Risk Management and Quality Improvement
Quality improvement is a fundamental aspect of EQuIP, and the ACHS handbook offers essential guidance on risk management and quality enhancement This resource aids organizations in effectively managing risks across various levels—organizational, divisional, departmental, and systemic—while ensuring that the quality of care and services is seamlessly integrated.
The EQuIPNational program offers a structured framework for organizations to assess their performance in risk management and quality improvement Organizations are expected to consistently identify and implement effective risk and quality management processes that align with their specific roles During evaluations, ACHS surveyors will focus on risk management processes, consumer and patient safety, and the quality of care and services, using these factors to assess organizational performance and provide recommendations based on survey findings.
Healthcare organisations’ systems for risk management and quality improvement are reviewed within the National Safety and Quality Health Service (NSQHS) Standards under Standard 1:
Governance for Safety and Quality in Health Service Organisations In addition, NSQHS
Standards 3-10 mandate organizations to conduct risk assessments of their systems, such as NSQHS Standard 4, which specifically addresses medication management systems These assessments are overseen by governance committees, with significant risks documented in the organization's Risk Register Additionally, organizations must present a Quality Improvement Plan during each phase of their accreditation cycle and ensure that the Risk Register is accessible to ACHS surveyors during onsite evaluations, highlighting the importance of effective risk management and quality improvement.
Handbook is provided to assist organisations to develop and monitor both the organisation-wide
Risk Register and the Quality Improvement Plan
This handbook offers supplementary healthcare-specific information and guidance on risk management systems, complementing rather than duplicating the AS/NZS ISO 31000:2009 Risk Management standard.
Developing a Commitment to Risk Management and Quality Improvement using EQuIPNational
Risk management and quality improvement are interconnected processes that form a comprehensive framework for enhancing organizational practices By focusing on how tasks are performed and seeking proactive improvements, organizations can prevent issues before they arise Successful implementation of these programs often involves engaged staff who are willing to share their insights Additionally, networking and discussions among peers can uncover problems and generate potential solutions, ultimately leading to improved outcomes and minimized risks.
Effective risk management and quality improvement programs require strong commitment from the governing body and leadership team, who must clearly define expectations for all stakeholders It is essential for leadership to allocate adequate resources to fulfill organizational requirements and implement systems that effectively mitigate and manage risks Ultimately, the focus should remain on delivering safe, high-quality care to consumers and patients within a clinical environment.
To create a safe and accountable healthcare environment for patients, staff, and providers, organizations must focus on implementing effective systems and processes Utilizing EQuIPNational as a comprehensive quality program enables organizations to monitor and manage risks while fostering continuous improvement in their operations.
Risk management and quality improvement systems establish a structured framework for identifying, analyzing, treating, and monitoring risks, problems, and opportunities Effective communication and consultation with stakeholders are essential for the success of these processes.
Continuous improvement and effective risk management rely on data-driven insights that are essential for executives, clinicians, managers, and governing bodies It is crucial that the data provided highlights the most significant issues facing the organization, rather than merely serving the purpose of data collection.
This handbook presents various tools designed for quality improvement that are also applicable to risk analysis It aims to assist organizations in implementing effective risk management and quality enhancement processes Beyond merely offering management tools, it emphasizes the importance of principles and frameworks necessary for the successful application of these tools, ensuring the establishment of effective systems.
Incorporating Risk Management and Quality Improvement into Organisational Planning
Integrating quality improvement and risk management into both strategic and operational planning is essential for all aspects of healthcare delivery, including clinical and non-clinical services This cohesive approach should influence decisions related to clinical practices, equipment design and procurement, capital development, information technology, contractor management, workplace health and safety, workforce management, and financial planning, ensuring comprehensive operational effectiveness.
To determine the priorities of risk management and quality improvement, the approach to quality, and the structure of an internal improvement and risk management program, the organisation should identify:
What activities has the strategic plan highlighted?
How will risk management and improvement activities relate to the strategic goals?
What problems have been identified and/or are reported?
Are there external requirements that must be achieved?
What aspects of care should be targeted?
Are there particular clinical areas that need support?
What resources are available to make improvements and manage risks?
What expertise do staff have in quality improvement and risk management?
What are the greatest risks to the organisation?
What are the greatest opportunities for the organisation?
What are the consequences of those risks or opportunities?
What is the likelihood of those risks or opportunities occurring?
What approach and structure to take:
How will the governing body be involved?
Who will be responsible for and coordinate the activities and programs?
How will the organisation involve the staff?
How will the organisation communicate its plans for improvement and risk management to stakeholders?
How will progress be monitored?
How will improvements be monitored?
What body / group / committee will monitor progress and/or improvements?
What tools should be utilised?
The results from the aforementioned questions should be integrated into the organization’s strategic and operational plans, ensuring they are interconnected While the organization may opt to create distinct plans for risk management and quality improvement, it is essential that these elements are also incorporated into both the operational and strategic frameworks.
Standard 1 of the NSQHS Standards emphasizes the integration of risk management and quality improvement strategies, which are essential for effective decision-making and planning Organizations must achieve a Satisfactorily Met rating in these core actions to obtain or maintain their accreditation.
The NSQHS Standard 1 emphasizes the necessity for organizations to implement a comprehensive system for risk management that includes the identification, assessment, rating, controls, and monitoring of patient safety and quality (items 1.5, 1.5.1, and 1.5.2) Additionally, the quality improvement segment (item 1.6) mandates the establishment of a system that not only monitors and reports on patient care safety and quality but also drives changes in practice (items 1.6.1 and 1.6.2).
Organizations must consistently monitor a comprehensive Risk Register and quality management system to mitigate risks to consumer and patient safety, ensuring high-quality care.
Systems for risk management and quality improvement apply across all of the 15 EQuIPNational Standards, and organisations should monitor their ongoing success through its processes of governance and evaluation
Healthcare organizations face inherent risks in their operations, necessitating effective risk management to meet community safety expectations The ACHS mandates that a comprehensive register of organizational risks be accessible to surveyors during onsite evaluations Additionally, organizations have the option to submit their Risk Register alongside their self-assessment to ACHS, in line with the NSQHS Standards.
Risk assessments for systems like infection control and medication management are mandated by standards 3 to 10, with governance committees responsible for their oversight For more details on implementing a risk management strategy to comply with the NSQHS Standards, visit the Australian Commission on Safety and Quality in Health Care’s website at www.safetyandquality.gov.au.
The goal of risk management in health care is to:
1 minimise the likelihood of possible events that have negative consequences for consumers / patients, staff and the organisation
2 minimise the risk of death, injury and/or disease for consumers / patients, employees and others as a result of services provided
5 support legislative compliance and to ensure organisational viability and development
Risk management is integral to the EQuIPNational framework, as it encompasses both corporate and clinical services Various Standards, particularly Standard 3 on healthcare-associated infection risks and Standard 4 on medication safety risks, explicitly address the necessity of effective risk management within healthcare organizations.
Implementing a systems approach to risk management is essential for making it a fundamental aspect of decision-making This involves creating a framework that allows for the assessment and prioritization of risks associated with both current services and future service planning To achieve this, a robust system for integrating the risk management process is necessary.
This risk management process, described in AS/NZS ISO 31000:2009 Risk management —
The principles and guidelines outlined in Figure 3.1 offer a comprehensive framework for organizations to assess, treat, and prioritize risks and opportunities Effective risk management must be contextualized within the organization, as the nature of risk issues, their potential consequences, and the organization's risk tolerance can differ significantly Understanding this context is essential for identifying the imperatives and constraints that influence successful risk management strategies.
Figure 3.1 Risk management process overview 3
The primary focus of health service providers is to deliver safe and effective patient care To achieve this, a relevant risk management program is essential, tailored to the specific clinical services offered For instance, the risks involved in obstetric services differ significantly from those in aged care, necessitating distinct risk management strategies for each area.
Risk treatment Establishing the context
The role and context relevant to the organisation should be documented with consideration given to:
the mission and values of the organisation
its location, for example rural facilities may have different risk issues from metropolitan facilities
the funding model, such as public, private, for profit or not-for-profit
physical infrastructure, whether it is a new facility, leased premises or heritage-listed building
clinical and non-clinical services provided
the governance structure for the organisation
The risk management framework of an organization must clearly outline its risk management terminology, tolerance levels, tools for implementation, communication protocols, escalation procedures, and reporting processes, all of which should be established during the context-setting phase.
The risk management policy should identify:
Who: is required to report, communicate, action
What: is required to be reported by staff, managers, executives, governance committees
When: risks are to be reported and when information is to be disseminated to the clinicians, staff, executive and governance committees / governing body
Where: information is stored, communicated
How: tools and processes are to be used – e.g risk assessments, risk registers and when a risk may be removed from the current risk register
The governing body must approve the risk management policy and set explicit criteria for the types and levels of risk that need to be communicated To clarify the context for the organization, it is beneficial to reference documents such as service agreements, strategic and business plans, quality improvement plans, organizational charts, committee structures, roles and responsibilities, policies and procedures, as well as risk-specific management programs.
Figure 3.2 Dimensions of risk in health care
To effectively address identified risks, organizations should develop risk-specific management programs, including Clinical Risk Management, Workplace Health & Safety, and Human Resources, that align with and support the integrated Risk Management Policy.
Risk-specific assessments are required for NSQHS Standards 3 -10 and these should also feed into the main risk system
Effective risk management requires clearly defined responsibilities and accountabilities within the overarching risk management program and specific risk initiatives The governing body must establish communication and escalation protocols for risk information, adhering to good governance standards As highlighted by Neil in the Institute for Healthcare Improvement’s Boards on Board, leaders are accountable for all aspects of the organization, particularly when issues arise The governing body and leaders must balance their focus on strategic priorities with the necessity of managing risks effectively, ensuring that the core mission of patient care remains at the forefront.
Accountabilities and responsibilities should be defined for all stakeholders including the governing body, managers, employees, clinicians, contractors and service providers
Responsibilities for key risk categories should also be assigned – for example infection control, quality improvement or work health and safety (WHS)
The management of roles and responsibilities within organizations varies based on their size, complexity, and specific roles In larger organizations, a dedicated Risk Manager may be appointed to oversee the risk management system, whereas smaller organizations often integrate these responsibilities into existing positions.
Risk management responsibilities should be integrated into credentialling requirements, position descriptions, service level agreements, contracts and agreements and terms of reference for committees
Effective risk management requires allocating resources that align with the organization's size and scope, as well as the potential consequences of failing to address risks These resources can encompass financial investments, skilled personnel, and physical assets, including building design and equipment.
To foster a robust risk management culture, it is essential to engage stakeholders through strategic planning and effective communication Both internal and external stakeholders have varying perceptions of risk and its potential impacts, making it crucial to acknowledge these differences in decision-making and action plans.
Identifying key stakeholders, such as decision makers, employees, managers, clinicians, contractors, volunteers, regulators, and patients along with their families, is essential for effective communication within the organization Establishing appropriate communication mechanisms is crucial for understanding the organization's context and analyzing individual risk issues This process should be guided by a comprehensive communication plan that ensures the confidential sharing of information related to risks and outlines management processes.
Effective communication and consultation channels should be established based on the services offered, the nature of the information shared or requested, and the organization's size Communication mechanisms for risk information can involve existing committees or forums, such as dedicated risk management committees In larger organizations, examples include the Medical Advisory Committee, Audit Committee, and Work Committees, which facilitate the dissemination of important risk-related information.
Organizations should adopt a systematic approach to enhance quality improvement, with the PDSA (Plan-Do-Study-Act) cycle by Shewhart and Deming’s PDCA (Plan-Do-Check-Act) cycle being among the most recognized methodologies This continuous cycle allows for entry at any stage, facilitating ongoing quality enhancement.
Figure 4.1 Plan, do, study, act
Plan what you are going to do, after you have gathered some evidence of the nature and size of the problem:
State the objective of the test
Make predictions about what will happen and why
Develop a plan to test the change (Who? What? When? Where? What data should be collected?)
Do it, preferably on a small scale first:
Document problems and unexpected observations
Begin analysis of the data
Study the results Did the plan work?
Complete the analysis of the data
Compare the data to your predictions
Summarise and reflect on what was learned
Act on the results If the plan was successful, standardise this new way of working If it wasn't, try something else:
Determine what modifications should be made
Prepare a plan for the next test
In 1991, the ACHS working party refined the quality cycle, highlighting the importance of feedback throughout all phases This cycle is applicable to any quality activity, initiative, or project, ensuring optimal results are achieved The core principle is that an activity is deemed complete only when evaluation confirms its effectiveness and the desired goals or outcomes have been reached.
To ensure the highest quality of care and services, it is crucial to gather relevant data, as this information is fundamental for assessing the effectiveness of the provided services Continuous improvement programs rely on monitoring various aspects of care, which aids in identifying issues, collecting data for analysis, and establishing a baseline for performance Effective monitoring methods include surveys, audits, observations, record reviews, and data extraction from databases.
Figure 4.2 Quality cycle refined by ACHS working party
To effectively evaluate the current situation, it is essential to analyze data collected during the monitoring phase of the cycle Utilizing analytical quality tools from this handbook can enhance this assessment Presenting data, identifying best practices, facilitating group discussions, and sourcing quotes from external resources are crucial steps in determining the actions required for the next phase.
Effective system improvement solutions must address the needs of consumers and staff while aligning with the service and organizational requirements Prioritizing actions based on thorough assessments is essential for successful implementation.
The quality activity does not finish once an action is taken To ensure the required result is achieved an organisation should ask itself:
Did the action achieve the desired result / outcome?
Is the improvement sustainable over time?
Is there any more that can be done for this activity / initiative / project? Is it complete?
Are the best possible care and services being provided?
Are staff aware of any resulting changes?
Monitoring that was undertaken in the first phase can be repeated and results compared
Effective communication is crucial throughout the review cycle, ensuring all stakeholders are informed of the evaluation results and their impact, as well as any subsequent organisational changes This transparency facilitates a culture of continuous improvement, driving excellence in consumer and patient care delivery.
Feedback provided to those managing activities can significantly aid in driving organizational change This feedback system can enhance grassroots interest in quality improvement programs, making the evaluation of quality care more professionally fulfilling and intellectually rewarding for everyone involved.
The cycle should be repeated until the desired result is achieved and/or maintained
A documented activity planner and maturity rating scale may be considered to measure and review actions and outcomes and to evaluate the quality improvement system on a regular basis
Quality improvement is essential for healthcare organizations, necessitating a Quality Improvement Plan at each stage of the EQuIPNational cycle This plan must be submitted to ACHS alongside pre-survey documents, including the organization’s self-assessment during Phases 1 and 3 Additionally, it should be accessible for surveyors to review during the onsite surveys conducted in Phases 2 and 4.
A successful quality improvement program must include fundamental essentials, though its design will vary based on the organization's size, type, complexity, and location To create an effective program, an organization should first identify the key principles necessary for quality improvement, establish its priorities, and then develop a tailored program that aligns with these factors.
For quality improvement to be successful, suggested principles are that it should be:
based on reliable evidence and accurate analysis
carried out with effective teamwork and communication
When creating a Quality Improvement Plan, organizations must recognize that a crucial aspect of quality improvement is the collective acknowledgment of the necessity to enhance services for consumers and patients The successful execution of quality improvement initiatives is supported by this shared commitment.
an approach that is appropriate for the organisation and is consistently applied organisation wide
a total organisational commitment to continuously improving the quality of care and service provided
an ongoing, comprehensive, multidisciplinary assessment system that engenders continuous improvement
an education program that enables staff at all levels to develop an understanding relevant to their level of responsibility and their active participation in the process
The Quality Improvement Plan must clearly identify specific areas needing enhancement, detail the methods used to recognize these needs, and outline the strategies for implementing improvements It should specify timeframes and assign responsibilities for each task, establish reporting structures, and define the evaluation processes, including anticipated outcomes and improvements.
Organizations can adopt a tiered strategy for quality improvement planning, creating either a single comprehensive plan or individual plans for each department or service It is essential that if a tiered approach is implemented at both the organizational and departmental levels, these plans are consistently updated and regularly reviewed to ensure effectiveness.
Requirements for a Quality Improvement Plan
In conjunction with the ACSQHC, the following main considerations for a quality improvement plan have been identified:
1 Identify the areas that require improvement:
how it is to be improved, i.e goal / KPI (determine the baseline data against which an improvement will be measured)
how will this be achieved
how will you know if it is successful (measured against baseline data)
2 Implement the strategies / changes in the organisation
3 Data collected and analysed against the baseline and evaluate the changes in the systems
4 Note if the objective has been completed or evaluated
The organisational Quality Improvement Plan must be submitted to ACHS at each accreditation cycle phase, as illustrated in Figure 4.3, which outlines the ACSQHC’s requirements developed in collaboration with the ACSQHC While this example does not include details on implementation or educational initiatives, organizations should retain this information for internal reference and future quality planning However, such details are not necessary for the Quality Improvement Plan submitted for accreditation Additionally, linking any identified issues can be advantageous for organizations.
EQuIPNational Standards, and particularly to the 10 NSQHS Standards
Figure 4.3 outlines the Quality Improvement Plan by detailing each heading and offering examples of the necessary information for various quality improvement activities.
Figure 4.3 Example of the minimum requirements a Quality Improvement Plan
To determine if the objectives have been achieved, it is essential to assess whether the changes and strategies have been implemented effectively If an evaluation is necessary, it is important to outline the methods used to assess these changes For instance, comparing hand hygiene audit results can illustrate trends across different audits, providing valuable insights into the effectiveness of implemented strategies.