred, this is understood from the risk estimation table. In case of risk areas where the impact score is high, it indicates critical risk and a score of 3 and 4 indicates medium risk and 1 and 2 suggest less significant risk (Given in appendix table 3). By this process of risk evaluation, decision-making and risk management process becomes easier and it adds clarity to the process. This will assist a risk manager and other team involved in the process to make adequate changes and allocate effective resources to reduce the risk. In the planning and strategic response phase also, everything is dependent on identify high and low priority areas (Hopkin, 2017).

7. Risk control

The following are the risk control measures proposed for all the five identified risk in Mildred’s story-

Identified Risk	Control measures
Operational risk	· Implement safe patient handover procedure in the hospital to maintain consistency and accuracy in sharing important patient information with multidisciplinary health care team (Redley et al., 2016). · Arrange induction and orientation training for all staffs regarding compliance with all the medical and administrative procedure to promote patient safety and quality of care (Grol et al., 2013). · Allocating resource and skills training to encourage staffs to engage in effective pre-operative assessment and legal procedure before surgery or operations (Metzger and Biomet Manufacturing, 2014).
Communication risk	· Foster a team collaboration and professional communication environment at the hospital. · Impose practice standards for effective communication to encourage effective teamwork. · Mitigate the barriers to inter-professional collaboration and communication process between multidisciplinary health care team (Rider et al., 2014, pp.273-280).
Environmental risk	· Allocate resource for creating a safe environment for patient to prevent fall related injuries. · Implement fall prevention program · Encourage staffs to identify and assess patients for risk of fall (Stevens & Phelan, 2013, pp.706-714).
Clinical safety and patient dignity risk	· Increasing awareness about patient centered care and ethically safe practice. · Strictly imposing directives to encourage health staff to maintain patient safety during clinical care. · Provide in-service education to provide emotional support to patients and reduce medical error (Lin & Tsai, 2011, pp.340-348).
Legal and ethical risk	· Advocate staffs regarding the importance of following ethical and legal standards in care. · Preserving and protecting the right to autonomy of patients and their family members. · Improving informed consent process by means of practical guide to the procedure (Tarzian & Force, 2013, pp.3-13).

8. Risk acceptance

Risk acceptance is a part of the risk management process in which the outcome of the risk treatment is communicated to the management of the organization. It is the process of accepting to the consequences of the exposure to the risk and evaluating the cost needed to address the risk. It also involves gaining approval from the leaders to further support risk mitigation process. The following are the risk acceptance phase for all the risk identified in case of Mildred’s scenario-

• Communication risk- The main resource required for this area isto adapt a systematic process where professional communication is enhanced and best practice standard for inter-professional collaboration is imposed.
• Operational risk- To avoid operational risk, organizational leader will have to take the responsibility to implement appropriate patient safety guidelines and make arrangements for required resources to reduce errors.
• Patient dignity and Clinical safety risk- In this area, the health team and support staffs  have the main responsibility to accept the consequence of  patient safety risk and take personal effort to improve the quality of care and promote safety of patients. The strategies and tools to enhance patient safety and performance can be used to bring improvement in interpersonal communication and reduce errors. This will increase the competence of the health care staffs and lead to a safe environment for patients (Keller et al., 2013, 253).
• Legal and ethical risk- Legal and ethical issue may arise in different areas of health care. However, in case of Mildred, it was mainly seen in the area of right to patient’s autonomy and informed consent procedure before surgery. To accept the risk and address the risk, there is a need to analyze the main requirement for informed consent and make health care staffs aware about basics features of informed consent before surgery (Faden et al., 2014, 766-768).
• Environmental risk- To bring changes to health care environment and reduce incidents of fall in patients, several resource is needed. For example, investment is needed to provide staff with relevant risk assessment tools to identify risk of fall in patients. Secondly, thoughtful consideration is needed regarding floor, furnishing, bed railing and bathrooms so that patients do not sustain any injury during the hospital stay (Matarese et al., 2015, 1198-1209).

9. Conclusion

The risk management report for health care based on the case scenario of Mildred presented the systematic steps needed to engage in risk management practice in health care setting. The condition of Mildred and the treatment given to her by the staffs and clinicians at the hospital depicted a serious case of medical negligence and risk to patient safety in the health care organization.

Through the observation of Mildred’s story and the application of ASHRM’s risk management framework, the systematic process to risk identification, estimation, planning and evaluation has been summarized. This systematic process of risk management reflects how certain tools like risk inventory and risk mapping helps to categorize risk and determine the high risk area. This promotes planning process and action in the high priority areas. Similarly, initiative is regularly needed in health care organization to sustain competitive advantage by mitigating risk factors within the health care system.

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