Clinical risk management in hospitals: strategy, central coordination and dialogue as key enablers

Development and validation of a short clinical risk management implementation (Short CRiMI) questionnaire

Clinical Risk Management (CRM) is an important instrument to continuously improve safety of health care delivery. In Germany, hospitals are required by law to implement CRM and incidence reporting systems. Since 2010, nation-wide surveys have been conducted periodically to evaluate implementation of CRM in hospitals. The instrument used in these surveys is constantly being updated to reflect previous experiences, as well as to adapt to ongoing trends and developments in CRM practices. The survey instrument used in 2022 consisted of up to 200 items and took up to an hour to complete. In this study, we aimed to develop a short instrument to measure the level of CRM implementation in hospitals, evaluate its psychometric properties, and to offer benchmarking data for health care facilities of different sizes. We used data collected in 2022 as part of KHaSiMiR study, employing a cross-sectional self-reported online survey. The hospital administrations were invited to designate one CRM manager to participate in the study. Out of 1,411 general hospitals invited, 401 responses were collected (response rate of 28%). After removing the cases with excessive missings, we imputed remaining missing values using multiple imputation, and split the resulting sample (n=362) in two halves (i.e., exploratory and testing subsamples). A principal component analysis was applied on the first subsample. We validated the resulting model using confirmatory factor analysis in the testing subsample. We evaluated internal consistency, and tested external validity of the established instrument using correlation analysis with two single-item measures: subjective evaluation of CRM implementation compared to similar organizations and compared to own ideal level. The principal component analysis included 45 items from the full instrument. The analysis resulted in a three-factor model with 26 items. In the confirmatory factor analysis, the model demonstrated acceptable fit with the data according to the commonly used fit indices: Chi2/df=1.36, CFI=0.941, TLI=0.930, RMSEA=0.045 (90% CI=0.032-0.056), SRMR=0.049. Cronbach's alpha of all three factors was good (>0.70). All three factors had statistically significant positive correlations with each other (0.359-0.497) and with the two single items (0.282-0.532). None of the correlations were high enough (>0.7) to indicate multicollinearity. The proposed short clinical risk management implementation (Short CRiMI) questionnaire is psychometrically valid and can be used to rapidly evaluate CRM implementation in hospitals. Further research can provide evidence of its external validity and association with quality and safety outcomes. Benchmarking data can be used to compare the results with the data from the most recent Germany-wide survey.

Implementation of a comprehensive clinical risk management system in a university hospital

BACKGROUND

Adverse events during hospital treatment are common and can lead to serious harm. This study reports the implementation of a comprehensive clinical risk management system in a university hospital and assesses the impact of clinical risk management on patient harms.

METHODS

The clinical risk management system was rolled out over a period of eight years and consisted of a training of interdisciplinary risk management teams, external and internal risk audits, and the implementation of a critical incident reporting system (CIRS). The risks identified during the audits were analyzed according to the type, severity, and implementation of preventive measures. Other key figures of the risk management system were obtained from the annual risk reports. The number of liability cases was used as primary outcome measurement.

RESULTS

Of the 1,104 risks identified during the risk audits, 56.2% were related to organization, 21.3% to documentation, 15.3% to treatment, and 7.2% to patient information and consent. The highest proportion of serious risks was found in the category organization (22.7%), the lowest in the category documentation (13.6%). Critical incident reporting identified between 241 and 370 critical incidents per year, for which in 79.5% to 83% preventive measures were implemented within twelve months. The frequency of incident reports per department correlated with the number of active risk managers and risk team meetings. Compared with the years prior to the introduction of the clinical risk management system, an average annual reduction of harms by 60.1% (95% CI: 57.1; 63.1) was observed two years after the implementation was completed. On average, the rate of harms dropped by 5% per year for each 10% increase in roll-out of the clinical risk management system (incidence rate ratio: 0.95; 95% CI: 0.93; 0.97) .

CONCLUSION

The results of this project demonstrate the effectiveness of clinical risk management in detecting treatment-related risks and in reducing harm to patients.

[Development of clinical risk management in German hospitals]

Clinical risk management supports healthcare workers in recognizing, reducing, and managing risks in patient care. It is mandatory for all outpatient and inpatient facilities in the German healthcare system. The contents of the clinical risk management are regulated in the Social Code (Title 5), the guidelines of the Federal Joint Committee, the Patients' Rights Act, and the norms and recommendations of the Patient Safety Alliance. The Federal Joint Committee explicitly points out that minimum standards of risk management, error management, error reporting systems, complaint management in hospitals, and the use of checklists for surgical interventions must be implemented.The legislator requires that the effectiveness of the clinical risk management be checked regularly. Questionnaire surveys on clinical risk management in Germany show an overall positive development. However, the data are not sufficient for a comprehensive assessment. Methodologically reliable procedures should therefore be developed that check the status of the clinical risk management much more frequently and regularly. The data measuring structure, process, and outcome should be collected systematically and presented in a comparative manner in relation to the facilities.Opportunities for clinical risk management arise from the World Health Organization's Global Action Safety Plan, advances in digitization, the integration of clinical risk management into organizational risk management, and the improvement of structural quality. Clinical risk management must be given even more space in the daily routine of doctors and nurses. This requires competence and human resources in this area. These are not sufficiently available in German hospitals.

Cross-cultural Adaptation and Validation of Patient Safety Culture Assessment Tool for Clinical Staff in Kazakhstan

BACKGROUND: Modern healthcare systems lack empirical models and appropriate tools to evaluate the safety culture, which encourages the need for their development. The national healthcare system of Kazakhstan has no empirically tested robust tools to evaluate the safety culture. AIM: The present paper aims at performing translation, cross-cultural adaptation, and validation of the “Patient safety culture” tool (from here – the tool) as a means for evaluating safety culture in healthcare establishments of the Republic of Kazakhstan. METHODS: The study design was cross-sectional. The original “Patient safety culture” tool is an integrated evaluation framework consisting of 7 scales and 62 items (6 general questions and 56 targeted questions) and reflecting different aspects of risk-related components of safety culture. The Cronbach’s alpha coefficient ranging from 0.0 to 1.0 was used to measure the internal consistency of the tool. To evaluate the tool’s reproducibility, we performed a test-retest assessment after 15 days and evaluated it using Pearson’s correlation coefficient. RESULTS: The overall Cronbach’s alpha for different scales ranged from 0.27 to 0.75. Subscales “Safety procedures” and “Safety Training” had the lowest coefficients. At test-retest, the Pearson’s correlation coefficient ranged from 0.934 to 0.969 among the scales. CONCLUSION: The study is dedicated to cross-cultural adaptation and validation of the “Patient safety culture” tool and describes the development of a translation protocol with subsequent cognitive debriefing and field testing. The field testing helped to confirm good validity, reliability, and reproducibility. The tool might undergo additional modification after further testing.

Strengths-Weaknesses-Opportunities-Threats Analysis for a Pediatric Anesthesia Program

Risk management in healthcare institutions begins by first identifying the potential risks within a certain organization or specific area and then goes on to develop further strategies to reduce harm. The most common tool for this type of analysis is Strengths-Weaknesses-Opportunities-Threats (SWOT).

METHODS

We conducted a SWOT analysis in our pediatric anesthesia program: key factors were identified in a matrix, prioritized in a score table, represented in a graph, and finally analyzed.

RESULTS

Items obtained partial scores from 20 to 120. The item "lack of clinical protocols" was given greater weight (60) and received a lower value (1), resulting in the highest partial score (60) among the negative key factors and indicating a need for greater efforts to improve this specific aspect.

CONCLUSION

The SWOT tool proved effective in identifying safety and quality key factors, and it provided information for initiating an improvement program.

E-learning on risk management. An opportunity for sharing knowledge and experiences in patient safety

QUALITY PROBLEM

E-learning methodology is a good alternative to more traditional methods when economical restrictions and geographical dispersion are important. However, there is still little knowledge about its utility in the development of patient safety (PS) improvement projects.

INITIAL ASSESSMENT

Evaluation of the acceptability and utility of an e-learning risk management (RM) course for healthcare professionals to develop PS improvement projects in different clinical settings.

CHOICE OF SOLUTION

E-course offered, in Spanish and English, to facilitate the design of PS improvement projects using RM tools under the continuous support of PS experts.

IMPLEMENTATION

The evaluation of the course was based on the reaction, learning and healthcare professional behavior. A free online database was created to disseminate and share the projects developed during the course.

EVALUATION

A total of 1426 professionals have completed the course (84.2%), of which 86.7% (1236) were from Spain, 8.3% (118) from Latin America and 5% (72) from other European and Eastern Mediterranean countries. More than 80% of the students were very satisfied with the e-course and 98% would recommend it to their colleagues. Learning and developing improvement projects through teamwork was highlighted as a very positive aspect. A total of 70.3% of the 387 PSIP were developed in hospitals. The most frequent topic was medication.

LESSON LEARNED

Team learning based on real cases was one of the most positive aspects of the e-course. The improvement projects developed are transferable examples of good practices that facilitate the application of RM tools in different clinical settings.

Attitudes of dental undergraduate students towards patient safety in a UK dental school

OBJECTIVES

Patient safety is an important issue in health care. In the United Kingdom, wrong site tooth extraction contributes to a significant proportion of adverse or harmful events, coined "never events." Therefore, patient safety within the field of dentistry is of paramount importance. This novel study aims to explore the teaching of patient safety to undergraduate dental students and their current attitudes to the subject.

METHODS

Focus groups were held at Barts' and The London School of Medicine and Dentistry, QMUL in 2018 to ascertain the views and opinions of thirteen third-year dental undergraduate students.

RESULTS

Thematic analysis was performed on verbatim transcripts. Key themes were highlighted. All students could provide a complete definition of patient safety and of "never events," with examples. There was a strong emphasis upon awareness of one's own competence and the need for effective communication to maintain patient safety. Small group teaching and the requirement for standardization of teaching were encouraged. The challenge of incorporation of the patient safety concept into the clinical routine without causing repetition during teaching was highlighted.

CONCLUSION

The results show a positive attitude towards the concept and the teaching of patient safety. All students understood patient safety concepts and techniques used to prevent adverse or harmful events. This study proves that teaching on the subject was thought to be of value. It is crucial that the teaching of patient safety is introduced and built upon within the early years of dental undergraduate training so that its practice becomes second nature.

The long way ahead to achieve an effective patient safety culture: challenges perceived by nurses

Background

The safety culture has recently attracted the attention of healthcare organizations. Considering the importance of the roles of nurses with regard to patient safety, their knowledge and experiences of the challenges that influence patient safety culture can facilitate the development and implementation of better strategies. The aim of this study was to explore the nurses’ experiences of the challenges influencing the implementation and integration of safety culture in healthcare.

Methods

A qualitative study with deep and semi-structured individual interviews was carried out using a purposive sampling method to select 23 nurses from four hospitals affiliated with a large medical university in Southeast Iran. Data were analysed using the conventional content analysis of Lundman and Graneheim.

Results

Data analysis reflected the main theme of the study, “A long way ahead of safety culture”. This theme includes four categories: 1) inadequate organizational infrastructure, 2) insufficient leadership effectiveness, 3) inadequate efforts to keep pace with national and international standards, and 4) overshadowed values of team participation.

Conclusion

While practical strategies for creating a safety culture may seem simple, their implementation is not necessarily easy. There are several challenges ahead for cultivating an effective and positive safety culture in healthcare organizations. To keep pace with international standards, healthcare managers must employ modern methods of management in order to overcome the challenges faced by the institutionalization of safety culture and to make a difference in the healthcare system.

Application of Bow-tie methodology to improve patient safety

Purpose - The purpose of this paper is to apply Bow-tie methodology, a proactive risk assessment technique based on systemic approach, for prospective analysis of the risks threatening patient safety in intensive care unit (ICU). Design/methodology/approach - Bow-tie methodology was used to manage clinical risks threatening patient safety by a multidisciplinary team in the ICU. The Bow-tie analysis was conducted on incidents related to high-alert medications, ventilator associated pneumonia, catheter-related blood stream infection, urinary tract infection, and unwanted extubation. Findings - In total, 48 potential adverse events were analysed. The causal factors were identified and classified into relevant categories. The number and effectiveness of existing preventive and protective barriers were examined for each potential adverse event. The adverse events were evaluated according to the risk criteria and a set of interventions were proposed with the aim of improving the existing barriers or implementing new barriers. A number of recommendations were implemented in the ICU, while considering their feasibility. Originality/value - The application of Bow-tie methodology led to practical recommendations to eliminate or control the hazards identified. It also contributed to better understanding of hazard prevention and protection required for safe operations in clinical settings.

A cross-national comparison of incident reporting systems implemented in German and Swiss hospitals

OBJECTIVE

This study aimed to empirically compare incident reporting systems (IRS) in two European countries and to explore the relationship of IRS characteristics with context factors such as hospital characteristics and characteristics of clinical risk management (CRM).

DESIGN

We performed exploratory, secondary analyses of data on characteristics of IRS from nationwide surveys of CRM practices.

SETTING

The survey was originally sent to 2136 hospitals in Germany and Switzerland.

PARTICIPANTS

Persons responsible for CRM in 622 hospitals completed the survey (response rate 29%).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Differences between IRS in German and Swiss hospitals were assessed using Chi2, Fisher's Exact and Freeman-Halton-Tests, as appropriate. To explore interrelations between IRS characteristics and context factors (i.e. hospital and CRM characteristics) we computed Cramer's V.

RESULTS

Comparing participating hospitals across countries, Swiss hospitals had implemented IRS earlier, more frequently and more often provided introductory IRS training systematically. German hospitals had more frequently systematically implemented standardized procedures for event analyses. IRS characteristics were significantly associated with hospital characteristics such as hospital type as well as with CRM characteristics such as existence of strategic CRM objectives and of a dedicated position for central CRM coordination.

CONCLUSIONS

This study contributes to an improved understanding of differences in the way IRS are set up in two European countries and explores related context factors. This opens up new possibilities for empirically informed, strategic interventions to further improve dissemination of IRS and thus support hospitals in their efforts to move patient safety forward.

The German clinical risk management survey for hospitals: Implementation levels and areas for improvement in 2015

BACKGROUND AND AIMS

Despite the growing recognition of the need to implement systematic approaches for managing the risks associated with healthcare, few studies have investigated the level of implementation for clinical risk management (CRM) at a national level. Therefore, this study aimed to assess the current level of CRM implementation in German hospitals and to explore differences across hospital types.

METHODS

From March to June 2015, persons responsible for CRM in 2,617 hospitals and rehabilitation clinics in Germany were invited to participate in a voluntary online survey assessing the level of implementation for various aspects of CRM: CRM strategy, structures and processes; risk assessment (risk identification, risk analysis, risk evaluation) with a focus on incident reporting systems; risk mitigation measures; and risk monitoring and reporting.

RESULTS

572 hospitals participated in the survey (response rate 22 %). Most of these hospitals had a formalised, binding CRM strategy (72 %). 66 % had a centralised and 34 % a decentralised CRM structure. We also found that, despite a broad range of risk assessment methods being applied, there was a lack of integration of risk information from different data sources. Hospitals also reported a high level of implementation of critical incident reporting systems with a strong preference for local (74 %) over transorganisational systems.

DISCUSSION AND CONCLUSION

This study provides relevant data to inform targeted interventions concerning CRM implementation at a national level and to consider the specific context of different types of hospitals more carefully in this process. The approach to CRM assessment illustrated in this article could be the basis of a system for monitoring CRM over time and, thus, for evaluating the impact of strategy decisions at the policy level on CRM development.

Rocky milieu: challenges of effective integration of clinical risk management into hospitals in Iran

Healthcare risks and clinical risks have been recognized as a major challenge in healthcare. Clinical risks can never be eliminated and can have serious adverse effects on patient safety. Thus, a clinical risk management (CRM) system has been introduced in the healthcare system to improve quality services. The aim of this study was to explore nurses' experiences related to the challenges of implementing CRM in the organizational context. This qualitative study was based on the conventional content analysis of the Lundman and Graneheim approach, and it consisted of 22 interview sessions with 20 nurses. The purposive sampling method was used to choose the participants from three hospitals affiliated with the Kerman University of Medical Sciences. We used semi-structured interviews and review of relevant documents to collect data. The analysis of the data led to the emergence of "rocky milieu" as the main theme, and it consisted of three categories that, along with their subcategories, explain the challenges of implementing CRM. The three categories and their subcategories were (1) organizational culture and leadership challenges (decision and performance of leadership and cultural resistance to change), (2) limitation of resources (financial, human, and physical and equipment resources), and (3) variations and complexities in working conditions (the emotional, psychological, and social atmosphere and the heaviness of workload). Attempts have been made to establish CRM through clinical governance and accreditation, but organizational challenges have created a rocky milieu for implementing CRM. However, from an organizational context concerning the suitability of healthcare in Iran, there are obvious needs to move toward quality improvement and safe practices through the effective implementation of CRM.

Assessment of Clinical Risk Management System in Hospitals: An Approach for Quality Improvement

Background:

Clinical risks have created major problems in healthcare system such as serious adverse effects on patient safety and enhancing the financial burden for the healthcare. Thus, clinical risk management (CRM) system has been introduced for improving the quality and safety of services to health care. The aim of this study was to assess the status of CRM in the hospitals.

Methods:

A cross-sectional study was conducted on 200 nursing staff from three teaching hospitals affiliated with the Kerman University of Medical Sciences in southeast of Iran. Data were collected from the participants using questionnaire and observational checklist in quality improvement offices and selected wards. The data were analyzed using SPSS version 20.

Results:

Almost, 57% of persons participated in at least one of training sessions on CRM. The status of CRM system was rated from weak to moderate (2.93±0.72- 3.18±0.66). Among the six domains of CRM system, the highest mean belonged to domain the monitoring of analysis, evaluation and risk control (3.18±0.72); the lowest mean belonged to domain the staff’s knowledge, recognition and understanding of CRM (2.93±0.66). There were no integrated electronic systems for recording and analyzing clinical risks and incidents in the hospitals.

Conclusion:

Attempts have been made to establish CRM through improvement quality approach such as clinical governance and accreditation, but not enough, however, health care should move toward quality improvement and safe practice through the effective integration of CRM in organizational process.

Challenges in evaluating clinical governance systems in iran: a qualitative study

BACKGROUND

In spite of the pivotal role of clinical governance in enhancing quality of services provided by hospitals across the country, a scientific framework with specific criteria for evaluating hospitals has not been developed so far.

OBJECTIVES

This study was conducted with the aim to identify the challenges involved in evaluating systems of clinical governance in Iran.

MATERIALS AND METHODS

For the purposes of this qualitative study, 15 semi-structured interviews with experts in the field were conducted in 2011 and the data were analyzed using framework analysis method.

RESULTS

Five major challenges in evaluating clinical governance include managing human resources, improving clinical quality, managing development, organizing clinical governance, and providing patient-oriented healthcare system.

CONCLUSIONS

Healthcare system in Iran requires a clinical governance program which has a patient-oriented approach in philosophy, operation, and effectiveness in order to meet the challenges ahead.

Clinical risk management in mental health: a qualitative study of main risks and related organizational management practices

Background

A scientific understanding of clinical risk management (CRM) in mental health care is essential for building safer health systems and for improving patient safety. While evidence on patient safety and CRM in physical health care has increased, there is limited research on these issues in mental health care. This qualitative study provides an overview of the most important clinical risks in mental health and related organizational management practices.

Methods

We conducted in-depth expert interviews with professionals responsible for CRM in psychiatric hospitals. Interviews were transcribed and analyzed applying qualitative content analysis to thematically sort the identified risks.

Results

The main concerns for CRM in mental health are a) violence and self-destructive behavior (i.e. protecting patients and staff from other patients, and patients from themselves), b) treatment errors, especially in the process of therapy, and c) risks associated with mental illnesses (e.g. psychosis or depression). This study identified critical differences to CRM in hospitals for physical disorder and challenges specific to CRM in mental health. Firstly, many psychiatric patients do not believe that they are ill and are therefore in hospital against their will. Secondly, staff safety is a much more prominent theme for CRM in mental health care as it is directly related to the specifics of mental illnesses.

Conclusions

The current study contributes to the understanding of patient safety and raises awareness for CRM in mental health. The mental health specific overview of central risks and related organizational management practices offers a valuable basis for CRM development in mental health and an addition to CRM in general.