The role of risk management in a rapidly changing healthcare environment

With the implementation of technology at pace and scale and the continuous need to evaluate rapid change in a highly regulated environment, we spoke to NHS governance, assurance & risk specialist Ann Highton about her view of the ‘new normal’.

What are your main observations of the Covid-19 response, in particular, the rapid deployment of technology?

I have been genuinely impressed at how well NHS organisations have responded to the current situation, in fact it has made me incredibly proud of the teams that have led both the clinical fight against Covid-19 and the unsung heroes behind the scenes that keep the cogs whirring.

When the situation initially escalated, we immediately saw people embracing new technology such as virtual meetings and consultations. Pre-Covid, the use of technology for these situations may have been perceived as a challenge to some individuals, but the onset of the pandemic required everybody to embrace the most effective method of providing care and has seen some who previously been reluctant to change, embrace the new way of working.

We are now seeing a lot of people accepting that systems like Microsoft Teams (for instance) will replace some face to face communication, because it’s proved itself to be effective in a such a short space of time.

One of the most significant changes we have seen within our Integrated Care System (ICS) has been the governance arrangements which have rapidly adapted to underpin the requirements of the response. There has always been an emphasis on performance measuring and regulatory monitoring. But Covid-19 reporting and the sharing of information across the country has become the priority. The challenge has been the direction and flow of information which is a moving target. Internal control systems and reporting structures have been quickly adapted to enable a more efficient escalation of information that’s required during the pandemic and we’ve been able to leverage technology to deliver significant improvements in the time it takes information to get from the ward to the recovery response teams at the Department of Health.

What do you think are the key outcomes of rapid change and tech deployment?

I think this situation has shifted the perception of change management – we’ve all gone through a very steep learning curve but have proven that there are better ways of working and that we do have the ability, and now the appetite to adapt to change efficiently and effectively. Pre-Covid, there wasn’t a reluctance to change, more the fact that people working in healthcare environments are so busy, and under so much pressure delivering optimal care against targets that they didn’t have the mindset to consider the possibility of doing things differently. By empowering the workforce to consider just one thing – to collectively fight this virus – it has facilitated collaboration and enabled new models of care to be developed at a pace we’ve never seen before. Remote consultations are a great example of this – being able to deliver continuity of care despite not being in the same physical environment.

The next step is to evaluate the decisions made throughout this crisis in a bid to understand what innovations have occurred, what will be embedded into policy and process long term and what is no longer deemed necessary. As part of that, there will be a review of the previous status quo and the emergent improvements that have resulted in a bid to regain a level of control over the innovation pathway and compliance.

It is important to make sure that we do not lose the learnings gained throughout the pandemic and revert to where we were, potentially losing service improvements.

In order to capture this intelligence, the Lancashire & South Cumbria Local Maternity System has utilised a methodology which requires each specialty to consider 6 questions; these are noted below:

1. What are the temporary measures which we want to end; we have done these things to respond to immediate demands, but are they specific to the crisis?
2. What are the innovations which we want to amplify? We have been able to try these new things and they show some signs of promise for the future.
3. What activity is obsolete and needs to be stopped. We have been able to stop doing these things that were already/are now unfit for purpose.
4. What activity has been paused and needs to be restarted. We have had to stop these things to focus on the crisis, but they need to be picked up in some form.
5. What are the lessons learnt?
6. Any other observations.

The outcome of the review will influence future changes.

Has this situation changed the perception of risk management?

As a risk specialist, I obviously embrace risk management and my hope is that there is a greater understanding of how important it is to effectively manage risk in healthcare organisations. There has been a continued focus on the management of risk to patient safety during this crisis; managing the compromise to service delivery both planned and in response to the Covid crisis and maximising the patient family and carer experience within the current constraints. I have been involved in the rapid development of robust Covid specific risk registers, supported by sound review and governance frameworks which are used to accurately inform partners both proactively and reactively throughout the system.

Throughout the NHS, risk registers and board assurance frameworks have always been a part of the regulatory process. I hope that one of the lessons learnt is how impactful good risk management can be. I say “good” as the management of risk is a part of the regulatory process for all NHS Trusts however the degree to which it is embraced, in my opinion differs dependent on the organisation’s leadership.

What is significant to me is how enthusiastic individuals have been during this crisis. I have seen teams come together to be involved in and develop the risk and issue management process.

What are the implications of becoming so risk tolerant in such a short space of time?

I would not say we have become risk tolerant, but I think that we’ve definitely become more risk aware.

Covid-19 has increased the importance of active dynamic risk across all areas of healthcare. Processes to identify, manage and mitigate risk have always been there, and risk management is very much embedded into NHS organisations; but with an unprecedented situation such as Covid-19, risks are continually emerging so it is essential that these are managed effectively to facilitate rapid mitigation identification and improvement planning.

One of the biggest risks we are currently facing is that of a second spike in cases. Although we now have well tested, robust systems of control, a second spike will place additional pressure on the NHS. Things such as revised bed spacing, outpatient clinic distances and other environmental challenges will affect patient flow and numbers. However, organisations are currently developing recovery plans to proactively manage the risk.

What do you think the recovery period will look like once regulatory bodies like the CQC recommence their inspection regime?

My experience is that the CQC is currently playing an incredibly supportive role, working alongside health and care organisations to manage the risk to patient safety.

The focus on continuous improvement, safe and effective delivery of care and a well-led leadership team has never taken a back seat – but the care delivery processes have changed so dramatically that everybody has had to adapt, including regulators.

Although most regulatory inspections had stopped, the Care Quality Commission is now restarting its inspection regime. Care providers will need to consider issues related to the Covid response to their established portfolios of issues. Inspections will continue to monitor and review recommendations from previous inspection reports and will focus specifically on those recommendations which fall under the ‘must do’ requirements.

Like any organisation right now, regulatory bodies will be reviewing their processes to make sure that they are fit for purpose as we move into phase 2 of the crisis. Regulators will need to acknowledge that organisational structures and service delivery systems may change, and these changes need to be reflected in future inspections; this will require significant flexibility in the regulatory approach.

I hope there will be an inherent understanding of the challenges which have been overcome across integrated care systems and that the expectations of regulators will adapt accordingly.

What are the key things health and care organisations should be doing now to prepare for evidencing regulatory compliance in the future and perhaps justifying some of the decisions made during this period?

What’s important is that organisations consider a reflective piece of work, to look at what they were doing before and how the current situation may have impacted.

There are three key areas to focus on here:

• Improvement plans from previous inspections need to be revisited giving immediate prioritisation to the ‘must do’ and consideration to the ‘should do’ requirements.
• Irrespective of the current crisis, if a mandatory improvement has been highlighted at a previous inspection then it should have been reviewed and explanatory narrative needs to highlight any considerations given to the recommendation.
• Decision logs need to be reviewed to ensure that they explain decision making processes and criteria. The rapid decision making required during the pandemic needs to be supported by a detailed audit process explaining why decisions were made and by whom.
• Organisations may need to justify why certain decisions were made in situations of challenge and enquiry from regulators.
• Risk registers and issue logs should provide evidence that you have both proactively and reactively mitigated any foreseeable risk to patient safety. Evidence will need to be available to demonstrate escalation to the relevant forum and if appropriate, challenge and agreement.

What do you hope will emerge as positive developments out of the current situation?

There is a real opportunity to take the lessons learnt from this situation to frame the strategic direction and future governance frameworks of each organisation. Without a doubt, this will result in more effective, streamlined processes which improve the patient experience; and I think there will be a renewed willingness to embrace change.

To facilitate this change, there will inevitably need to be a focus on competency; the training that underpins that and a motivated workforce with a willingness to learn. We’re just at the start of this journey and I’m not quite sure whether any of us know exactly what that looks like just yet.