Risk-Based Thinking Data Management - CoxHealth › ... › LDIBreakoutsessionGoodBrown21… ·...
Transcript of Risk-Based Thinking Data Management - CoxHealth › ... › LDIBreakoutsessionGoodBrown21… ·...
Breakout session 2
Risk-Based Thinking
Data Management
Vicki Good & Jim Brown
Continual Improvement & Innovation
Some common techniques for fostering innovative thinking include:
– Visualizing the problem in different ways & from different angles
– Representing thoughts in visuals– Thinking fast and frequently– Trying different combinations– Investigating the opposite side– Thinking beyond what is known– Looking for disconnects– Thinking in teams & building on others’ ideas
Risk Based Thinking & OpportunitiesRisk Based Thinking Risk & Opportunities
Overview
• Clause 6.1 actions to address:
– Risks (negative)
– Opportunities (positive)
• When to consider risk-based thinking:
– New projects/programs
– Routine changes
– Business situations
• Management is accountable
Unacceptable Risk?
As Low as Reasonably Practicable (ALARP)
• Weigh the risk against the trouble, time, and money needed to control it.
• Describes the level to which we expect risks to be controlled.
• For high risk situations need formal decision making techniques (FMEA, etc).
• “How much risk are we willing to accept”
“Proof is in the Pudding”
• Can we demonstrate what process may cause the risk?
• Can we link the project we have built to prevent the risk?
• Have we conducted an analysis of the risks of the new product?
• Have we planned for variation, i.e. the variables that can impact our plan?
• Have the undesired effects been considered?
Proactive: Actively seeking the identification of hazardous conditions through the analysis of the organization’s processes
Reactive: Responds to events that have already happened, such as incidents and accidents
Proactive vs. Reactive
Risk Identification
• Risk Definition: combination of the consequences of an event and the associated likelihood of occurrence.
• Hazard/Risk Identification:
– Customer feedback
– Nonconformance reports
• Incident reports
• Word of mouth
• Surveys
What Can Go Wrong?Hazard Identification
How Often? Frequency Analysis
How Big?Consequence Analysis
So What?Risk Assessment
What Do I Do?Risk Mitigation
1Negligible
2Minor
3Serious
4Major
5Catastrophic
5Frequent 5 10 15 20 25
4Probable 4 8 12 16 20
3Occasional 3 6 9 12 15
2Remote 2 4 6 8 10
1Improbable 1 2 3 4 5
Severity
Pro
ba
bili
ty
Evaluating risk
Risk Assessment
Low 1-4 Medium 5-14 High 15-25
Failure Modes Effects Analysis
• Select the process you want to examine
• Assemble the team
• Define the process steps
• Analyze the failure modes
• Define the actions and outcome measures to prevent the failure
Bowtie Tie Technique
Threat Proactive Barriers Hazard Reactive Barriers Consequence
Summary
• Risk is everywhere, so are opportunities
• Organization must define our risk tolerance
• Organization must proactively manage risk in every location
Data Management
Key ISO Management Principle…
“Factual approach to decision making”
• Effective decisions should be based on the analysis of data and information
• Focus on facilitating information/knowledge sharing
• Focus on Alignment of Goals/Activities
Organizational Knowledge• Internal Sources
– Lessons learned
– Intrinsic staff knowledge
– Subject matter experts
– Intellectual property
• External Sources
– Evidence based literature/benchmarking
– Regulations/standards
– Conferences
– Customer/supplier feedback
Achieving Quality Objectives
• SMART Goals
– Specific
– Measureable
– Attainable
– Realistic
– Time-bound
• Key Performance Indicator (KPI)
• Organizational Balanced Scorecard
Enterprise Scorecard
Leadership Evaluation Manager
Setting Goal Targets
Target set by Sr. Leaders
National Benchmarks
Yes
Yes
No
No
Internal Benchmarks
3 = Defined Target4,5 = Desired progress
1,2 = Unacceptable movement
Ex. Budget, firm org goals, WWTK
3 = Desired comparison4,5 = Attainable progress2= Current performance
1= Unacceptable comparisonEx. PSI-90, Core Measures
3 = Central group of distribution5 = Best performers
2,4= Logical gaps1= Lowest performers
Ex. Internal Satisfaction
SME / Accountability
Team
3 = Desired comparison4,5 = Attainable progress2= Current performance
1= Unacceptable comparison
No
Yes
Yes
How do you capture and use knowledge?
Learn from your experiences, both good and bad: • Project debriefs• Staff meetings• Case/Patient reviews• Examination /Assessment of data such as
Customer/Patient Feedback or established Quality Measures
How do you capture and use knowledge?
Evaluate how you capture and use knowledge in your team/work unit:
• Is there a process? Is it clear and functional? • Is the knowledge maintained and accessible (i.e.,
documented and available)? • Simple audit could be to inquire about recent
failures or successes with one of your processes. • How and what did you learn from these events?• How are you going to help make it more
successful going forward?
Focus on facilitating information/knowledge sharing
Questions