Why Hospitals Should Embrace Risk-Based Thinking

Patrick Horine

Several years ago, the television series “The Knick” followed surgeons in New York City in the early years of the 20th century, when modern medicine was born. Based at the fictionalized Knickerbocker Hospital, the show dramatized the enormous risks physicians and patients of that era took in performing and undergoing innovative procedures. Patients were more likely to die gruesome deaths than recover; the physicians themselves often suffered deep psychological damage as a result of their work. Both took huge risks in order to advance medicine and prolong lives.

At the time of the storyline of “The Knick,” an entirely new sector was birthed when Orville Wright flew an aircraft on a windswept North Carolina beach.

Both healthcare and aviation have made huge strides over the next century-plus. The surgeries performed in “The Knick” not only became routine but were refined to the point that a patient could go home the same day. Aircraft can now fly for thousands of miles, some at more than a thousand miles per hour.

But aviation and healthcare often diverge when it comes to implementing safety measures holistically. The aviation sector takes as many precautions as possible in preparing an aircraft for flight. Only a handful of people perish each year in airplane crashes as a result, and this number that continues to decline. But as the landmark Institute of Medicine report, To Err Is Human, revealed in 2000, as many as 98,000 Americans died each year as the result of medical errors, many of which were preventable.

There are numerous reasons for this. The most important are the huge operational differences between aircrafts and hospitals. Encounters in aviation are almost always a group experience, with passengers ferried to a destination together, often hundreds at a time. That means any mishap has the potential for an enormous loss of life. By contrast, each hospital patient is treated separately. A single death due to a medical error is very unlikely to make news beyond the patient’s family and friends.

Risk-based thinking—a linchpin of the ISO 9001 quality management system and integrated into every aspect of the standards from the National Integrated Accreditation of Healthcare Organizations (NIAHO) that my firm uses to accredit hospitals—has emerged as a way for hospitals to improve outcomes as an institution. It allows a hospital to adapt an outlook that is not only effective but can fit within the ethos and culture of individual facilities.

Although risk-based thinking takes issues such as an institution’s human, organization and systemic reliability systems into account, it first values seeing risk for what it is and understanding it inimically.

The primary components of a risk-based approach are commonsensical:

• Determine the risks and opportunities of any treatment or approach to a treatment or system
• Plan actions to weigh and address those risks
• Implement those actions within the framework of a quality management system
• Evaluate the overall effectiveness of those actions
• Leverage all of the above to achieve continuous quality improvement

Risk-based thinking should not be confined to just patient care; it must be implemented among all aspects of hospital operations in order to be successful. Processes should be created for all departments, including clinical, support (lab, dietary, etc.) and management, which holds the key to planning and providing resources.

There are some safety protocols developed by aviators that are a great fit both for healthcare delivery and the risk-based approach. For example, checklists that are performed during procedures such as inserting central lines in patients have proven extraordinarily effective in eliminating infections. More examples are available in John Nance’s remarkable book, “Why Hospitals Should Fly—the Ultimate Flight Plan to Patient Safety and Quality Care.”

Checklists not only promote consistency, but also require all care providers to pay attention and communicate directly with one another. The most disturbing of medical errors—such as items left in a patient during a surgery—are almost always the result of flagging attention or a communication breakdown. Checklists help avoid that and galvanize staff to work as teams.

Risk-based thinking also encourages institution-wide collaboration. It can be used to break down silos, one of the most problematic issues in a large institution such as a hospital.

Embracing risk-based thinking is not easy. Getting essentially every employee onboard for such an initiative requires hard work and hard decisions by hospital leaders. But any hospital or healthcare institution that has embraced risk-based thinking will not only see improvements in patient outcomes but higher overall performance and improved morale.

The physicians of “The Knick” took risks that could never be imagined today in order to move forward medical practices that had been essentially unchanged for centuries. But even when new techniques and procedures are mastered, the risks never go away. They need to be more closely examined and analyzed in order to continue pressing forward without leaving anyone behind.

About the Author

Patrick Horine is president of DNV Healthcare USA Inc., the fastest-growing hospital accrediting organization in the United States. Horine is part of a team that created and brought to market the first new hospital accreditation program in the United States since Medicare began in the 1960s. This program, the National Integrated Accreditation of Healthcare Organizations (NIAHO), has attracted more than 400 hospitals, and is recognized for a unique design that integrates Medicare compliance with the ISO 9001 Quality Management System.