EXECUTIVE SUMMARY

Risk management should encompass a broad process of reporting adverse events and incidents, monitoring compliance and safety, and initiating quality improvement projects and activities.

Employees can use checklists to monitor each other for compliance with infection prevention and other standards.

Encourage staff to report adverse events and all near misses, process failures, and workarounds to the risk manager.

Surgery centers should create a culture of safety that makes it safe for employees to report problems and does not punish people for owning up to mistakes.


Risk management requires more than reporting incidents and adverse events. It is a broader process of monitoring compliance and safety that requires multidisciplinary tools and activities.

“You can teach your staff to monitor what’s important, and it helps to put together a simple but thorough checklist,” says Sandra Jones, MBA, MSM, CPHRM, LHRM, CHCQM, CASC, FHFMA, chief executive officer of Ambulatory Strategies, Inc., in Dade City, FL.

With checklists, employees can monitor one another, taking turns. For instance, after teaching staff about safe medication practices, one person could be the monitor for a period, and then another person will take over. Employees will use a safe medication checklist (which should include definitions and specific instructions) to ensure everyone follows safe practices, she suggests. “The person doing monitoring would make sure that once someone opens a multidose vial, they label it with a beyond-use date,” Jones says.

There are a few ways to improve risk management in surgery centers:

Develop checklists. “We set up a 10-point checklist to use as a monitoring tool,” Jones says. “It has enough definitions that staff know what to look for.”

Checklists, used as monitoring tools, reinforce learning through monitoring, she says. Employees can take turns using checklists, following the workflow and dividing checklist monitoring by floor sections.

“Have one person be responsible for section A in October, and then they’re at section C in November, and they’re responsible for monitoring that area for multidose vials and outdated cabinets,” Jones offers.

Train staff with specific instructions. “Train staff to look at how they’re cleaning things between patients,” Jones says. “I’ve seen checklists that are not thorough enough. They say that all areas are wiped down, but that doesn’t tell the person who is doing the checking enough information.”

Instead, the checklist should include specific action items, including: check that all handrails are wiped down, wipe down all surfaces, use sanitary and disinfection wipes according to manufacturer’s instructions for use, use enough wipes to keep surface visibly wet, and wipe the monitor.

“The wipes are wet cloths pulled from a canister, and the canister tells you how to use it,” Jones says. “That’s the kind of detail that should be on the checklist.”

If the instructions are for one wipe to be used to clean and one to disinfect, then it is a mistake for an employee to use one wipe to clean and disinfect. “Put those details on the checklist so everyone learns not to use just one wipe,” Jones adds.

Ask staff to report all risks. “Encourage your staff to report to the risk manager not only the adverse events, but also the near misses, the process failures, and workarounds,” Jones says.

Risk managers want to know everything that could have been an adverse event. They want to know about incidents that almost created patient or employee harm. “By encouraging staff to let you know of [near misses], you can trend these incidents to show that something is happening more often than people thought,” Jones explains.

Using those additional data, risk managers could say the surgery center needs to create a better policy, create more steps, and give more training because twice in the past month, someone caught a problem before it happened, Jones says. “That’s great that it was caught, but what did we do that almost caused the problem?”

These near misses also are great opportunities to reinforce the use of checklists and monitoring. Checks and balances should occur in real time as employees are engaged in their day-to-day tasks. “You want to do the checklist when it should be done and do it every step of the way,” Jones says. “Maybe someone had to do a workaround because a supply wasn’t available or a teammate wasn’t available. If your staff is educated in how to help you know of these issues, then you can start looking at whether the problems are because of education or staffing changes.”

Through monitoring, risk managers can ensure that all processes are smooth and all steps are followed. They can see that obstacles and problems are not fixed at the last minute, which can lead to staff injuries.

Make improvements continuous. Using monitoring checklists to also collect data on mistakes and workflow issues can help surgery centers develop quality improvement projects. In fact, the data should help the center maintain an atmosphere of continuous quality improvement.

“If I ever have someone tell me they can’t figure out what to do on a quality improvement/process assurance [QI/PA] project, I wonder how many checklists they’ve ever worked on because I don’t think anyone could find something that doesn’t need to be fixed,” Jones says.

Often, there are too many issues and processes that need to be improved, she adds. “Work with your staff without pointing fingers,” Jones advises. “Look at processes that need to be improved, and then you have a QI/PA project.” Perhaps the monitor checked 27 open, multidose vials, and found that four were still on the anesthesia cart after the patient left the room.

“You say, ‘Here’s what we can look for, here’s the gap in performance we found, and here’s what we can do about it,’” Jones explains. “Educate, monitor, and then look in a few months to see if the changes worked.”

Involve staff. Surgery center risk managers have to engage staff and teach them to be the eyes and ears of the center. The risk manager cannot be the only enforcer, Jones cautions.

“They have to know how to alert the risk manager when something needs to be addressed,” she says. “Have a culture of safety, not just ratting on someone, not making someone look bad or pointing fingers.”

Encourage people to speak up when they find it necessary to do something that is against protocol. It is better to hear about these lapses before they cause harm. “The staff needs to be comfortable that they won’t be punished [for reporting],” Jones says. “Help create a system that is safe for them and the patient.”