Risk management - when it is OK not to talk about Kevin

This is article seventeen in an RCVS Knowledge series of features on patient safety, clinical human factors, and the principles and associated themes of Quality Improvement (QI).

Jane’s Diary
3 January 2022
Wow! Where did last year go? It seemed to fly by. One minute it was March, the next it was November. But at the start of a new year, I have to say I’m feeling quite chuffed with how 2021 turned out. Of course, it began in complete disarray - even without Covid - but I really feel like we turned it around.
It was the day we got confirmation that the case was settled – that was the day I knew we needed to change. To prevent a case like 'Kevin’ ever happening again. I remember the feeling to this day as I first heard news of the accident – my heart thumping, and a prickly feeling around my neck. I can’t imagine how the team felt – watching him run off across the field at the back of the clinic, lead trailing after him. But, to everyone’s credit, we sat down afterwards and tried to figure out what went wrong. There were lots of contributing causes - I could probably write a book about it all! Maybe I should?!
Anyway, it was my colleague Tim who suggested I draw up a risk management strategy for the business. And having done some research it makes so much sense - I see risk management as a friend now. For me, it’s all about getting my ducks in a row – for the patients, for the clients, for the staff, and for the practice.
After nearly a year at it I feel like we are getting somewhere too – talking about accidents, investigating them, and improving what we do. What will we achieve in 2022? More of the same I hope – with every audit and honest conversation we have, I feel like the team and I are moving forward. Funnily enough I feel more relaxed these days, now that I know a bit more about risk.

What is risk management?

An integral part of veterinary medicine is of course the management of risk and it’s something we as veterinary professionals do almost instinctively. Through a combination of training, experience and what could be called our ‘risk antenna,’ we manage workflows, look out for our colleagues, and ourselves. It is in large part because of the veterinary team’s ability to manage risk, that veterinary care so often has a positive outcome. However, occasionally an accident happens. Why is this? Anyone is capable of human error, particularly at times of stress, or when rushing to complete a task, but research shows that even these accidents can be addressed. Not by telling someone to ‘be more careful,’ but by using risk management tools and techniques – these help us to look at our practice as a system, rather than at individual personalities. ¹

Risk management is a way of increasing the quality and reliability of the services we provide - an administrative discipline that helps teams think about risk in a fresh new way. It helps us plan for likely sources of risk and investigate the accidents that do occur. An important element of risk management is fostering an appropriate workplace culture too - one where mistakes can be discussed openly, staff routinely report incidents, and action is taken when a risk is identified. In summary, risk management is a ‘whole team’ approach for the wellbeing of patients, staff, and the practice. ²

Breaking risk management down

Risk management can be broken down into three broad categories:

• Detection – monitoring the practice for events including near misses and accidents.
• Mitigation – this includes anything that helps reduce harm immediately after an incident has occurred. For example, speaking up about an error so that a potential remedy can be instituted as soon as possible.
• Amelioration – the findings from investigations, and the actions taken to prevent a recurrence of the same or similar event in the future.³

Another way of thinking about risk management is to use a football analogy – the ultimate risk in a football match is of course conceding a goal, and for this reason players are always watchful for bursts into the penalty area by the opposition. But, without coaching and help from the sidelines, a team will always be at a disadvantage. To improve performances, the managerial staff run post-match analyses, drill and train the squad. In the veterinary world a risk management strategy is similar - it means examining significant events and talking about the lessons learnt.⁴ It is also about holding regular meetings to improve teamwork and the flow of information around the practice. And it is about leadership - nurturing trust and cooperation.⁵ Finally, it’s not about ‘controlling’ people to control risk, but engaging with the team to learn more about their concerns, for their benefit, but also the practice’s.

But risk management is not simply about patient safety - it can be seen as an integrated approach to everything that could harm a patient or a person or the practice – from trips and falls in the waiting room, to cyber-attacks, from prescribing errors to a mistake by the most revered specialist.²

So how might Jane and her management team have addressed risk management after the incident with Kevin?

Using the principles we’ve just outlined she:

1. Discussed the high-risk nature of veterinary care with the whole team and addressed human error head-on. ‘We all make mistakes – that’s just life,’ she said, ‘I don’t think we should unfairly blame anyone. Let’s learn from them and move forward.’
2. Talked about the practice as a large system, and said, ‘the chance of an accident - any accident - occurring can be reduced when our system is working well. This means that communication is important, as is compassion for our colleagues, and a willingness to listen to ideas, questions or concerns.’
3. Encouraged staff to tell her about accidents and near misses directly, or indirectly through the practice’s anonymous reporting tool.
4. Planned to meet with her senior clinical board every two months to review events using a template she had downloaded from the RCVS Knowledge website to assist them.
5. Completed a short course on quality improvement so she felt comfortable leading the discussion.

Started to feed back the results of these significant event audits to everyone so that they were all learning from incidents large and small.

Risk management is a relatively new concept in the veterinary sphere but offers many benefits - for care quality, staff well-being, and practice reputation. Risk management also reduces the frequency of events that tie up managers’ time and that pose a risk to the financial health of the business – in short, risk management makes it less likely that we’ll ever need to talk about Kevin.

To get you thinking about risk in the context of your job or role, it may be helpful to think about the following questions:

• How do you feel about risk personally? Is it something you naturally embrace, or shy away from?
• Veterinary care often involves making decisions about the relative risks of doing something, versus not doing something. Does it help to think about your job in this way? If so, why is this do you think?
• Do you discuss risk with your colleagues at work?
• Imagine that you’re having a conversation with your team about risk for a moment, does this feel good, or bad?
• What might help you have this conversation?

Checklist: What you can do next

• Use root cause analysis tools to understand which contributors factors lead up to significant events. These tools can help the team to embed a culture of psychological safety.
• Make the most of RCVS Knowledge’s free Significant Event Audit resources which provide templates, courses and resources to help the team put processes in place to help improve outcomes.
• Enjoy the free Quality Improvement Boxset, a series of free, small bite-sized episodes of content. Just like streaming services, you can scroll and pick and choose what you want to watch or listen to, to learn about Quality Improvement in veterinary practice.
• Read our real-life case example of how a practice team reacted after a patient escaped while trying to maintain social distancing during COVID-19. This example will show how the practice used Significant Event Audit to bring about improvement.

References

1. Turner, M. (2021) Building a safety culture in practice - a whole team approach (RCVS Knowledge) (online). Available from: https://knowledge.rcvs.org.uk/news-and-events/features/building-a-safety-culture-in-practice-a-whole-team-approach/ (Accessed 9 March 2022)
2. What is risk management in healthcare? (NEJM Catalyst: Innovations in Care Delivery) (online). Available from: https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0197 (Accessed 9 March 2022)
3. Duckers, M. et al. (2009) Safety and risk management in hospitals (The Health Foundation) (online). Available from: https://www.health.org.uk/publications/safety-and-risk-management-in-hospitals (Accessed 9 March 2022)
4. McGowan, J., Wojahn, A. and Nicolini, J.R. (2022) Risk management event evaluation and responsibilities (online) Treasure Island, Florida: StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559326/ (Accessed 9 March 2022)
5. Compassionate and inclusive leadership (The King’s Fund: Organisational Culture) (online). Available from: https://www.kingsfund.org.uk/topics/organisational-culture/compassionate-inclusive (Accessed 9 March 2022)

About the author

Mark Turner BVSc MRes MRCVS

Mark graduated from the University of Liverpool in 1996 and in 2017 completed a Masters degree at the RVC investigating patient safety culture in the UK veterinary professions.

The research project investigated contemporary knowledge of patient safety behaviours in practice including significant event reporting and auditing.

He has an interest in the application of patient safety as a tool for improving staff engagement and success. He has written for Vet Times, Companion magazine and appeared as a guest blogger for the BVA/RCVS Vet Futures project.

Back to top