Dossier n. 223/2012 [Abstract] Risk analysis and measurement in health organizations

The complexity of the theme of risk management requires healthcare organisations to implement specific measures for contrasting single problems, but above all to develop real strategies that will be completely incorporated in their programmes. Elaboration of these strategies requires, in the first place, the availability and knowledge of a series of informative elements, ranging from data present at the level of the organizational to subjective assessment by professionals: spontaneous reporting of incidents and near misses, process analyses, use of user reports, study of non conformities, of breakdowns and poor service, recording of incidents and every other pertinent data. However, only a combination of these elements will permit comparative analyses of the different types of criticality, which is a prerequisite for defining the priority areas of possible intervention. In other words, what is defined as “integrated risk assessment” constitutes a fundamental step toward identifying criticality, a more precise evaluation of critical events, of their causes and consequences and the subsequent planning of preventive and protective actions.

The initiative of the Agenzia Sanitaria e Sociale Regionale of the Emilia Romagna Region (ASSR-RER), documented by this report, aimed to reinforce the strategic capacity of healthcare trusts to identify critical areas and propose corrective action. The proposed approach therefore is suitably placed in the group of diverse techniques and methodologies that support the function of risk management in the assessment of critical events, of their causes and consequences.

In the early months of 2009, a working group (coordinated by ASSR-RER, with the participation of persons responsible for risk management from a number of regional healthcare trusts) was set up with the aim of defining a model for “risk mapping”. More specifically, the project proposed to create a self-evaluation tool that would allow the organisations to:

• identify hazards in relation to the vulnerable target exposed to these hazards;
• describe dangers with relation to the individual organisations;
• classify hazards in relation to associated risk, combination of probability of the event occurring and the consequent damage, using mandatory and voluntary information flows managed by the healthcare trust in an integrated manner;
• gather information useful for defining improvements to be implemented in order to reduce risk.

The regional working group first shared basic definitions and analytic processes and tools. Experiences that were already ongoing at the trusts were analyzed as well as tools that were already available, from incident reporting to medical malpractice claims, from AHRQ (Agency for Healthcare Research and Quality) indicators to the prompt lists.

Afterwards, with the technical support of specific types of expertise and the adoption of an integrated approach (qualitative analysis of clinical, technological and environmental risks present in the different healthcare settings/processes), the hazards present in the healthcare trusts were identified and a hierarchical (tree form), multilevel (from general to specific) regional “Hazard Log” was developed. In addition, tools were elaborated for the semi-quantitative assessment of hazards (risk matrix), taking into account the probability of occurrence and the impact on vulnerable target (patients, staff, public/visitors, healthcare trust). Such tools are useful for prioritizing interventions and implementing improvements. This second stage was characterized by training-action in which the healthcare trusts involved contributed to the development of the regional register by establishing a “list of hazards” referring to specific settings and/or processes.

The interest demonstrated by the participants and the evident increase in empirical knowledge of the phenomena studied suggested, on one hand, the involvement of the remaining regional healthcare trusts and, on the other, the further development of the experience, with the intent to also explore the consistency of the tools in an international context, in particular with the International Classification for Patient Safety (ICPS) of the World Health Organisation. A three-day training course offered in 2011 was followed by a series of interactive learning seminars in which the healthcare trusts used the tools in various ways in their own organisations and then shared their application methods, pointing out criticality and opportunities for improvement.

The authors present the material prepared for the training course (reference model, analytic tools) and the healthcare trust experiences reported in the above mentioned seminars, with the awareness, however, that effective use of the proposed tools still requires further study.