Risk Management: Where Things Happen

Setting the scene

A number of messages are being learned as we navigate our way through the 2020 coronavirus pandemic… not the least being that there is a time to talk and a time to act. We all share a collective responsibility in manging the risks of an unseen threat; but, we also all have to step up to our own individual responsibilities for maintaining our personal safety, and that of people immediately around us. We need clear leadership when managing difficult and dangerous risks; but, then we need to act in clearly thought out ways when putting guidance into action. 

Perhaps another prescient message in recent times has been the reminder about lies, damn lies and statistics (insert your Government of choice into this narrative). A frequent issue I have been confronted with, over 35 years of experience working in healthcare and case management, has been the preoccupation with risk assessment by numbers. It makes life so much easier for auditors, but offers far less clarity for practitioners. Government briefings on the pandemic have been characterised by a blizzard of claims backed up by numbers, none of which stand up to much scrutiny (the BBC Radio 4  More or Less programme does a fine job of skewering the regular misrepresentations of data). 

Essentially, the change in the numbers becomes the mesmerising attraction… but as they rarely directly informed you what to do in the first place, their ability to accurately measure what you’ve done should be called into question. Statisticians, auditors and bureaucrats (and politicians) will argue all day long that these measures are the only way we know we are doing things right. In the meantime, practitioners frequently find themselves on the receiving end of numerous demands for generating more and more data, which becomes a risk in its own right… that of distracting time and attention away from what they should be doing with the people they are working with.

Establishing the dilemma

·      Do we need to be gathering data? Yes, where it is relevant and guided by the context of the work in hand.

·      Communication shrouded in numbers is more usually called mathematics.

·      Do we need to shine a spotlight on the gulf in priorities between bureaucratic and practice demands? Most certainly; the gender contrast notwithstanding, Venus and Mars come to mind.

·      Can I have a pound for every time I have heard a bureaucrat say their intention is to reduce bureaucracy? Please… bank account details to follow!

·      What is needed is good quality guidance that helps drive the accurate narrative that reflects and informs individual circumstances.

Cutting to the chase

Within the complex area of working with risk there is a place for risk assessment, but it only helps us to identify what the risks are. A clear and obvious danger is that we apply rigorous attention to developing the fine details of a risk assessment, but less detailed consideration to what we should then be doing with people. An inordinate amount of energy may be required of practitioners to complete complex and often numerically focussed risk assessment documents… but what happens next? 

The frequently heard phrases: “Where is the risk assessment?” “Have you completed the risk assessment?” convey the wrong message… that completion of such a document is the end of a process rather than the means towards clinically reasoned decision-making. Furthermore, a summary of risks presented in a numerical presentation bears little direct relevance to the day-to-day lived experience of people. When was the last time you heard practitioners quoting these numerical representations in their interactions with each other, or with clients? All-too-often the reality is one of practitioners completing required risk assessment documents, and then going about their work with little or no reference to what has been written (largely because it doesn’t reflect the reality they are working with). 

It is my contention that risk management is where things really happen, where the action is… informed by the risk assessment. After all, you can’t successfully manage a risk you haven’t identified. The two concepts go hand-in-hand, but I like to think of risk management as the overriding function, clearly underpinned by a guided qualitative risk assessment. 

Defining what we mean

RISK MANAGEMENT: is the statement of plans and the allocation of responsibilities for translating collective decisions into real actions. It is the activity of exercising a duty of care where risks are identified. It entails a broad range of responses linked closely to the wider process of care planning. The activities may involve preventative, responsive and supportive measures to diminish the potential negative consequences of risk and to promote potential benefits of taking appropriate risks. These will occasionally involve more restrictive measures and crisis responses where the identified risks have an increased potential for harmful outcomes. It should also clearly identify the dates for reviewing the assessment and the management plans. [Morgan, 2013].

Phases of risk management

Working with frontline practitioners should be about helping people refine their mindset. It is about presenting guidance that is based in the wealth of both evidence based practice and practice based evidence; whilst communicating a trust in them to adapt to the flexibility of individual circumstances. It is about adopting the strengths-based work of the Gallup organisation, particularly through the concept of Organisational Agility, promoting quality through mentoring and supervision rather than bureaucratic rigidity. When managing complex risks the last thing we should be creating is the stifling experience of another form-filling exercise.

Risk management can be thought of in three phases:

·      Preventative approaches to help people in managing their own risks:

-       Education about causes and/or early detection

-       Access to flexible support

-       Development of skills and/or coping techniques.

·      Managing risk behaviours as they occur:

-       Direct treatment

-       Diffusion strategies

-       Crisis responses.

·      Management of supported learning:

-       Counselling (open to all parties involved)

-       Accurate incident reporting

-       Appropriate pressing of charges, when needed.

Examples of each of the above phases:

·      Before an event:

-       Intensive clinical case management

-       Flexible outreach working practices

-       Engaging trusting working relationships

-       Working with a person’s strengths, wishes and priorities

-       Comprehensive health and social care interventions

-       Supportive counselling techniques

-       Systematic monitoring of evidence-based treatments

-       Anger management techniques

-       Cognitive behavioural approaches

-       Social skills training

-       Goal-setting and problem-solving

-       Controlling emotional arousal

-       Working with significant others in social networks.

·      During an event:

-       Evidence-based crisis intervention responses (medication management, negotiation skills, practical help, respite)

-       Setting clear ground rules and limits, with explicit consequences for specific behaviours

-       Helping the person to maintain control of their own experience

-       Monitoring clinical symptoms

-       Determine the need for formal assessments/legal procedures

-       Encourage discussion of recognised signs and patterns

-       Problem-solving and coping strategies

-       Forensic assessment, as needed

-       Calling for emergency services, as appropriate

-       Offering help and support to the wider social network, as appropriate.

·      After an event:

-       A learning experience that should be talked through with all the appropriate people, as part of psycho-social education, or for its contribution to the refining of early warning signs of relapse

-       Staff members should be encouraged to talk through the experience with their supervisor/manager, based within a service setting of psychological safety (including consideration of the potential difficulties of a worker having to re-face a perpetrator of distressing risk, continuing the role of key worker)

-       Discussing experiences in the larger staff group, when the practitioner(s) involved feel ready, as a learning exercise for the whole team

-       An opportunity for the client to assess the causal relationships

-       An opportunity to understand the potential consequences for organisational policy and procedures.

Developing a plan

There are a number of ways in which we may articulate risk management, but they all mean essentially the same thing… translating our knowledge about an individual into clinical interventions designed to minimise the impact of risk on all concerned. While risk management is often discussed in the context of organisational responses, we should not lose sight of its firm basis in clinical judgement and clinical practice.

Providing a cognitive framework: 

·      What is the organisational context in which you are required to operate (e.g. Care Programme Approach)?

·      Who should be involved in developing the plan?

·      What is your specific assessment of the risk(s)?:

-       Individual/personal risk (e.g. medical condition, behavioural/personality attributes)

-       Situational context of the risk (e.g. interpersonal problems, isolation, clashes with authority)

-       Systems risks (e.g. poor communication/coordination, poorly supported staff, unclear expectations)

·      What planned interventions are most appropriate for meeting the risks you have identified?

·      What strengths and opportunities can you identify that may support the implementation/success of the planned intervention(s)?

·      What dangers do you anticipate in the implementation of a plan in these circumstances?

·      What type of rapid response may be required in the event of the above dangers materialising?

·      In what circumstances may an extraordinary review be required, and how may it be organised?

·      How frequently should the plan be reviewed, in what way, and who should be involved? 

Communication is the most essential skill of risk management… keep talking with your client; keep discussing and reflecting on what is happening with colleagues.

Reference

Morgan, S (2013) Risk Decision-Making: Working with risk and implementing positive risk-taking. Brighton: Pavilion Publishing & Media.

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