We are pleased to be bringing you the first in our series of Healthcare Risk Management articles from Ms Ann O'Driscoll who is the leading member of our Legal and Healthcare Risk Management Team. Ann and her team at DAC Beachcroft Dublin also operate our Challenge Medical Indemnity 24 hours, 7 day consultant helpline.  

'Getting to grips with the Risks'

Although the terms "Clinical Risk" and "Risk Management" are relatively new to the Irish healthcare sector, the fact of the matter is that clinical risk and risk management have always been part and parcel of what healthcare professionals do, in particular doctors.

An example of this is where a doctor decides to carry out a complicated high risk surgical procedure on a patient. The doctor manages the risks associated with the procedure by, firstly, having a discussion with the patient and informing him/her fully of the risks/possible complications associated with the procedure. The doctor may then put together a team with the appropriate expertise to assist in carrying out the surgery which may involve surgeons from other specialities. If a complication arises during surgery, measures are taken to contain the problem. Intra-operatively and post-operatively, antibiotics may be prescribed and administered to manage the risk of infection. If infection does occur, the surgeon may consult a microbiologist to ensure that the appropriate antibiotics are being administered. This is a classic example of team risk management in action by a surgical team i.e. clinical risks are identified throughout the patient's clinical course while under the care of that team and are actively managed with a view to minimising or eliminating the risks. However, if while recovering post-operatively on the ward, the patient falls while attempting to get out of bed unaided (due to a shortage of nursing staff) and slips on a wet floor (due to a shortage of cleaning staff), thereby sustaining a severe fracture and developing an embolism resulting in death, this brings into sharp focus the issue of organisational risk management. In such circumstances, it is little consolation to the surgical team that they carried out a very successful operation and managed the risks associated with the surgery if their excellent work is subsequently unravelled by a series of adverse, but avoidable, events which occur while the patient's management is no longer directly under the control of the surgical team.

If one goes back further in time to the 1850's, to the Crimean War and Florence Nightingale. Florence and her team of nurses arrived in December 1854 at Selimiye British Barracks in Scutari where she was confronted by rats and fleas, appalling hygiene standards, a dearth of medical supplies, no uniform system for recording clinical care or maintaining records, and mass infection among the soldiers leading to high mortality rates.  She and her colleagues began by thoroughly cleaning the hospital and equipment and reorganizing systems of patient care. A Sanitary Commission was sent out by the British government to Scutari, almost six months after Florence had arrived, flushing out the sewers and making improvements to ventilation. Death rates were sharply reduced. Mortality rates dropped from a very high 42.7 per cent to 2.2 per cent. This was organisational risk management in action at its best i.e. teams of varying knowledge and expertise (both clinical and non-clinical) working together towards a common goal i.e. the reduction in infection rates, in this instance, leading to the saving of lives.

There is a difference between team risk management and organisational risk management, and the indications to date suggest a seeming reluctance on the part of medical practitioners, including consultants, to become involved in organisational risk management. One explanation for this might be the professional indemnity system which was in existence prior to the introduction of 'Enterprise Liability' by the State in 2002, whereby non-consultant hospital doctors (NCHDs) and consultants in the public health sector had separate professional indemnity cover to nurses, midwives, radiographers, physiotherapists etc. This meant that in the event of a medical negligence claim with multiple defendants, each indemnifier maintained an adversarial position vis-à-vis the other defendants, with the result that hospitals were generally regarded as frequently having hung the doctors "out to dry". Unfortunately, this system created a great deal of mistrust between doctors and hospitals and, obviously, within the medical team. Many of the NCHDs who worked under the pre-2002 regime are now consultants and it may that the legacy of mistrust in healthcare organisations/hospitals is difficult to shake off.

The important thing to realize about risk is that there are two types: the risks we know about and the risks we don’t know about. In healthcare, the latter category usually arises in the context of organisational risk where if there is no system within the organisation (and this would include a consultant's private rooms) for the identification and management of risk, then patient safety is at risk and also the reputations of the treating healthcare professionals, particularly in the context of their exposure to complaints, claims, inquests and fitness to practise inquiries. The clinical claims experience in this country, of which I have 20 years in defending NCHDs, consultants, nurses and midwives, provides a wealth of information about the lack of risk management systems in healthcare generally; in particular, the claims experience demonstrates that, in some instances, the same mistakes keep occurring. This is worrying as it frequently strikes me, while engaged in the investigation of clinical claims, how easily many organisational risks could be corrected without involving any financial expenditure whatsoever on the part of the organisation. Contrary to popular belief, the solution to a risk is often a mixture of common sense coupled with good communication skills and a bit of thinking "outside the box".

Consultants bring with them a wealth of knowledge and experience. However, it takes an organisational effort, with the varying degrees of knowledge and expertise of the teams (both clinical and non-clinical) employed by the organisation, to ensure that every patient who is admitted to a hospital/clinic for surgical or medical treatment or both, leaves the hospital in a better state of health than he/she had when entering the hospital. This is the organisational goal and one team alone cannot achieve it. Therefore, it follows that where a consultant is depending not only on his own team but, also, on other teams (clinical and non-clinical) within the organisation to ensure delivery on the common goal of quality patient care, consultant involvement is axiomatic to ensure that there are robust risk management systems in place in the healthcare environment in which he/she operates. The input of consultant expertise is essential and core to the clinical risk and patient safety agenda of any healthcare organisation.

If you are a consultant who owns and operates out of private rooms, implementing risk management can be a relatively simple task. If, for example, your team consists of yourself, a nurse and secretary, it would be prudent to engage an external consultant to conduct a risk analysis (clinical and non-clinical) on your practice which is, essentially, a business. The positive thing about a risk analysis is that it frequently highlights the good systems already in place. I have found this to be the case during the course of an investigation of a claim, fitness to practise inquiry or an inquest where one sees not only sub- optimal care in some cases but, also, examples of best and effective practice and, very often, exceptional care. Likewise, if you are part of a group of consultants who own and operate out of private rooms, it would be prudent and, indeed, very cost effective, for the group to engage a healthcare risk consultant to carry out a risk assessment of your business and to make recommendations for change where appropriate. Patient safety should not be a reaction in the business of healthcare, but a pre-requisite.  Patient safety has been and is a fundamental tenet of the vocation of the practice of medicine.

Many consultants have now been appointed as clinical directors, medical directors and clinical leads in our public, voluntary and private hospitals. These appointments serve to strengthen the risk management function in a healthcare organisation. While this development, in itself, is most welcome and long overdue, the worrying aspect of it is that no formal training has been provided for these important roles. The roles require a multiple skill set e.g. good management and leadership skills and the ability to engage with multidisciplinary personnel in a fast-moving and highly technical environment, where issues must also be mediated at times. Quite frankly, these are skills which do not come naturally to many of us, no matter how qualified or expert we are in our own particular fields of expertise. One practical and highly cost effective way around this would be, for example, for a group of private hospitals to consider coming together and co-operating to jointly fund a 2-day training session for consultants who have been appointed to such roles. Many well known teaching hospitals in the UK have already been down this road and might, if approached, be prepared to participate in the training days. Likewise, the HSE could organise similar training days for its medical directors and clinical leads. These are all very practical measures and with the right will and attitude could easily be incorporated into the cultural mind-set and practice of a healthcare organisation. 

Healthcare organisations and professionals are often daunted by the prospect of having to set up a Risk Management Committee/Group, however, the reality is that once you gather together a group of appropriately qualified, interested and vision-sharing individuals, it is a relatively easy process. Some of the key components of a successful Risk Management Committee are as follows:

• The terms of reference, the membership, the roles, duties and responsibilities of the Committee should be agreed and drawn up at the outset. Depending on the size of the organisation and the nature of its services, the membership should include the Clinical/Medical Director, the Director of Nursing, the Risk Manager/Quality Manager, the Chief Pharmacist, the Manger of Laboratory Services and the Manager of Theatre Services. If you are working in an organisation which is accountable to a Board of Directors, one of the Board Members should be asked to sit on the Risk Management Committee and to attend the monthly meetings. Some hospitals have a separate Risk Management and Clinical Governance Committee, however, there is no reason why consideration should not be given to merging the two committees into one and, for example, re-naming it the 'Quality, Risk and Safety Committee'.
• The appointment of a strong leader to chair the group (the chair should rotate every 2 years);
• Regular monthly meetings. The meetings should last not more than 1 hour as, firstly, it focuses minds on the agenda and, secondly, healthcare professionals are busy people.  Early morning or late afternoon meetings might suit best.
• An agenda should be drawn up and agreed prior to each meeting. If the same unresolved issues/problems keep appearing on the agenda each month, then this needs to be addressed and actioned.
• Invite people, who are not members of the group, to make presentations to the group, when the circumstances warrant it.
• Prepare an annual report to the Board or the Hospital Manager whichever is appropriate for your organisation. An annual report is imperative in order to keep the Manager or the Board informed of the risks within the organization and how the risks are being managed. A short monthly report highlighting any acute risks, to include staff shortages (but one has to show how the shortages impacted on patient safety), should be furnished to the Manager or Board. 
• Channels of communication should be strongly encouraged to remain open at all times so that the Committee is constantly engaged in the issues that arise at any given time within the organisation.  The better the level of information flow within the organisation, whether between doctor and patient, nurse and doctor, doctors and management, the more a culture of transparency and trust becomes established and embedded in the mind-set of the organisation and which can only lead to a more positive quality of service, safety and care.
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• In relation to the Challenge Medical Indemnity Helpline, consultants should be aware that the helpline is not merely there to assist with medical malpractice claims, inquests and fitness to practise inquiries, it is there to assist you with patient complaints, complaints to the Medical Council, the management of adverse clinical outcomes, risk management and governance issues and any matters which impact on your day to day practice. It is a 24 hour helpline which is manned by people, such as myself, who are there to guide, assist and support you through the ever increasing medico-legal and organisational governance complexities of every day practice.

The number of the Helpline is 01-2319640.

Ann O'Driscoll,

DACBeachcroft Solicitors