Healthcare Risk Consulting

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Risk, Learning & Leadership

The NHS is under the greatest amount of strain since Nye Bevan created it over 70 years ago. Managers and clinicians are trying to maintain their drive to provide the safest and most reliable care they can in the toughest of circumstances.

The pressures couldn’t be greater to improve care quality and access standards and simultaneously drive through efficiencies programmes while facing ever increasing patient demands. Building much needed resilient and sustainable integrated services intensifies these challenges. The virtuous circle of risk, learning and leadership couldn’t be more apt. Inclusive risk management to foster prevention, pervasive learning to enrich care and compassionate leadership to empower clinicians is a compelling way through.

Our Philosophy

Incidents, learning and organisational responsibility

When organisations review failures, acts or omissions an individual often becomes the centre of concern. Sometimes it is convenient to hold the view that ‘human error’ is much more likely a root cause than a series of failings of systems or processes. The clinicians must be at fault.

Everyone accepts that clinicians never intend to cause patient harm, that is, until there is an incident. Placing individuals in the ‘dock’ can cause immeasurable harm to the clinicians – notwithstanding the impact on teams and the organisation.

Instead, when incidents occur clinicians should be involved in designing improvement work, which can, in turn, support their ongoing well-being. We know, through extensive work with clinicians and healthcare providers, that clinicians are best placed to define actions or process changes to prevent further incidents. Meaningful engagement is key.

The much famed swiss cheese model of risk management continues to be a useful analogy of how contributory factors within a process conspire, leading to an adverse event. Dispassionate systematic analysis can identify the barriers or safeguards that were compromised (or where the holes in slices of swiss cheese aligned) and where improvement is required.

Hindsight (armed with all the facts from varying perspectives) enables powerful insight into the factors leading to an incident. This is important to fully understand the conditions leading to an incident, however, unfortunately it (and outcome bias) can unfairly cloud consideration of the actual circumstances, knowledge and view point of clinicians involved on the day. In a ‘just’ work environment incident reviewers (led by the organisation) need to try to understand why the clinicians did what they did and why it made sense at the time.

It is also fair to say the very systems designed to protect patients and staff, were designed by people and as a result those systems can be fallible – just as the clinicians working within them.

We need to ask was the system poorly conceived? Were clinicians using a ‘work around’ because of the system? This can create a fine line between fault, blame, accountability and responsibility, though the central intent must be to learn from the event and to develop insightful, effective mitigations. Forward thinking organisations ask clinicians, how can we make the ‘work around’ safer and can you help us make delivering care safer for you and your patients.

Most organisations say their workforce is their most important asset. Experience has shown us that if clinicians are meaningfully engaged in risk mitigation and problems solving, not only do systems and processes become safer but such approaches can build empathy and break down inherent siloed working. This applies to cross-boundary care delivery too, as rarely does a healthcare provider work in isolation.

Creating the safest services relies on clinicians themselves feeling supported and safe when reporting incidents. It is the organisation’s responsibility to ask how can we help and what do you need to prevent further incidents. It could be argued that how clinicians learn is in direct response to how they are treated by an organisation. Learning is a natural by-product of meaningful engagement.

In essence, incident reporting, management and learning processes could be more human, and more humane.

The most effective response to incidents is openness with patients, supported learning for clinicians, and teams and a proactive, data-driven risk management focussed on empathic mitigation design.

We know compassion and transparency helps patients and their families on so many levels. This applies to clinicians too. The journey of learning starts with honesty and compassion.

Our Approach

How we make a difference

Utilising our knowledge and expertise we offer specialist services across the clinical risk continuum – from incident to learning.

It takes focused effort to understand the key factors driving a type of incident. Deep consultation with those on the frontline is critical in clarifying risk issues as well as in designing and testing potential mitigations.

Clinician engagement builds employee confidence in an organisation’s willingness to address concerns and strengthens the foundations of sustainable improvement work. Most importantly, meaningful engagement around risk incidents builds trust that reported workforce or patient safety events and risks will be embraced to drive learning processes. Reporting incidents should be a worthwhile looped process with notable, effective outcomes.

Patient safety incidents often occur due to miscommunication and systems or process failures. These events are important opportunities for healthcare providers to support the harmed patient and family and proactively learn to prevent similar events. Incidents are usually a symptom of much wider issues.

Our mission is to work with healthcare providers to identify these issues to reduce incidents and patient harm and build a just culture that promotes learning as a core value.