Sunday, March 10, 2013

Taking some of the Risk out of Risk

If you look at Quality blogs these days, including this one, you see a lot of discourse about Risk.  Risk has become, I fear, today’s Quality flavour.  It’s too bad, of course because flavours come and go, but true and valid concerns about putting patients, clinicians, laboratory staff, and the community and environment at risk in a constantly changing healthcare landscape are very real. 

Most times when you look at the blogs, the breadth and depth of the discussion is about Failure Mode Effects Analysis (FMEA), but as a colleague once told me, Risk goes a lot further than that.  The FMEA approach says that you can look at a piece of equipment or a procedure and break it down to all of its parts and sort out what can go wrong and then fix them.  That’s simple.  Solve all your problems before they exist using an FMEA strategy.  Live is solved.

Recently I have been spending a lot of time in the Risk arena, and I have come to appreciate that Risk owes a lot to both Game and Chaos theory – two mathematical systems that address decision making.  Both make the point that life is a cause and effect experience but it is loaded with uncertainty, most of which is immeasurable and unpredictable.  Often the chain of events that leads to an outcome may not be easy to trace. 

Benjamin Franklin, a lot time before Chaos theory said it poetically: 
“For the want of a nail the shoe was lost,
For the want of a shoe the horse was lost,
For the want of a horse the rider was lost,
For the want of a rider the battle was lost,
For the want of a battle the kingdom was lost,

Donald Rumsfeld said it more recently, but equally poetically, when he talked about the decisions that surround the famed weapons-of-mass-destruction:

“There are known knowns. These are things we know that we know. There are known unknowns. That is to say, there are things that we know we don't know. But there are also unknown unknowns. There are things we don't know we don't know.

The point is that it is impossible to calculate all risk out of life’s equations. 
For me, the real Risk challenge is referred to by Frame as “Planning for Risk”.  Regardless of what risk analysis tool is used, and regardless of what business or industry you are working with, at some point someone has some decisions to make.  Can we live with this risk, or are we better off not getting involved.  Can we use a different approach?  Can we off-load the risk to an insurance company?  Or can we provide people with an informed consent making it clear that we will only go ahead if they clearly understand the risks and are prepared to live with them one way or another?

Frame says that companies fail at this game when they don’t create the process that says this is the person whose responsibility it is to make the decisions for this level, and that is the person whose responsibility it is to make decisions that that level.  And that person is the one who makes the ultimately hard and final decisions. 

What I see especially in hospital and government politics is the opposite of “planning for risk”; junior people refusing to taking on decisions, because they fear repercussion (aka cover-your-backside) or worse, senior people creating road blocks and bottlenecks by demanding all decisions get made only inside their office. 

Competent management sets up the structure for decision making well in advance, and ensures that people understand their zone of authority.  And if circumstance changes, to let the people know that too.  Then when decision time comes, people can be forearmed, informed, and ready and comfortable to do what makes sense at that time.  If they still can’t make a decision then either they don’t understand the question, or they are the wrong person in the wrong job.

Bottom line;
Risk is about making decisions.  Risk tools are about helping to make more informed decisions.  Risk Management is about making the most benefit from informed decisions that turn out well, and reducing the downside when they don’t.

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