The RADICAL Framework For Implementing and Monitoring Healthcare Risk Management
The RADICAL Framework For Implementing and Monitoring Healthcare Risk Management
The RADICAL Framework For Implementing and Monitoring Healthcare Risk Management
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Background
Safety is a key aspect of healthcare delivery, and hospitals are obliged to have robust
systems in place to continually monitor and improve the safety of care. Unfortunately
efforts in this direction are often haphazard rather than tailored, reactive rather than
proactive, and diffuse rather than integrated. Risk management has consumed an
increasing proportion of healthcare resources in the last decade, most of it committed to
promotion of incident reporting. It is narrowly and misleadingly perceived by many
frontline staff as little more than incident reporting, and clinicians often wonder
whether, for all the resources committed to it, incident reporting makes substantial
difference to patient care (Kingston et al., 2004). It can be argued that, at national and
local levels, incident reporting has been over-emphasised, to the detriment of other
domains in risk management. Despite this perception and the huge investment in the
National Reporting and Learning System (2011), many patient safety incidents are
unreported, and huge resources are expended on low level incidents. Incident reporting
is an important component of risk management, but it is not the only means of
Competing interests: The author has no financial interest in the framework. It is freely available
to all for non-commercial use. Funding: Nil.
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identifying risk. The over-emphasis on incident reporting takes attention away from
other sources of patient safety data and other means of identifying risk, such as
horizon scanning, prospective risk assessment, case reviews and system analysis. It
also diverts attention away from other domains such as user involvement and safety
science.
Another limitation of the prevailing approach to healthcare risk management is that
the role of the individual practitioner in protecting patient safety is insufficiently
emphasised, and frontline practitioners are inadequately trained to recognise and
interrupt error chains. As a result of the need to eradicate the culture of blame, risk
managers are moving from a person approach to a system approach, but we are
now at risk of swapping one extreme for another. What is required is a suitable balance
between person and system: as well as building resilience into the system, individual
practitioners should be equipped with the cognitive and other skills necessary for safe
practice.
With the financial squeeze, the time has come for hospitals to demonstrate in
concrete terms the output of their risk management programmes. Unless the
programmes are built on an integrative framework, they are likely to yield sub-optimal
outcomes.
This need motivated the author to devise the RADICAL framework for healthcare
risk management. The framework was first suggested as a tool that could be applied in
gynaecology (Edozien, 2009). In this paper the concept is further developed and more
fully described. Examples of how the framework may be applied in practice are given,
and the strengths of this framework compared to other approaches are discussed.
The framework
RADICAL is a framework designed to facilitate an integrative approach to the
implementation, monitoring and reporting of risk management in healthcare settings.
It comprises the following domains in an integrated grid: Raise Awareness, Design for
safety, Involve users, Collect and Analyse patient safety data, and Learn from patient
safety incidents (see Figure 1). None of these domains is an original idea, so this
framework can be seen as an enhancement of what currently exists. On the other hand,
the idea of situating these domains in an integrated grid and with an inviting acronym
is original. A unique attribute of RADICAL is that the links between domains are as
important as the domains themselves. The framework challenges service providers not
only to address each domain but also to demonstrate how each domain has informed,
and been informed by, other domains. Apart from providing a procedural framework,
RADICAL is also a way of conceptualising risk management, expanding the scope of
risk management beyond incident reporting and finding a balance between the
individual practitioner and the system.
Raise awareness and understanding of patient safety
Commitment to patient safety begins with awareness of the problem and understanding
of the mechanisms underlying patient safety incidents. Awareness of the scale of patient
safety has grown in the last decade, but understanding of its epidemiology, psychology
and sociology remains less than satisfactory (Armitage, 2009; Weingart et al., 2000). It is
important for staff to grasp basic concepts such as latent and active factors in medical
accidents, situational awareness, and defences. When we understand how errors happen,
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Figure 1.
The RADICAL framework
for healthcare risk
management
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error chain. The safety wise individual at the sharp end is in a better position to
trap errors and prevent accidents. Training and educational activities aimed at
promoting non-technical skills such as situational awareness, decision making,
communication, combating stress and fatigue are an important part of this
domain.
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Design for safety deliver health care in ways designed to protect patient safety
Human error cannot be totally eliminated, but the risk of patent safety incidents can be
reduced if, at individual and unit levels, we aim to provide care in a way that reflects
safety awareness and a commitment to reducing the likelihood of error. Interventions
such as clinical practice guidelines, care bundles, communication tools, handover
protocols, promotion of hand hygiene, use of a surgical safety checklist and team
training fall under this heading.
Involve service users in enhancing the safety of health care
As with other aspects of care, risk management calls for partnership with patients
there should be no talk of patient safety without patients (Davis et al., 2007). Patients
can be engaged in a variety of ways: keeping them informed of the units policies,
initiatives and statistics relating to patient safety; involving them in the design or
reconfiguration of services to enhance safety, and in the protection of their own safety
(e.g. by avoiding misidentification). Patient information leaflets on various medical
conditions and interventions should include succinct information about how the
patient can contribute to safety while undergoing treatment. We can also involve
patients in safety by sharing with them lessons learned from patient safety incidents. It
should be part of the organisations corporate responsibility to keep users informed of
its efforts to ensure that safe care is provided.
Collect and analyse data on safety of care
To improve safety in the care we deliver, we must know the current rates of patient
safety incidents in our practice, and then we must have structures and procedures for
monitoring our progress on the road to safer care. This is not always as easy as it
sounds. Patient safety science still a relatively new field in health services so
appropriate metrics are often not available, or staff are not familiar with them. Also
this is a field where human behaviour is a dominant confounder, and one that is often
difficult to predict, assess and control.
It is not enough merely to collect incident reports and amass huge data on patient
safety incidents. For such data to be useful, they have to be analysed and used
constructively to change practice where necessary and demonstrate safer care. The
raw data have to be converted to information that is meaningful and of practical
benefit to staff and service users. Finally, there is no size or form that fits all and each
unit will have to adapt the general principles described here to its own circumstances.
Learn from patient safety incidents
Learning is an important element in risk management. It is harrowing enough to have
patient safety incidents; to fail to learn from them runs counter to professional ethics.
Organisational learning, however, is not a passive osmotic process; it has to be actively
promoted and a learning environment has to be nurtured. In the context of patient
safety, a learning organisation is one that is able to create new knowledge from patient
safety incidents, learn from its experience and that of others, transfer knowledge
acquired, and bring about change in its behaviour as a response to the new knowledge.
Once collected data has been transmuted to intelligent information, learning points
should be underscored. Learning should be shared. Lessons learned should inform the
design of services and can be used to raise awareness of the causes, consequences and
prevention of patient safety incidents.
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Table I.
Potential applications of
the RADICAL framework
for various stakeholders
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Figure 2.
Checklist for
implementation of the
RADICAL framework
each domain is provided in Figure 2. Target goals for each domain can be set locally,
for clinical units and for the organisation as a whole.
Reporting quality and safety. Promoting integration
RADICAL provides the headings for periodic reports on safety and quality of care in the
department or organisation. These include quarterly or annual departmental reports,
internal reports tabled before the organisations Board, and external reports to
commissioners, regulators and other stakeholders. For risk management to yield optimal
results, efforts should be made not only to enhance all domains but also to integrate
them. Internal and external reports should, therefore, not treat the domains as silos but
demonstrate how each domain has linked with and impacted on other domains. Progress
in each domain becomes not an end in itself but a route to achieving strategic objectives.
Take infection control as an example. The mandatory annual corporate training of
Central Manchester University Hospitals NHS Foundation Trust includes a graphic
demonstration of the dramatic fall in bacteraemia rates after institution of hand hygiene
in the Trust. Reporting this in the RADICAL format will bring into sharp relief the
following pathways (with the RADICAL domain in parentheses):
.
Data on morbidity and mortality from bacteraemia highlight a patient safety
concern (Collect and Analyse data).
.
A Trust-wide hand hygiene campaign is undertaken, during which individual
accountability is stressed (Raise Awareness).
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of user involvement or explicit coverage of the role of the individual practitioner (other
than as a loop in quadruple loop learning). RADICAL is a much simpler framework
while also covering more domains. Attention to the balance between person and
system a central tenet of the Raise Awareness domain is unique to RADICAL.
The Department of Health in Western Australia produced a five-step framework
(Office of Safety and Quality in Health Care, 2005) for managing clinical risk: Establish
the context; Identify the risks; Analyse the risks; Evaluate and prioritise the risks;
Treat the risks. Two additional processes flow across the five steps: Communication
and Consultation and Monitoring and Review. Both are implemented
simultaneously at each level of the five-step process. This framework does not have
the breadth captured by RADICAL; learning does not stand out as a key objective, and
user engagement is not explicit.
Further development
Formal evaluation of the RADICAL framework its implementation and impact
across organisations is planned. The elements of each domain can be further defined,
without adding complexity to the main framework. For example, an incident
management protocol can be incorporated under the Collect and Analyse domain.
Conclusion
The RADICAL framework provides a simple but comprehensive approach to the
implementation, monitoring and reporting of healthcare risk management. It is
designed to facilitate learning and accountability at both individual and organisational
levels, advocating a balance between person and system. It covers all domains of
patient safety while also being flexible to allow local customisation of the content and
metrics for each domain. Presented as a grid rather than a linear structure, the
emphasis is not just on the domains but on integration between domains. As a catchy
acronym that also serves as a mnemonic, RADICAL appeals to staff. There is scope for
further development and application of this framework.
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Corresponding author
Leroy C. Edozien can be contacted at: Leroy.Edozien@manchester.ac.uk
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