Paramedics work in a unique environment full of risk and uncertainties. The way a paramedic manages this risk will determine how successful he or she will be at achieving their pre-hospital care objectives. So, what is risk? Risk can be defined as the ‘effects of uncertainty on objectives’ (ASNZS 2009, p.1).
Risk can be identified as the relationship of a particular consequence of an event and the likelihood of that event occurring. Risk, in itself is not a negative thing to an organisation; more so, the outcomes of risk may be negative or positive to the organisation’s achievement of its objectives.
It is important to understand risk as a matter of:
- Likelihood of an event; and
- Consequence of an event.
The likelihood of an event refers to how probable an event is of occurring. It should also include how often the organisation is exposed to the risk. For example, given correct lifting techniques, the likelihood of a paramedic injuring his or her back while lifting a patient is low; however, if the policy is to lift every single patient, the paramedic’s exposure to this risk increases, and with this increased exposure, there is a greater likelihood that the paramedic will injure his or her back.
The consequence of an event can be defined as the ‘outcome of an event affecting objectives’ (AZ/NZS ISO 31000: 2009, p. 5). Consequences of an event can be expressed as a quantitative measure, such as the number of work place injuries per year; or, as a qualitative measure, such as minor, medium, severe or catastrophic. An example of a qualitative measure is the consequence of a paramedic being involved in a motor vehicle crash. The crash may be minor, such as small dents to the vehicle and no injuries to the occupants, or it may be severe involving complete damage to the vehicle and serious injury or death to the occupants.
It is this relationship between likelihood and consequence of an event that establishes the severity of a risk. For example, there is a high likelihood that a paramedic will be verbally abused at work by a patient during some stage of the year; however, the consequence of such an event has only a minor effect on the objectives of the organisation. Alternatively, the consequence of a paramedic physically assaulted by a patient is potentially severe; however, the likelihood of such an event is much less likely than being sworn at.
Risk is present in all industries, and all activities of daily life. Because of the nature of the environment that paramedics are employed, there is an increased exposure to risk. Acknowledging this fact, it is evident that ambulance services need to be diligent in their risk management practices to mitigate these risks.
What is Paramedic Risk Management?
The field of study, known as ‘Risk Management’ is a relatively new concept. It has been described by the AS/NZS ISO 31000 (2009) as a set of ‘coordinated activities to direct and control an organisation with regard to risk’ (p.2). Based on this definition, paramedic risk management can be defined as the development of methods that will effect change in the likelihood, consequence and severity of an event towards the objectives of a paramedic, which include: the treatment of and transport of sick an injured persons. Paramedic risk management is almost an unheard of concept, and has largely been incorporated into basic legal requirements under occupational health and safety laws.
When should the risks be managed?
Ideally, risk should be managed well before an event occurs. Therefore, risk should be managed when an organisation develops its management objectives. Once these objectives are known, risk management processes should be developed in order to then manage the risks associated with achieving these objectives. Although risk management is primarily about avoiding or mitigating loss, it can also lead to the identifications of new opportunities. Because of this, it is important to integrate risk management into an organisation’s management plans and objectives.
By managing risks early, an organisation potentially protects against significant financial, human and operational costs in the future related to poorly managed risk, such as loss of productivity, damage, and injuries. Risk management is dynamic, and requires continual monitoring and review of the risk management process to ensure that it still meets the required objectives. Proactive risk management allows for risks to be managed before adverse events occur and hindering the organisations ability to achieve its objectives.
Why should an ambulance service manage risk?
Effective and appropriate application of risk management guidelines in ambulance practice will result in the following benefits for an ambulance service:
- Improved understanding of the potential risks in ambulance practice
- Improved ambulance management practices
- Identifications of new opportunities
- Greater ability for the organisation to achieve its goals and objectives
- Provide a safer and more cost effective ambulance service
- Improved occupational health and safety within the ambulance service
- Improved management of ambulance resources
- Greater confidence in the institution from both internal and external stakeholders
- Reduction in unforseen costs
- Reduction in injuries at work (and their associated costs)
What are the risks in ambulance practice?
Because of the nature of ambulance practice, paramedics work in an area of intrinsically higher risk than many other organisations. These risks encompass the following areas of risk and will be discussed in depth later on:
- People risks
- Organisational environment risks
- Organisational management risks
- Ambulance practice specific risks
What is the Risk Management Process?
Risk management in its basic forms has been utilised in business practices for more than six decades. Like any other area of study, risk management has evolved and improved throughout this time. In 1995 the first Risk Management Standards were developed by the Australian Standards/New Zealand Standards of Risk Management (AS/NZS 4360:1995) in which a generic risk management framework was first clearly identified. This framework has regularly been reviewed and is currently identified by the AS/NZS ISO 31000:2009.
Risk is unavoidable, and risk management is a dynamic process. Therefore, continual efforts in risk management are the only measures to ensure that the goals and objectives of an organisation are achieved. It is essential to an organisations ability to achieve its goals and its overall success.
The AS/NZS ISO 31000 (2009) identifies five primary processes to managing risks.
- Establishing the context
- Identifying the risks
- Analysing the risk
- Evaluating the risks; and
- Treating the risks
(AS/NZS 2009, p.14).
In combination with these five processes, there is the need to develop a specific risk management committee, or planning group who continually communicate, consult, monitor, review and document throughout each stage of the process.
Paramedic Risk Management Process
The following steps identify the risk management processes and their application to ambulance practice:
- Step One: Establishing the Context
- Step Two: Identify the Risk
- Step Three: Analyse the Risk
- Step Four: Evaluate the Risk
- Step Five: Treat the Risk
- Step Six: Monitor and Review
- Step Seven: Communication and Consultation
Managing Risks in Ambulance Practice
Step One: Establishing the Context
This is the start of the risk management process and requires the development of a clear understanding of the organisation’s objectives, external and internal parameters to be considered when designing a management plan for risk, and identifying the scope and risk criteria to be utilised. By outlining these key contexts at the onset of the management and risk management development, an organisation is better positioned and equipped to establish an effective risk management program. Failure to adequately establish the context, may result in the requirement of multiple reviews and re-designs of a risk management program, as the result of unintentionally targeting a tangent risk or re-prioritising the objectives of the program.
By establishing a concise context, an organisation can identify its objectives and the normal parameters that the organisation must perform its tasks within to achieve those objectives. The parameters in ambulance practice often refer to areas such as:
- Financial restraints and budgets
- Equipment availability, such as vehicles, medical equipment
- Human resources, including recruitment, retention and competency of paramedics
- Government regulated/agreed upon ambulance response times to medical emergencies in the metropolitan, semi-rural and rural settings.
When determining specific parameters that an ambulance organisation must remain within while achieving their objectives, it is easier to identify what risks exist to prevent the achievement of these objectives. The management of risk should be undertaken with the full consideration of the need to justify the resources used in carrying out the risk management.
For example, it is poor risk management for an ambulance service to allocate $500,000 in the development of a financial risk treatment of medical equipment worth $100,000. In this circumstance, it would make sense to make a conscious decision to accept the original risk.
Establishing the external context
Establishing the external context requires identification of the external environment in which the organisation seeks to achieve its objectives. It is important to understand the external context to ensure that the objectives and concerns of external stakeholders are considered when developing the risk criteria.
In ambulance practice, the external context includes:
- The social, cultural and political perceptions;
- Legal and regulatory requirements;
- Financial constraints;
- Technological, economic, natural and competitive environment.
- The key drivers and trends that impact on the objectives of the ambulance service.
The relationship with perceptions and values of external stakeholders must be examined in order to achieve successful risk management. This is because the stakeholders’ perceptions of risk often dictate the potential risk management objectives and strategies. If the stakeholders do not perceive a threat as a result of the consequence of an event, it is hard to justify the resources allocated in managing it.
Establishing the internal context
Internal context refers to anything within the organisation that can influence the way in which an organisation will manage risk.
In ambulance practice, the internal context includes:
- The objectives of the ambulance service, including providing emergency pre-hospital health care and transport of patients to hospitals
- Providing the most up-to-date and best emergency health care for patients; and
- Promoting an image of duty, credibility, caring and trust.
Establishing the context of the Risk Management process
The objectives, strategies, scope and parameters of the activities of the organisation, or those parts of the organisation where the risk management process is being applied, should be established. The management of risk should justify the resources used.
In ambulance practice, establishing the context of the risk management process may include:
- Defining the goals and objectives of the risk management activities
- Defining the responsibilities for and within the risk management process
- Defining the scope, as well as the depth and breadth of the risk management practices
- Defining the risk assessment methodologies
- Defining the way performance and effectiveness is evaluated in the management or risk
- Identifying the specific decisions that must be made.
Defining the risk criteria
An organisation should define the criteria to be used to evaluate the significance of the risk. This criterion should reflect the organisation’s values, objectives and resources. Some criteria can be imposed by legal and regulatory requirements. For example, many ambulance services are governed by state and federal legal requirements based on Occupational Health and Safety (OH&S) laws, which clearly define specific risk criterion. In New South Wales for example, there is a legal requirement under work cover’s OH&S laws to wear a high visibility uniform that mitigates the risk of being hit by vehicles while working on a road, such as a florescent yellow vest.
When defining risk criteria, factors be considered include:
- The nature and types of causes and consequences that can occur and how they will be measured
- How likelihood will be defined
- The timeframe/s of likelihood and/or consequence/s
- How the level of risk is to be determined
- The views of stakeholders (this should include their perception of the risk)
- The level at which the risk is acceptable or tolerable
- Whether or not a combination of multiple risks should be taken into account or not. For example, in Ambulance Practice, a single risk such as entering a house at night in a low socio-economic neighbourhood may be considered an acceptable risk, but combined with a history of a recent brawl may be considered unacceptable.
Step Two: Risk Identification
The second step in the risk management process requires the risks to be identified and the general process of risk identification, risk analysis and risk evaluation to take place. Through this process, an ambulance service is able to develop an understanding the risks that need to be managed, risks not to be managed, and where opportunities for better achievement of objectives can be realised.
The ambulance service should create a list of risks based on those events which may: create, enhance, prevent, degrade, accelerate or delay the achievement of objectives. Included in this, should be risks associated with not pursuing an opportunity.
Risk identification should also consider any cumulative or cascading effects of an event. For example, if a paramedic gets injured attending to a patient because he or she has not been adequately equipped to lift the patient, the consequence of that event will lead to an immediate negative consequence to that paramedic, being a back injury. The cascading effect of this event, will mean that the paramedic will not be able to attend work for many weeks, resulting in numerous costs to the organisation, including: overtime costs for other staff, inability to respond ambulances in a timely fashion, costs of rehabilitation and so forth.
Risk identification in ambulance practice includes risks associated with:
- the organisation’s people
- the organisation’s environment
- organisation’s management; and
- ambulance practice specific risks
The following provide some areas of risk associated with an ambulance service:
Risks to the organisation’s people:
- Human resources
- Failure to recruit and retain staff
- Induction training and competency
- Continued education and skills maintenance
- Occupational Health and Safety (OH&S)
- OH&S Management Systems
- Equal Employment Opportunity
- Professional Services and Conduct
- Health and wellbeing of the paramedic
- Threat to the physical safety of employees
- Threat to the physical safety of other emergency service personnel
- Threat to physical safety of the general public
- Threat to physical safety of the patient/s
- Hazard Management
- Industrial Action
- Rehabilitation and Work Cover
Risks relating to the organisational environment:
- Natural hazards
- Technological hazards
- Hazardous and toxic materials
- Public health
- Waste and refuse
- Radiation/contaminated waste
Risk relating to the organisational management:
- Ambulances, Property, Equipment
- Public Liability
- Legal Relationships
- Information Technologies
Paramedic Specific Risks:
- Failure to respond an ambulance to an emergency
- Driving an ambulance during emergency procedures and (lights and sirens) parking an ambulance at an emergency site/disaster site
- Interacting with other emergency personnel at an emergency
- Treating patients at an emergency
- Violence towards paramedics
- Transporting patients to a hospital
- Failure to maintain competent and up-to-date with ambulance practices
- General wellbeing of the paramedic; and
- Promoting an image of duty, competence and compassion to the community
How are risks and sources of risks identified?
Risk management committees may use a multitude of risk management tools and techniques to identify risks and their potential sources in ambulance practice. It is important to utilise people with appropriate knowledge of the industry to be involved in identifying the risks. Often, poorly managed organisations develop risk management programs without involving the front-line employees who are most likely to be affected by the risk. Without having appropriate knowledge of the risk, any management plan is bound to fail. Therefore, paramedics should be involved in the process of identifying risks and sources of risks.
These are examples of resources used to identify risks in Ambulance Practice:
- Experiences as a paramedic
- Historical records
- Legislation compliance records
- Inspections and audits
- Interviews and surveys of paramedics, patients, and other emergency service personnel
- Inter-Service Communication with other Emergency Services
- Group Brainstorming Sessions
- Review of adverse events, including route cause analysis.
Step Three: Risks Analysed
This is the third process in risk management and is utilised to analyse the specific risks that have now been identified. This process provides background information that will later be used by the organisation to develop potential treatment options. It should also provide a triaging or prioritisation process of the risks to ensure that the most significant risks to the objectives of the ambulance service are evaluated and treated first, rather than the risks in which the consequences have little or no impact on the Ambulance Service’s objectives.
Risk analysis looks at considering the cause and source of risk, their positive and negative consequences, and likelihood that those consequences can occur. Any factors that may affect consequences and likelihood should be identified (AS/NZS 2009, p.18). An event can have multiple consequences and can affect multiple objectives. Existing controls and their effectiveness and efficiency should also be taken into account.
The way in which consequences and likelihood are expressed and combined in order to determine a specific level of risk should reflect the type of risk, the information available, and the purpose for which the risk assessment output is to be used. Through this process, a risk can be determined to be acceptable or unacceptable by an ambulance service.
Methods for Analysing Risks
The methods for analysing risk include the following types of data analysis:
- Semi qualitative; and
This method enables paramedic experience, judgement and intuition to be used in the decision making process and is therefore generally less time-consuming and less costly in terms of resources. The negative aspect of this method is the potential for risks to continue to be managed in the same way as they have always been managed and therefore the same mistakes are potentially being made time and time again. An example in ambulance practice would include an incident debrief, in which paramedics are able to sit around a room and discuss with their colleagues how they felt the risks were managed.
In certain circumstances an in depth quantitative analysis may not be appropriate or viable due to the time constraints, cost implications, level of risk or availability of data. In these cases, a semi-qualitative analysis may be useful, in which data is collected and analysed through experiences, judgements and intuition, but is supported by quantitative data where the likelihood and consequences may be quantified. This may include taking surveys from paramedics about incidents, events or adverse outcomes in order to determine what went wrong or what could have been done better.
Quantitative analysis requires the data collectors to gather data that can be quantified in order to represent the consequence and likelihood of risks. Examples of quantitative analysis includes: reports of amount of injuries paramedics have sustained during particular events, how long they have been unable to attend work, and the specific financial costs of rehabilitation including replacement staffing (overtime costs) incurred as a result.
Step Four: Risks Evaluated
This is the fourth process in risk management and allows decision makers to determine if a risk is acceptable or not by comparing the outcomes of the risk analysis to the established risk criteria (identified in the establishing the context stage). Here, paramedics and decision makers need to determine the risks that require treatment and the priority for treatment implementation.
Decisions made should involve the broader context of the risk, including not only the organisation undertaking the risk management, but also including the wider context of the risk, such as parties outside the organisation that are affected by the risk. This should also include identification of any legal, regulatory or other requirements (AS/NZS 2009, p. 18).
It should be recognised that not all risks, once evaluated require treatment. In some circumstances, the potential adverse effects on the objectives of the organisation are less than the cost of the implementation of risk management strategies. In these circumstances the organisation should make the decision to accept the risk by informed consent. In this circumstance, some ambulance services choose to self-insure their ambulances.
The fifth process in risk management involves identifying and implementing risk treatment options in order to treat the risks that have already been identified as unacceptable during the risk identified, analysed and evaluated processes.
Risk treatment involves selecting one or more options for modifying risks, and implementation of those options.
Risk treatment involves a cyclical process of:
- Assessing a risk treatment
- Deciding whether residual risk levels are tolerable
- If not tolerable, generating a new risk treatment; and
- Assessing the effectiveness of that treatment.
(AS/NZS 2009, p. 19).
It was identified during step one (identifying the risk) that risk identification is a potentially limitless process and therefore effective risk management in ambulance practice often requires paramedics to develop a culture of risk management, rather than a guideline of every possible risk. The following are examples of risk treatment options available and applied to one common risk identified in ambulance practice. This risk treatment options apply to paramedics who are treating a patient who is violent:
a) Avoiding the risk – this could include if a patient is deemed to be too aggressive or violent a paramedic may choose to avoid the risk by organising the police to transport the patient in a locked police wagon;
b) Taking or increasing the risk in order to pursue an opportunity – this could include increasing the financial risk by trialling mechanical restraint devices, which if successful could reduce the number of paramedics required to attend and treat a violent patient;
c) Removing the risk source – if a patient, especially one that is violent or has a mental illness with a history of aggressive behaviour is sitting next to a knife or potential weapon, one solution can include, walking the patient outside (away from the knife) or simply picking the knife up and putting it away.
d) Changing the likelihood – one solution here is to effectively communicate with the patient before approaching that you are a paramedic and there to help. Many patients become violent because they are unaware that you are a paramedic and not a police officer there to arrest them;
e) Changing the consequences – one solution available here would include wearing protective clothing, such as Kevlar vests to protect against stabbing injuries or bullets (although the level of risk should never reach this stage in ambulance practice);
f) Sharing the risk with another party or parties (risk financing/insurance) – this can include involving police for assistance while treating all patients who are potentially violent;
g) Retaining the risk by informed decision – one example of this could include an ambulance service acknowledging the documented fact that paramedics are more likely to be assaulted during night time than the day (FEMA 2006, p.2), but accepting this risk by informed decision and acknowledging that paramedics must still respond to medical emergencies during the night.
Selection of risk treatment options
Selecting the most appropriate risk treatment option involves balancing the cost and efforts of implementation against the benefits derived. The benefits must also consider the potential legal, regulatory and social responsibility that the ambulance service may be obliged to adhere to.
Multiple treatment options can be considered, including individual, or a combination of risk management strategies. As a paramedic at the scene of a motor vehicle crash, this may include: wearing high visibility vests, parking the ambulance in such a way as to re-direct traffic and create a shield, using police assistance to manage traffic, or block the road completely. When selecting treatment options the organisation should consider the perceptions or values of the stakeholders. The perceptions of the paramedics may often differ from those of the other key stakeholders, such as politicians who make decisions on the services that will be capable of providing to a community.
The treatment plan should clearly identify the priority order in which individual risk treatments should be implemented. As a paramedic, it is paramount to identify those risks that need to be treated immediately and those that can be managed at a later time.
Risk treatment itself can introduce risks. For example, in ambulance practice, the introduction of goggles when working inside a car, may introduce the risk of temporary vision impairment due to the goggles fogging up. When risk treatments introduce secondary risks these risks then need to be assessed, treated, monitored and reviewed. If further treatment options are identified for these risks, a clear link between the two risks should be identified and the risks treated as a single process and not a new risk on its own (AS/NZS 2009, p. 20).
Preparing and Implementing Risk Treatment Plans
The purpose of risk treatment plans is to document how the chosen treatment options will be implemented.
The following information should be provided within the plan:
- The reasons for selecting the treatment options, including expected benefits to be gained
- Those who are accountable for approving the plan and those responsible for implementing the plan
- Proposed actions
- Resource requirements including contingencies
- Performance measures and constraints
- Reporting and monitoring requirements; and
- Timing and schedule.
(AS/NZS ISO 3100) p. 20)
Decision makers and other stakeholders should be aware of the nature and extent of the residual risk after risk treatment. The residual risk should be documented and subjected to monitoring, review and, if required, further treatment.
Step 6: Continuously Monitor and Review
The continuous process of monitoring and reviewing should be maintained throughout the entire risk management process. Because risks are dynamic, a continuous review and monitoring of their management should be diligently maintained in order to achieve long term risk management success. As with every other treatment option in paramedics, a repeated evaluative process must be used to determine its continued effectiveness.
Both monitoring and review processes should be built into the entire process of risk management. It can be done periodically, based on time intervals or stages of development, or on an impromptu basis throughout random timeframes and stages of development.
Monitoring and review in ambulance practice can be achieved through the following methods:
- Self-reporting system, such as the IIMs system in NSW Health in which paramedics are able to self-report the consequences of a risk, such as near misses or adverse events;
- Risk management committees;
- Work cover reports of accidents and injuries;
- Reports of the organisation’s ability to meet its objectives, such as providing ambulances to meet the needs of the community.
Progress in implementing risk treatment plans provides a performance measure. The results in monitoring and review should be recorded and externally and internally reported as appropriate, and should also be used as an input to the review of the risk management framework.
Documenting the risk management process
Risk management activities should be recorded. In the risk management process, records provide the foundation for improvement in methods and tools, as well as in the overall process. Furthermore, documentation is often a legal requirement of many areas of risk management, such as OH&S and Work Cover NSW accident and injury reports.
Step Seven: Continuous Communication and consultation
The continuous process of communication and consultation in risk management ensures that both external and internal stakeholders’ needs are taken into account during each stage of the risk management process. This allows early recognition of potential discourse amongst stakeholders and allows early detection of potential solutions where required.
In ambulance practice, the perception of risk is likely to be different based on the type of stakeholders, management roles, and front-line employees. For example, the perception of risk that a paramedic may be ‘threatened with physical violence at work’ may vary depending on if you are asking the senior managers, who are required to provide safety alarms under the OH&S laws or the frontline paramedics, who may refuse to enter a property that they feel unsafe.