• Bristol Inquiry
• patient-caregiver communication
• teamwork

The historical summary of risk management by Kuhn and Youngberg¹ in this issue of QSHC concludes with the provocative challenge: “Those risk managers who accept change and think of new ways to embed risk management principles into their organization to help create meaningful and sustainable change will prosper. Those who don't should get out now. They are destined to fail and to fail their organizations.”

This judgment may be a bit premature, too focused on the individual risk manager, and actually reverse cause and effect—that is, rather than “a need for risk management to evolve to assure a culture of safety”, perhaps the opposite is true. Is it possible that a culture of safety (high reliability) is the necessary prerequisite for allowing risk management to evolve? It is possible that, in a highly reliable safety culture, the risk management function as outlined by Kuhn and Youngberg may turn out to have minimal functional usefulness.

Svedung and Rasmussen² have recently suggested that the following considerations are necessary for effective management of future risk:

1. It is … becoming increasingly difficult to explain accident causation by (retrospective) analysis of local factors within a work system. Safety and risk management increasingly become sociotechnical system problems (rather than the study of accidents themselves).

2. A very aggressive and competitive environment tends to focus the incentives of decision makers on short term financial criteria rather than on long term criteria concerning welfare, safety and environmental impact … court reports from several recent accidents show that they have not been caused by coincidence of independent failures and human errors but by a systematic migration of organizational behavior toward accidents under the influence of pressure toward cost effectiveness in an aggressive competitive environment.

3. Risk management has been reactive and primarily guided by studies of past accidents and incidents. It is suggested that future risk management strategies be based not on analysis of accidents, but rather on normal work practices and sociocultural factors that shape those work practices in an actual work place. It is therefore entirely possible that the ultimate “root cause” of any accident is production pressure, the origins of which lie outside the domain(s) currently considered manageable in the framework proposed by Youngberg and Kuhn.

This is not to suggest that risk transfer and claims resolution will cease to be important corporate functions. Healthcare accidents are, after all, accidents. While it may be possible to decrease the probability of an accident occurring, given the complexity of human nature and technology that are integral to the delivery of health care, mishaps will remain a natural part of our delivery system. Indeed, as Kuhn and Youngberg point out, the ability to “negotiate risk transfer agreements with steadily declining costs” contributes operating capital and increased margins, both of which have been shown to decrease mortality, thereby increasing patient safety and mitigating risk.³

Kuhn and Youngberg raise the interesting question: “How could we (risk managers) have worked so hard and accomplished so little?” This question in turn creates others. How can anyone know what has not been accomplished? How is it possible to measure accidents or injury that have been prevented and therefore did not occur? It is impossible to know what the total cost of risk would have been had an attempt to manage healthcare risk (even with paradigms suggested as not effective) not been undertaken.

When pricing and rates are soft, the very hard work of negotiating favorable terms ironically ensures that incentives do not exist to thwart what the German sociologist Ulrich Beck has described as “an acceptance of uncertainty and organized irresponsibility”.⁴ By contrast, the prediction of dramatic environmental change such as the twin tower disaster in New York on 11 September 2001 that leads to an industry wide knee jerk reaction is no more the purview of individual risk managers than of corporate senior management itself.

Indeed, some responsibility for whatever proposed shortcomings are inherent in the current model of healthcare risk management must include corporate governance and accountability by senior management. As Kuhn and Youngberg point out, managing risk is about corporate design and improvement and changing systems of work rather than simply a staff function assigned to an office or someone labelled “risk management”. Integrating the work of risk into organizational and managerial culture and making it an explicit step in the decision making process is critical to future successful management of corporate healthcare risk.

Managing future risk is not, as suggested by Kuhn and Youngberg, about “embedding risk management principles into healthcare organizations”—that is, reporting for the purpose of analyzing, characterizing and trending accidents, incidents and near misses. Rather, it is about replacing current risk management principles with those found in organizational development, the social sciences, financial modelling, knowledge management, and story telling. The chaotic and complex nature of healthcare risk suggests that anything else will fall short.