Principles of risk management

Within mental health settings, risk management used to be considered the business of predicting and preventing dangerousness.

The focus of risk management today is not so much on the end point of preventing the adverse outcome, but more on enhancing clinicians’ performance at all stages of treatment to achieve a good outcome for the patient. This is attained through focus on:

This problem becomes the nub of risk management within mental health. On the one hand clinicians try to treat the illness while at the same time managing the risk, which is often a complication of the disease process rather than a symptom of the disease itself. ‘Risk, especially violence, can be a preventable complication of some types of mental disorder.’⁵

This book focuses primarily on skills acquisition and the process of decision-making. It provides opportunities to practise some of the suggested techniques in the case examples. Organisational factors are touched on briefly but are predominantly the brief of senior clinicians, team leaders and clinical leaders. Detailed discussion of organisational factors is beyond the scope of this book but an introduction is given in Part 4.

Guidelines vary from country to country and are dependent mostly on the structure of health services rather than clinical differences. Good risk management involves having knowledge of guidelines and knowing how to access them. Guidelines should be available in printed form at your workplace. Some guidelines currently available, and useful in conjunction with this book, include:

The development of a risk culture within mental health services

All mental health clinicians should be trained in the assessment and management of suicidality and violence. There is a growing body of evidence to assist the clinician in making more structured decisions in his/her assessment and management of risk. In more recent times, risk management has been introduced as a phrase to encapsulate much of what clinicians have always done in a relatively unstructured way.

In the 1960s insurance companies in the United States coined the phrase ‘risk management’⁸ and around the same time an increasing number of medical lawsuits led to insurance companies applying the same concepts to the health sector.⁹ Over the last 50 years there has been a movement towards greater accountability for all professionals and a parallel movement of consumer empowerment. Litigation and complaints have continued to become an ever-present component of clinical practice whilst the culture of blame in which we live has become more pronounced.¹⁰

Political focus and media commentary on (risk) have increased. Society has become, in general, more risk averse.¹¹ Across all media, people with a mental disorder are portrayed in a negative manner, and typically as dangerous.¹² The pendulum may be swinging, however, with calls for the culture of blame to be given up.¹³ Some clinicians feel that they work in a riskier environment but it may be that this is a response to increased scrutiny and accountability of their work. Consumer empowerment and access to information has allowed patients to become more aware of treatment options and more able to demand the best quality of care available. This change should be welcomed. Clinicians have had to adapt to this new environment: some have been more successful than others. Some clinicians may be more defensive in their practice as a result of anxiety driven by a fear of accountability and a fear of complaints being laid against them. ‘The effects of this (blame) culture appear to be counterproductive, leading to defensive practice, and undermining both professional morale and recruitment into the profession.’¹⁴

Clinicians may think they are in the vicious circle outlined in Figure 1.1.¹⁵

Figure 1.1 Potential consequences of the blame culture on risk management

The blame culture is unlikely to change in the near future. Clinicians are increasingly accountable, which is appropriate, but if increased accountability is allowed to heighten anxiety, clinical practice will be stifled.

Out of concern about the ‘blame culture’, Carson (2008)¹⁷ developed proposals which were to be understood as an integrated program for tackling blame culture. The evidence and theory to support these proposals were presented in a recent book by Carson and Bain (2008).¹⁸

The House of Lords, in a leading court case on the standard of care expected of professionals, assumed that ‘risk’ involved the chance of harm and it specifically recognised that it would be appropriate to balance this with the chances of benefit (Bolitho v City and Hackney Health Authority [1998] AC 232). Risk decisions need to be made with clear thought given to the potential benefits. These benefits need to be articulated within the decision-making process.

Carson’s proposals for tackling the blame culture are outlined below. He says they are self-evident ‘truths’ about risk-taking, and are generally agreed with by professional associations and employers. As this should improve staff morale, and reduce the risk of litigation, employers ought to embrace these principles.¹⁹

Clinicians often fear an adverse outcome not so much because of the outcome, but because of the possibility of being sued, appearing in an inquiry or losing their registration. Having an awareness of the law of negligence and how this relates to duty of care can be useful. Some of these principles are outlined below.

If clinicians find themselves anxious about taking risks, practice deteriorates and patients may suffer. Do risk management techniques offer any advantages? The following points outline the benefits of risk management and give some cause for hope.