On 26 and 27 of November 2015 the 10th National Health Care Forum anniversary had taken place in Katowice. Some of you had the chance to particiapte in our lecture concerning safety in clinical processes. We talked about how clinical process can be defined (from beginning to end), how to find and calculate risks, and how can it be decreased. I had displayed an abstract of how we can evaluate the risks in clinical processes.
- Define the process, for which you want to evaluate the risks. It could be the main process, for example, process of hospitalization patient in the ward xxx.
- Define beginning and the end of the process, but please remember that patient starts and finish the process. It depends on you whether beginning will be patient eneters on the ward or patient’s contact with physician.
- In order to list actions from the process, the best solution is to go to GEMBA (place, where process works, ward) and observe the process.
- When you do the flowchart of your clinical process, you need to take next step and create a team, multidisciplinary team. Organize the meeting with your colleagues from the ward and conduct brainstorm to point all potential failures, than can occure in your clinical process. You can refer to problems that occured in the past. Remember that we are looking for POTENTIAL failures, which have cause for our process.
- After that point, collect and get your problems in order. Now you have to find the root cause of the failures. For this steo you can use ISHIKAWA diagram and 5WHY tool.
- While we have all root causes, now we can evaluate our clinical risks. In order to specified objectively the risks, use FMEA method (failure modes and effects analysis).
- Based on factors SEVERITY FAILURE FOR PATIENT, OCCURENCE PROBLEM IN OUR PROCESS, DETECTION we can evaluate the possibility of occurence the our risks, it could be high, medium or low.
- By relying on RPN (Risk Priority Number) we have to take the actions to decrease or eliminate risks. Now we have an action plan, which realization infuences on process safety, quality level of medical services, personnel awareness and people commitment.
- For evaluation process the best is involve colleagues for example: physicians, nurses, ward nurses, administration. The more specialist in the team we have, the better brainstorm we can do and risk evaluation is more precised.
- You can conduct risk evaluation while process is implemented or when medical entity is just built. Thanks to that you will find WEAK POINTS IN THE CLINICAL PROCESS which you will eiminate.
I had presented briefly the risk process evaluation ( it concerns every medical process, which you can meet in big and small hospitals, doctor’s office).