RISK MANAGEMENT IN HOSPITAL FACILITY MANAGEMENT - A ...

RISK MANAGEMENT IN HOSPITAL FACILITY MANAGEMENT
- A CASE STUDY IN HONG KONG
Mary WAN
General Manager (Administrative Services),
Pamela Youde Nethersole Eastern Hospital
Ir Alfred SIT
Chief Engineer, Electrical & Mechanical Services Department,
Hong Kong SAR Government
ABSTRACT
The paper is about how Pamela Youde Nethersole Eastern Hospital of Hong Kong, with the
support of the Electrical & Mechanical Services Department, developed a risk management
strategy in the facility management services of its premises. The hospital, being an acute
regional hospital serving the Hong Kong East region, is well known for pioneering new systems
and good practices for its developments in facility management during the last decade. The
paper will also demonstrate how risk management can help improve service quality and
enhance the cost-effectiveness of facility management in a large public organization.
Keyw ords: risk management, hospital
PAMELA YOUDE NET HERSOL E EAST ERN HOSPITAL
The Hospital Authority (HA) of the Hong Kong Special Administrative Region (HKSAR) was
established in December 1991 to assume responsibility for the management of all HKSAR
government and subvented hospitals and health care institutions.
Pamela Youde Nethersole Eastern Hospital opened in October 1993. It is a regional acute
hospital with about 1,800 beds serving the population in Hong Kong East. As the hospital is
the first to be opened after the establishment of the Hospital Authority, getting the “best” for the
hospital was the common goal.
Apart from healthcare, Facility Management (FM) is one of key services of the hospital. Its’
strategic objective is defined as “the management of facility resources and services in support of
the operations of the hospital”.
RISK MANA GEM ENT PHILOSOPHY
Hospitals are complex and tightly coupled systems that are quite prone to accidents.
Concomitant with increasing legislation and public expectations, a new health care environment
is emerging. The extent of the business risk borne by their facility management teams is very
significant in hospitals. Business operations rely on a continuity of support for FM services.
The risk to processes of patient care due to closures, breakdowns, and interruptions to support
services must be better understood if downtimes are to be minimized.
There are a number of FM tools and techniques for identifying, evaluating, treating, and
monitoring risk. The general approach is to respond to the common hazard-based threats in
isolation. The key to navigating a safe organisation lies in appreciating what is manageable
and what is not. Merely struggling vainly to exercise direct control over accidents and incidents
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will result in risk management being seen as a negative factor in the business. If FM is seen
as a business function, a broader view of risk should be considered and its impact on the
business as a whole should be the main concern. Risk management should not be carried as
an “add-on” exercise because it is part of general management. In a dynamic organisation like
a hospital, a strategic approach in risk management addressing both management and
technical issues should be adopted.
RISK MANA GEM ENT STRAT EGY
In developing a comprehensive risk management strategy to improve patient and staff safety,
the hospital management recognizes the imperative to create an environment that encourages
staff to identify errors, evaluate causes, and take appropriate actions to improve performance in
the future. Like quality and value management, risk management is the responsibility of
everyone in the organisation; the problem is to encourage everyone to play his/her part. Staff
must be aware of the risks, but also of the steps that can be taken to prevent threats from
becoming reality.
SAFETY CULTURE
Engineering a safety culture plays a critical role in the hospital where staff will not only
understand it, but will accept, deliver, and find ways to promote it. There must be a strong
commitment from top management in leading this cultural change. Messages stating that
safety improvement is a serious priority of the hospital have to be consistent and repeatedly
promulgated to all staff. In 1997, the Risk Management Committee chaired by the Hospital
Chief Executive was set up so that a well-defined structure could be established to steer the
movement in a coordinated manner throughout the various departments of the hospital. The
governing board demonstrated its commitment through regular and close oversight of the safety
of the hospital they shepherded. In fact, progress reports of risk management are a standing
agenda item in governing board meetings.
Commitment alone is not enough. A hospital needs to possess the technical competence to
achieve its safety goals. Competence is closely related to the quality of its safety information
system. Does it collect the right information? Does it disseminate it? Does it act upon it?
In other words, our safety culture must be an informed culture.
REPORTING CULTURE
The most important barrier to improving safety is lack of awareness of the extent to which
incidents and errors occur in hospitals. It is difficult to remedy problems that you do not know
exist. The lack of awareness occurs because in most cases, incidents and errors are not
reported.
As for facility management services in hospitals, critical incidents reporting is a valuable tool in
risk identification. It highlights risk areas previously overlooked, such as false fire alarms,
water leakage damaging expensive medical equipment, frequent breakdowns of lift services,
loss of property in wards, sewage and drainage problems in psychiatric wards, wet floors in
kitchens, etc. We understand that persuading our staff to file critical incident or near miss
reports is not an easy task. This depends on the willingness of individuals to report events in
which they may have played a significant role. There are powerful disincentives for the staff to
participate in a reporting scheme, such as extra work, a lack of trust, and fear of reprisals.
What is needed is a just culture and an atmosphere of trust in which staff are encouraged to
provide essential safety-related information. FM professionals need to foster a management
style and develop a working culture in which communication flows freely regardless of the
authority gradient. It is paramount for management to earn the trust of their staff and to
motivate them to file incident reports.
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LEA RNI NG C ULT URE
The goal of the reporting system is to analyze the information they gather and identify ways to
prevent future errors from occurring. Collecting reports and not doing anything with the
information serves no useful purpose. To drive the learning culture, the hospital designated a
Hospital Incident Review Panel chaired by its chief executive to review the incidents and
complaints. The composition of the panel included representatives from the clinical, nursing,
allied health, and administrative departments. This was to ensure that when investigating
incidents, staff would not miss important information, their diagnosis of root causes would be
complete, and their remedies would be effective. For effective knowledge management, the
improved actions and lessons learnt as identified in major incidents would be disseminated to
and shared by all departments.
CHALLENGES TO FM PROFESSIONALS I N RISK MA NAGEM ENT
FM is still an emerging and new area in the development of health care. What are the
challenges facing FM professionals in support of core business on risk management issues?
In addition to their technical expertise, do they have the management knowledge and
competence to develop workable solutions, to bridge the gap between promises and
performance, and to realign their FM values when applying their solutions?
I shall now demonstrate how our FM colleagues use the strategic approach to align users’
needs in two priority risk areas.
FIRE SA FET Y
The occurrence of a fire in a hospital can result in serious consequences because of the
difficulties and dangers in evacuating patients. Fire prevention is of utmost importance.
In the past, our hospital’s fire safety plan was as follows:-
Traditional Approach
• Training
• Generic in content
• Not applicable to a health care setting
• Isolated approach, conducted by different parties
Safety talk – Community Section
Drill & Debriefing – Operational Team
Evacuation plan – Fire Protection Bureau
• Reliance on Fire Services Department
• Incident Report and Alert System
• No structure incident reporting system
• Management review of major incidents only
• No data collection and analysis
• No corporate-wide alert mechanism in place
• Fire Services Installations
• Only focused on meeting minimum legislative requirements (e.g. yearly
inspections)
• No regular monitoring of FS installation performance
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Feedback from users clearly reflected that our fire safety plan didn’t work. Why? It was
because the fire risk in each department is unique and subject to the following factors:
Env ironmental Design
• Availability of fire service installations: smoke detectors, sprinkler systems,
extinguishers
• Availability of fire protection construction: fire compartments, fire exits
• High rise buildings vs. low rise buildings (vertical evacuation vs. horizontal
evacuation)
Patient Condition
• High mobility vs. low mobility (e.g. geriatric patients, orthopaedic patients, infants)
• General patients vs. psychiatric patients
• Reliance on life saving equipment (e.g. intensive care units, pediatric intensive care
unit, renal patients)
Tools & Equipment
• Bed
• Stretcher
• Wheelchair
• Baby cot
• Evacuation mattress
• Evacuation chair
Eventually, our FM colleagues redesigned the comprehensive system on fire safety
management.
Current Approach
• Training
• Department specific
• Focus on unique health care settings
• Integrated approach by one single authority
Safety talk
Drill & Debriefing
Evacuation plan
• Train up hospital trainers
• Incident Report and Alert System
• Standardized incident reports to the Hospital Incident Review Panel and the
Head Office
• Management review – root causes and trend analysis
• Head Office coordinates with various sections to issue fire incident alerts to
other hospitals for sharing purposes.
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• Fire Services Installations
• Monthly monitoring of FS installation performance
• EMSD to provide system improvement advice
HOSPITAL SEC URITY
In 2000, the hospital’s management found that ward theft incidents had increased significantly.
The Risk Management Committee examined the issue and concluded that there were serious
inadequacies in the hospital’s security program, which contributed to unsafe conditions in the
hospital.
Traditional Approach
• Policy & Procedure
• Fragmented
• Not updated to meet changing needs
• Risk Assessment and Improvement Programs
• No ri sk asse ssment
• Accorded low priority by improvement initiatives
• Incident Reporting
• Isolated
• No standardized reporting procedure
• Not forwarded to senior management
• No data collection and analysis
• Safety Culture
• Security was viewed solely as the Facility Management Department’s
responsibility.
With valuable input from expert agencies like the Crime Preventive Bureau and feedback from
hospital users, the hospital’s FM team developed a strategic approach to security management.
Current Approach
• Policy & Procedure
• Head Office provides the policy framework
• FM team coordinates to issue up-to-date guidelines for colleagues
• Risk Assessment and Improvement Programs
• Continuous risk assessment to systematically identify risky areas
• Prioritizing improvement initiatives based on risk level
• Incident Reporting
• Standardized reporting procedures
• Root causes and trend analysis
• Management review
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• Drawing up of specific improvement programs (e.g. ward theft prevention
program: locking devices, patrols in high risk areas during high risk hours)
• Safety Culture
• Promote “Security is Everybody’s Business” concept (e.g. seminars on specific
security issues, such as office and changing room security)
Correction of these system failures has resulted in a significant drop in ward theft (property loss
cases).
Year 2000 2001 2002 2003
Total Ward Theft/ 79 51 25 23
Property Loss Incidents
FM professionals have to recognise fire safety and security as an integral part of a hospital’s
operation. Trying to design a safety program without taking into account the specific needs of
clinical teams is likely to be an exercise in frustration, and will result in a waste of well-intended
plans and energy.
The importance of partnership with service providers in risk management should not be
overlooked. Partnership is about establishing and strengthening relationships, raising the level
of trust, and a mutual commitment to resolve problems and conflicts with a win-win attitude.
Without the partnership attitude, service providers are likely to “cover up” problems and faults,
and facility managers would be exhausted in policing their facilities to identify the inadequacies
and shortcomings of service providers. Worst of all, service providers without long-term
commitments would choose to ignore risks and treat problems identified as isolated cases;
when the same event recurs, it may become an uncontrollably costly affair with damaging
effects on the hospital.
The Electrical and Mechanical Services Department (EMSD) of the HKSAR Government is the
long-term strategic partner of the hospital in building facility management. The hospital and its
partner share the same philosophy in risk management. The EMSD has established and
implemented a critical incident reporting system in the hospital. Incidents leading to death or
serious personnel injury and loss of property, major disruptions to hospital operations, and
media attention are reported to the senior management of the EMSD as soon as practicable.
Other less critical incidents are reported within 24 hours. The EMSD keeps the hospital
continually informed of such incidents. Also, there are regular meetings between the hospital
facility manager and the EMSD to discuss feedback and feed-forward views for continuous
improvement. In addition, the EMSD has adopted a risk-based maintenance system as part of
its facility management approach.
THE ELECTRICAL AND M ECHANICAL SERVICES TRADING FUND
Under the EMSD is the Electrical and Mechanical Services Trading Fund (EMSTF), which was
established in August 1996. Although it is part of the EMSD and hence part of the HKSAR
Government, it operates on commercial principles and is accountable for its own profit and loss.
It focuses on providing quality operation and maintenance services for engineering plants to
government departments and public bodies in Hong Kong.
Since its establishment, EMSTF has adopted proactive approaches in cost control, service
quality enhancement, service diversification and partnership with customers. Comprehensive
facility management service and risk management are two cornerstones among such strategic
moves.
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RISK MANA GEM ENT FRAM EWORK
In risk management, we follow the framework under the Australian/New Zealand Standard
AS/NZS 4360:1999 to identify, analyze, evaluate, and treat risks. Like other established quality
management systems, we stress the need for continuous improvements along the plan, do,
check, and act (PDCA) cycle, and to consult, seek views, and communicate our findings/results
to our clients, so as to continuously improve the system. An overview of our risk management
framework is in line with AS/NZS 4360:1999.
We would illustrate the adoption of risk management approach in two cases:
a) maintenance of biomedical equipment; and
b) occupational health and safety management in facility management.
RISK MANA GEM ENT – MAINT ENA NC E OF BI OMEDICAL EQUIPM ENT
A hospital is equipped with a variety of specialized biomedical equipment such as defibrillators,
resuscitators, surgical lasers, renal units, etc. for clinical purposes, patient treatment, and
monitoring. Many of this equipment are mission critical, in that they are directly related to
fulfilling the hospital’s mission and the life and death of patients. It follows that risk
management on the maintenance of biomedical equipment was taken on board seriously right
at the beginning.
The objectives of the risk management system for biomedical equipment are:
a) to minimize operation risk;
b) to provide a decision making tool for better resource management; and
c) to contain and/or reduce risks with existing resources.
Once the objective and context of the risk management system are identified, the next steps
would be to identify and evaluate the risks associated with each piece of biomedical equipment.
In ranking or measuring risk, the AS/NZS 4360:1999 and the ECRI’s recommendation have
been adopted. Risks are measured by a 3x3 risk matrix in this case based on:
a) the likelihood/frequency of the risk occurring; and
b) the impact/severity (consequences) should the risk occur.
The likelihood/frequency of the risk is based on historical fault statistics, system design,
professional knowledge, personnel experience in the equipment, and expert judgment. These
are classified into three levels: likely, possible, and unlikely.
Likelihood/Frequency Rating
Likely Frequent major faults reported, excessive equipment shutdowns
Possible Some major faults, short duration shutdowns
Unlikely Some minor faults or no faults
The impact/severity of the risk is assessed based on our experience and with inputs from
medical professionals and nursing staff. These are classified into three levels: high, medium,
and low.
Impact/Severity Rating
High Death/extensive injuries seriously affecting user’s operation (e.g. need to
vacate wards/areas) and/or patient treatment, ECRI high risk device
Medium Injuries affecting user’s smooth operation and/or patient treatment, ECRI
medium risk device
Low No injuries, inconvenience to user’s operation, waste of resources, ECRI low
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isk device
The 3x3 risk assessment matrix below determines the Level of Risk (LOR) as high, moderate,
or low based on impact/severity and the likelihood/frequency of the risk.
Likelihood
Consequence
High Medium Low
Likely High High Moderate
Possible High Moderate Low
Unlikely Moderate Low Low
The initially assessed LOR is then reviewed and adjusted with due consideration according to
the:
a) condition of particular equipment, which may range from brand/new/good condition to
aged/obsolete/poor condition;
b) clinical operation impact of the equipment, which depending on the type of wards in
which the equipment is located and/or the patients on whom the equipment is used,
may range from highly critical to less critical even for the same type of biomedical
equipment.
c) occupational health and safety effect of the failed equipment to staff, patients, and the
general public.
Once the LOR has been assessed and adjusted, proper risk treatment measures are
considered. Risk treatment measures can be categorized into two different types in this case:
a) the maintenance level; and
b) the contingency plan.
In the maintenance of biomedical equipment, the range of maintenance strategy considered is:
a) the proactive approach:
• condition-based maintenance involving periodic equipment condition
inspections, measurements, recording and data analyses, and the carrying out
of corrective actions before equipment failure
• time-based maintenance involving periodic equipment servicing, overhaul,
calibration, and recommissioning.
b) reactive maintenance:
• corrective maintenance to be conducted when equipment failures occur
• equipment replacement strategy involving little or no maintenance with failed
equipment being replaced direct.
When there is a choice of appropriate maintenance strategies for different levels of assessed
risk, due considerations are also given to the following factors:
a) safety to users and patients;
b) statutory maintenance requirements, relevant guidelines, and international standards;
c) clients/end user feedback; and
d) availability of standby equipment and/or loaner units.
Having considered the above, the optimum service modes generally adopted for high, medium,
and low risk equipment are as follows:
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Risk Level
Maintenance Service Modes
High risk Periodic preventive maintenance (Levels 1 or 2)
Medium risk Periodic safety checks
Low risk Corrective maintenance or replacement strategy for low cost equipment
In Hong Kong, there has up to been now few statutory requirements on biomedical equipment
maintenance and safety. The EMSD, however, has adopted the best international practices,
standards, and recommendations of relevant learned societies (e.g. ECRI) in delivering such
maintenance services. Adopting a mix of proactive and reactive maintenance approaches, the
different maintenance service modes above are as follows:
Maintenance Serv ices Mode
Electrical safety
check
Functional &
Alarm Test
Parameter Test
and Calibration
Preventive maintenance
(Level 1)
Preventive maintenance
(Level 2)
Safety Check
As for the contingency plan, it addresses the service recovery measures in case equipment
failures occur. The plan was devised jointly with end users. The options adopted are:
a) providing loaner units;
b) switching to alternatives, other facilities, and/or standby equipment;
c) standing agreement with outside suppliers; and
d) adopting no contingency plan for extra low risks and interruptions involved.
Coupled with the contingency plan is a critical incident reporting system aimed at providing
timely notifications to hospital management of critical incidents, and documenting procedures to
mobilize the necessary resources for executing the contingency plan.
The new risk-based maintenance arrangement was adopted in line with the ward-based
preventive maintenance program. The new system avoids the end user’s need to transfer
biomedical equipment within a ward back to the maintenance workshop on different dates for
servicing. Instead, maintenance personnel bring with them necessary tools and instrument to
conduct preventive maintenance for a variety of biomedical equipment within the same ward on
a pre-appointed date. Feedback from end users on the service improvement approach has
generally been very positive.
With the risk management approach, we successfully achieved:
a) the proper containment/minimization of risk to a pre-determined level;
b) better resource allocation and prioritization and cost control; and
c) the establishment of a high-quality and cost-effective service delivery mechanism
meeting users’ expectations and operational needs.
The new system succeeded in achieving a 10% cost reduction in the maintenance of biomedical
equipment within a 3-year period.
The adoption of a risk-based maintenance approach further enhances our communication with
the hospital’s facility managers and frontline clinical users, with a shared ownership of the
finalized risk management plan.
In pursuit of continuous improvements leading towards service excellence, the established
master risk assessment table and risk treatment measures are regularly reviewed and
fine-tuned along the PDCA concept and risk management framework to suit changing
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circumstances, new equipment commissioned, new reports and findings from health safety
alerts, etc.
This risk management approach can also be applied to other building facilities, such as the
electrical, mechanical, air-conditioning, building service plants, and systems and buildings in the
hospital.
RISK MANAGEM ENT - OCCUPATIONAL HEALTH AND SAFETY IN FACILITY
MANAGEMENT
Another example of risk management is in respect of occupational health and safety (OHS) in
the delivery of facility management services. The objective is to provide means whereby job
hazards and potential hazards are identified, evaluated, and managed so as to eliminate or
reduce them to an acceptable level.
Job Hazard Analyses (JHA) for identifying risks are conducted by Safety Officers registered by
the HKSAR Labour Department and/or qualified officers conversant with site activities and the
associated risks. The JHA includes all routine and non-routine activities carried out by the
EMSD or its contractors/visitors, and covers premises such as offices, workshops, plant rooms,
and customer-occupied areas. JHA are reviewed at least once a year or when there are
substantial changes in the activities concerned.
According to the results of the JHA, risk assessments were carried out via a 5x4 matrix
approach, with 5 levels for likelihood and 4 levels for the consequences of each risk.
For the likelihood of the risk, the 5 levels adopted are:
a) Likely/Frequent: occurs repeatedly/event only to be expected;
b) Probable: Not surprised, will occur several times;
c) Possible: could occur sometimes;
d) Remote: Unlikely, although conceivable;
e) Improbable: so unlikely that the probability is close to zero;
For the consequences of the risk, the 4 levels adopted are:
a) Catastrophic: could result in fatality or detrimental property damage;
b) Major: could result in major/extensive injuries or property damages;
c) Minor: could result in minor injuries or property damage;
d) Insignificant: could result in no injury or negligible damage;
Consequences
Catastrophic Major Minor Insignificant
Likely/Frequent Extreme High High Moderate
Probable High High Moderate Low
Possible High Moderate Moderate Low
Remote Moderate Moderate Low Low
Improbable Low Low Low Low
The recommended follow-up management actions for each of 4 risks are:
a) Extreme risk: Immediate action is required to eliminate or reduce the risk.
b) High risks: Urgent action is required and the work activity should not proceed unless
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appropriate risk control measures are in place.
c) Moderate risk: Consider whether further practicable actions are available to
eliminate or reduce the risk. Management responsibility for risk control and time
frame for completion should be specified.
d) Low risk: No additional risk control measure is needed, but monitoring is required to
ensure that the existing controls are maintained effectively, and safety working
procedures are followed.
For work activities and situations where specific risk assessment requirements are prescribed
by legislation, the legislative requirements are followed instead. These include aspects such
as noise in the workplace, tasks which required to be handled manually, works in confined
spaces, display screens, asbestos works, etc.
In risk treatment, the following control measures in order of decreasing effectiveness and
preference have been adopted to eliminate or reduce hazards identified with reference to the
findings from the risk assessments, and with due consideration to cost effectiveness and
practicability:
a) elimination of hazards;
b) substitution with something that is less hazardous or risky;
c) engineering controls such as enclosures or safeguards to segregate hazards from
people;
d) a safe system of work that reduces the risks to an acceptable level;
e) written procedures that are known or understood by the affected people;
f) adequate supervision;
g) provision of adequate training, information, and instructions to those affected;
h) personal protective equipment.
EMSD has adopted this risk management system for OHS matters and was certified to the
OHS18001 since 2001. This is amongst the first few of such certifications granted in the
HKSAR and the first among the HKSAR Government departments. The most encouraging
outcome is the sustained reduction in accident rates in the past four years, as follows -
Year
Accident Rate
(No. of reportable accident per 1000 staff)
2000/01 26.2
2001/02 17.6
2002/03 16.8
2003/04 14.8
Note : The industrial-wide average accident rate in the HKSAR is 37
reportable accidents per 1000 staff.
CONCLUSION
Risk management has been adopted in managing facilities and delivery of services in Pamela
Youde Nethersole Eastern Hospital. This has been illustrated by examples in biomedical
equipment maintenance, the management of occupation safety, and health in service delivery.
Not only have there been improvements in service quality, but also improvements in cost
controls to meet diminishing budgets. In risk management, the principles of teamwork,
partnership with service providers, proactive and positive attitudes, and knowledge sharing have
been crucial to this success.
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REFERENCES
WAN YEUNG, K.S. Mary (1999), “Managing change: facilities management at the Pamela
Youde Nethersole Eastern Hospital, Facilities Vol. 17, No. 3/4
AS/NZS 4360: 1999 Risk Management, Standards Australian & Standards New Zealand
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