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Haitham Shoman & Samer Ellahham, Sheikh Khalifa Medical City managed by Cleveland Clinic, Cleveland Clinic Foundation
16 March 2017
Can risks in healthcare be mitigated? Can caregivers be all be part of the assessment methodology? Can all their inputs be used to develop solutions to previous and potential adverse effects? Can healthcare staff be part of improving the quality of healthcare tailored to their circumstances?
As in any industry, hazards have always seen its way in jeopardizing the growth and thriving of industries, and poor rules in place play a part of the process. The oil and gas, aviation, nuclear, transport and petrochemical are all full of risks and hazards that threaten its employees. Managers in these fields have studied different methods to mitigate risks. A novel model was initiated looking at risks both retrospectively and prospectively providing a pictorial presentation of the threats and consequences of a certain hazard and then putting barriers to prevent the undesired outcomes from happening.
The history of Bow-Tie goes back most likely to 1979 where diagrams were shown in Imperial Chemistry Industry notes at the University of Queensland. The actual origin remains vague. The Royal Dutch Shell group in the early nineties were amongst the first to adopt the Bow-Toe as a standardized methodology in risk assessment, management and control.
In order to improve the quality of service delivery in healthcare, one of the major pillars to be adequately and thoroughly explored is risk assessment. It not just helps protect the safety of the people and the organization, it creates a system that is well protected, healthy and offers the opportunity for organizations to excel in their service delivery. The Bow-Tie model has been used by several oil and gas industries for prospective risk assessment that has proven to be very effective in deploying barriers to potentially occurring threats. The model seems to be very well designed and it is about time to replicate its implementation in the healthcare industry. Only three studies so far has used this model in their healthcare organizations. The authors of this article are working on widening the scope of this model in the region and further expand it across the world. The Bow-Tie model is designed in a comprehensive way where risks are drawn and results are graphically presented in a bow-tie shaped diagram.
A good model is one that reports on data quality, illustrates examples, assumptions if any were used, if the model is potentially available and transparent to the user and if potential limitations were discussed and Bow-Tie is no less. Bringing this model to healthcare and disseminating its usage will not only offer comprehensive risk analysis, it will revolutionize the methodology of comprehensive risk assessment and establish frontline barriers to prevent the risks from happening.
Bow-Tie methodology: The Bow-Tie methodology includes risk management cycle that covers hazard identification, risk evaluation and risk control along with adverse events that may occur. It commences by identifying the major event which is the centre of the diagram. On the left-hand side lies the threats that can trigger the major event in the centre. On the right-hand side of the diagram (right to the major event in the centre) lies the consequences. After identifying the major event, threats and consequences, barriers can then be identified. Barriers can be preventive or protective. Preventive barriers are those that already exist in the threats’ path to prevent their initiation and protective barriers can protect or minimize the adverse events caused by threats. Sometimes the barriers could be jeopardized by an escalation factor. Barriers that are identified following the emergence of escalation factors are called secondary barriers. A comprehensive Bow-Tie diagram would have a pictorial presentation of the threats, consequences, escalation factors and the barriers along the pathways. Recommendations and strategies could then be proposed based on the preventive and protective barriers.
Hazards can be identified from existing reports, events, conferences and team members’ input. Studies have shown that deploying adequate risk analysis methodologies in healthcare operations are effective in reducing harm and undesirable events to healthcare beneficiaries. The Bow-Tie diagrams are also useful in presenting the relationship between the individual, organizational and cultural factors that contribute in the way risks are managed. It is important to have a model that shows all barriers in an eye-friendly manner where the user can easily navigate through and look at all the threats in one place rather than having to flip over pages and sometimes lose track of the threats and what needs to be done. Non-healthcare industries that have plenty of risks associated with the nature of their work have been using the Bow-Tie and their staff have all contributed to its development in analysing risks where some people have even referred to it being a goal oriented model to improve the quality of a service and mitigate risks effectively. In this model, error detection and recovery is easily presented offering staff the insight of their role in different phases of the recovery process including identifying, preventing and fixing errors.
In addition, the three studies that used the Bow-Tie methodology in risk assessment, have shown that it was successful in promoting healthcare staff awareness about threats and errors and errors provoking conditions in their environments ad workplace.
Despite the usefulness, practicality and great potential of this tool, it has its limitations. The Bow-Tie can be time-consuming in its development requiring extensive work and awareness on how to use it. The practicality and reliability of the outputs depends on the inputs given. Data gathering needs to be adequately managed and should be of high quality for reliable results. Since it is considered a new model in the healthcare industry, users of the model needs to be trained on how to use it along with the necessary software for its implementation with particular emphasis on the terminologies of threats, consequences, hazards, escalation factors, hazards and barriers. Sometimes in a model, the results generated cannot be generalized across all healthcare settings especially when the inputs used were of explicit nature for a specialized healthcare setting.
In conclusion, the Bow-Tie model seems to be a feasible and a proactive risk assessment and management model. This tool helps in the generation of practical solutions to address gaps in the healthcare service delivery and identify the necessary barriers to overcome them. It also helps in creating awareness about risks and hazards to healthcare providers by visualizing the entire pathway of the risk assessment. It is crucial for the users of this model to be aware and understand the terminologies associated with the use of the model to be able to allocate the necessary terms under each category. The authors are studying in depth the adaptability of the Bow-Tie model in the healthcare industry and are working on further research of increasing its dissemination across the region and the world. They believe that this model will be a breakthrough in improving the quality of healthcare, mitigate risk and above all improve patient safety. The authors are working and conducting further research regarding the Bow-Tie model and its use in the healthcare industry and increasing its use in the region.