Risk Management : Element of Safety Strategy in Public and Private Hospitals

Carina Cristina Melo Silva1, Rennaly Kelly de Araújo Ferreira1, Rozileide Martins Simões Candeia2, Daniela Alves Cardeal dos Santos3, Ericka Silva Holmes4, Nívea Trindade de Araújo Tiburtino Neves5, Gyl Dayara Alves de Carvalho6, Stella Costa Valdevino7, Jamilton Alves de Farias8, Aurilene Josefa Cartaxo Gomes de Arruda9, Maria Bernadete de Sousa Costa10 1 Academic of Nursing Course, UFPB*. 2 Nurse. Specialist in Family Health*. 3 Physiotherapist. Specialist in Functional Cardiorespiratory Physiotherapy*. 4 Nurse. Doctor student of the Postgraduate Program in Decision and Health Models (PPGMDS/UFPB)*. 5 Nurse. Master student of the Postgraduate Program in Decision and Health Models (PPGMDS/UFPB)*. 6 Nurse. Master in Nursing at UFPB*. 7 Nurse. Doctor student in Nursing at UFPB. University lecturer at Department of Clinical Nursing (DENC/UFPB)*. 8 Nurse. Doctor in Psychology. University lecturer at Department of Clinical Nursing (DENC/UFPB). 9 Nurse. Doctor in Science from the National School of Public Health Arouca Oswaldo Cruz Foundation. University lecturer at Department of Clinical Nursing (DENC/UFPB). 10 Nurse. Doctor in Health and Hospital Administration. University lecturer at Department of Clinical Nursing (DENC/ UFPB)*. *: Member of the Study and Research Group in Administration and Computing in Health (GEPAIE).


Introduction
Traditionally, risk management in the context of health services is a systematic and continuous implementation of policies, procedures, behaviors and resources in risk and adverse events assessment, which affect patient safety, human health, professional integrity, environment and corporate image [1].
Risk management in health care began to develop in the United States from the decade of 50.Some large American companies have incorporated the Risk Management function, which initially consisted of the purchase and management of insurance policies.With the industrial development, the risks that were submitted to the equity of the company increased in number and complexity; therefore the insurance market activated to cover these risks became more technically improved; as consequence, companies noted the need for seek a relationships with specialized professionals who insurance companies might be encouraged to question the risks of companies.Thus, were consolidated the figure, the functions and the activities of the risk manager [2].
From the 2000 decade, patient safety comes to the agenda of researchers around the entire world and become internationally recognized as a fundamental dimension of quality in health [3].In this context, the analysis of different surveys conducted in several countries, such as England, Australia, Canada, Denmark, New Zealand, Portugal, France, Sweden, Spain, Netherlands and Brazil, showed a high number of cases of adverse events focusing on a portion significant of hospitalized patients, which concluded that approximately 10% of hospitalizations result in some kind of adverse event [4].
Recognizing the magnitude of the global patient safety problem, the World Health Organization (WHO) established in 2004 the World Alliance for Patient Safety.The purpose of this initiative was to define and identify priorities in patient safety area in several parts of the world and contribute to a global agenda for research in the field [3,5].
This program was introduced in the context of the reforms of health public systems of almost every country in the world.In Brazil, the risk management started in mid 1999.At that time, parameters were set, evaluation criteria and analysis; in the medical and surgical, dental, nursing, pharmaceutical, laboratory and other areas, related to the complexity of care both professionals and experts, as well as the profile and complexity of healthcare organizations.The criteria were created and inserted in the terms and types of policies to some Brazilian insurance related or not to banks.
Having as background the technological advances in clinical areas in the past six decades, Anvisa [1] considers that the risk is the combination of the probability of occurrence of damage and the severity of such damage.While, risk management, in turn, constitutes the decision-making regarding the risks or action to reduce the consequences or probability of occurrence.
Within the hospitals, it is observed that professionals, in their work exercise, are exposed to occupational hazards that can interfere directly or indirectly in their health, causing they illness for a personal injury and functional disorder that causes death, the loss or reduction, permanent or temporary, to the work ability [6].In the case of health care in Brazilian hospitals, it is believed that the errors and the implementation of continuing education actions focused on risk management to improve the level of knowledge among professionals who serve in the public and in private sector.their consequences are considerably higher due to the precariousness of services, lack of proper staff quantity, excessive workload and poor professionals remuneration [7].
Considering there are many health and safety issues associated with facilities that include blood, pathogens, biological risk, chemical, physical, ergonomic, potential drugs, anesthetic waste gas and respiratory exposures, and many other products used in laboratories and in service health [7], in Brazil, the Labor and Employment Ministry -MTE ranked occupational risks in five risk groups: physical, chemical, ergonomic, incidental and biological, highlighting that undertake their physical, mental and social state [8].
The literature reveals that in the hospitals institutions the biological risks (biohazards) are directly related to health professionals for these are connected to their daily practice, in addition, can cause contamination of the environment, being capable of transmission to patients/clients [9,10].In this context, health organizations should establish safety management, while as a cultural process, promoting greater awareness of professionals regarding the safety culture, ethical commitment to risk management with consequent acquisition for themselves and the clientele supplying the gap in aspect of patient safety.
The current concept to patient safety indicates as the main factors responsible for the occurrence of adverse events the deficiencies in the provision of health care system in its design, organization and operation, instead of blaming singly professionals or products [3].
Thus, patient safety is understood as the reduction to the acceptable minimum risk of damage associated with care.The practices for their implementation should include organizational learning from the error.Thus, replacing the practice of individual culpability for idea to rethink processes of care that can make the necessary corrections, to create mechanisms that anticipate errors and allow to prevent them from damage [11].
It is observed in institutions, situations that predispose to the risk of adverse events include technological advances with poor development of human resources, lack of motivation, failure to apply the systematization of nursing care (SNC), care delegation without proper supervision and overload services.
Faced with some features and characteristics that make it difficult the perception of risk and safety approach, essentially due to the complexity of the hospitals, and also the sensitivity that the subject arouses, we propose in this study to answer the following questions: Hospital organizations have the risk management program?What strategies hospitals adopt to patient and professional safety?To answer these questions the following objectives were formulated: Characterize the public and private institutions that use risk management; determine the strategies that hospitals adopt to patient and professional safety, and identify the positive and negative aspects that imply the risk management in the hospitals surveyed.
The option to search this theme is attributed to the fact that while being health professionals, there was the need to contribute to the improvement of services and the assistance of local hospitals and the country, boosting the reflection of managers and professionals as the need for risk management on the legal aspects/legal, epidemiological, biological, healthcare, occupational and others.

Method
This is a descriptive research with quali-quantitative approach developed in the State of Paraiba -Brazil, in the city of João Pessoa-PB.The search was conducted in eight hospitals registered by the Sistema Único de Saúde -SUS (Unified Health System), classified as public, private and philanthropic hospitals large and medium-sized.The choice of location is due to the fact that the State of Paraíba city with the highest number of hospitals registered by SUS and reference for patient care throughout the state.This research had as object of study managers/ professionals responsible for risk management in hospitals in João Pessoa-PB.For inclusion manager in the search criterion adopted was to develop risk management in the hospital and to accept participate.The hospitals whose managers are part of the criteria established in this study were named as follows: 4 Public Hospitals -A, B, C, D; 1 Philanthropic Hospital -E, and 3 Private Hospitals -F, G, H.
As exclusion criteria were excluded professionals who refused to participate, claim lack of time to answer the questions, in view of the heavy workload they face or fear of committing to the data provided in the search.
To the data collect, was used an instrument consisting of two parts: The first part consists of questions related to the risk manager profile (gender, age, professional category and length of service); and the second part consists of variables related to the characterization of risk management in the hospitals surveyed.
Data were collected from February to March 2016 and, participants completed the instruments during the working hours of these professionals, in a previously agreed time, in order not to compromise the continuity of their work activities.Data were grouped and analyzed by descriptive statistics and then discussed in the light of the relevant literature.
The project which derives from this study was approved by the Research Ethics Committee (CEP/ HULW), and is registered under the Protocol CAEE No: 50217115.5.0000.5183.It is noteworthy that the research was conducted taking into account the ethical aspects of research involving human beings, according to Resolution no.466/12 of CNS/MS [12].Participants were instructed about the research objectives and signed the Free Consent and Informed Term (FCIT).

Profile of risk managers in the surveyed hospitals
Regarding the sociodemographic characteristics, was observed for the gender variable the total of 4 (50%) male participants and 4 (50%) female.About the professional category were identified that individuals responsible for risk management both in public hospitals and in private hospitals are the Occupational Safety Technicians 4 (50%) and nurses 4 (50%), and have an average of 35 years old.Regarding the variable time of professional experience, it was found that 3 (37.5%)have more than 5 years of experience in the surveyed units.
For characterization of the hospitals used as evaluation parameters the tools developed by the Medical Assistance Coordination of the Ministry of Health (Brazil, 2006), as shown in Table 1

Characterization of participating hospitals
In this part, is present an approach to characterize hospitals participating of the study, based on the hospitals classification variable, considering the legal nature of these, according to the Ministry of Health/National Council of Hospitals Classification [13].The hospitals surveyed are classified according to the number of beds as large (151-500 beds) and medium-sized (50-150 beds).(Figure 1)

Strategies used by hospitals institutions for patient and professional safety
The risk management strategies adopted in health institutions setting of this study, according to the risk managers.(Figure 2)

Positive and negative aspects of risk management
The positive aspects mentioned by the interviewees identified as a set of educational activities related to biosafety, highlighting the management of various risks, such as biological, physical, chemical and ergonomic, in the prevention of adverse events that include professional, patient and institution.
Regarding the negative aspects, the results revealed that there is a resistance of professionals to adherence to a safety culture, related to work overload, lack of knowledge about regulated standards in health safety, lack of human and material resources.

Discussion
About the characterization of the hospitals institutions, they were classified according to the National Health Council/Ministry of Health in public and private institutions.Public hospitals institutions are formed by organizations that are maintained with funds from the government.In Brazil, these organizations offer their services free of charge to all the population and has its operation governed by the Organic Law of Health.Private institutions are formed by companies that are the result of the entrepreneurial spirit of its shareholders and directors and are subject to various laws market [14].
In this study were considered aspects of epidemiological risk management with emphasis on detection of risk factors that affect patient safety in the surveyed institutions, the risk prevention actions taken by managers or responsible for control, reporting, monitoring and information risk and/or adverse event for decision-making.
Indeed in Figure 2, referring to strategies, that public hospitals empower professionals through refresher courses on risk management, addressing the importance of epidemiological surveillance, notification, monitoring and reporting of epidemiological data to network health system, arousing and moti-  vating professionals responsible for providing assistance to patient; while private hospitals are limited to offering information about default prevention security measures and the use of Personal Protective Equipment (PPE) such as safety strategies to the patient and professional in hospital scope.
Taking into account that the existence of biological, chemical, physical and ergonomic risks in hospitals institutions directly affect the patient and the health professional who performing the care procedures, it can be said that the lack of risk management as part of the continuing education process harms the development of actions, and, therefore, the reduction of technical and scientific capacity of health actions, minimizing their effectiveness and efficiency, resulting in increased operating costs and decreased ability to resolutions of health problems.
The lack of management programs in institutions fails to adopt broader and complete strategies to promote improved quality of care in hospitals, and to adopt a scope addressing sets of actions, which aimed at minimizing risk situations, prevention of adverse events and other health damage to the patients, professionals and to the institution image.
It should be noted that the risk in the healthcare area is considered a problem of significant proportions due to medical failures, as long the doctor was recognized as infallible and even devoid of basic human characteristics such as wrong, get tired, get angry and others, however this event has changed over the past two decades.Since then, public and private institutions have turned to the control, monitoring and preventing errors that occur in hospitals, in order to make them more suitable environments to their end, which is to promote health [15].
To minimize this problematic issue, monitoring were adopted, the investigation of professional errors and dissemination of patient safety concept.This should be the beginning of all risk management program in health services, whether public or private because it depends on the participation of all involved in health care in hospital institution [16,17].
Thus, this study showed that the adoption of security strategies to strengthen the health services is necessary, whether public or private, and research, reporting and analysis of events to assist in the planning of interventions based on regulatory standards health security -NR32, aiming the development of mechanisms that promote the improvement of the quality of care services.

Conclusion
The complexity of working risk management in the hospital, occurs for several reasons: the variety of professional experts in various fields of knowledge; difficulty inserting them in the management process (especially medical); resistance thereof to participate in training intra and/or extra-hospital; and the fact that most professionals are only abiding hours due to work overload due to various employments, even those not involved in this process.
The participation of professionals responsible for risk management in the surveyed hospitals was of fundamental importance to the achievement for the proposals objectives, as these professionals live with various occupational risk factors, which may eventually cause damage to their health and also interferes in the quality of care provided to patients, because care must be executed with quality without causing unnecessary harm to the individual.
The discrepancies observed in the assessment of risk management between public and private hospitals surveyed revealed that they are far from ideal, because only public hospitals A and B, and private G and H, have risk management program in place where It is observed in practice that the risk prevention measures do not cover the whole hospital.It is detected yet, that the quality tools that help in the risk assessment process, are little used and/or unknown for most of the subjects.
Was observed that public hospitals participating in this study have a risk management program under implementation, while private hospitals, have not yet deployed the culture of risk management.Therefore, no institution researched follows the risk management standards as a strategic security element.
It was possible to observe that hospitals use a model of empirical administration, and the professionals responsible for risk management is a technical, not a manager.In addition, the services do not have a Risk Management Manual, which include: definition and analysis of indicators, establishing measures for notification of adverse events, analysis of adverse event reports, issuing notified Adverse events related opinions, and the development preventive measures in the analysis of processes and of welfare risk prevention measures Strategic actions developed by the institutions researched are insufficient, there is a lack of a continuous effective action education to encourage interaction between professionals and patients in a more safe manner, with the adoption of standard action of risk prevention in the health facility.The lack of strategic actions of continuous education discourages and wearing out physically and emotionally health professionals, contributing to the emergence of adverse events among professionals that may reflect the patients.
Among the positive aspects identified, its emphasize the importance of dissemination of information in order to improve the health care and patient and professional safety.However, we find that there is need for more effective implementation of risk management, covering a greater number of professionals from health institutions studied, as well as the injection of funds and material resources for prevention, control and evaluation of more common hospital risk to provide a safer work day.
For the negative aspects which affect the implementation of risk management, found in this research the resistance of workers to safety culture, the lack of material resources and equipment needed to prevent potential risks and for implementation of risk management, limiting the use of PPE, not observing the standard rules for the adverse events and injury prevention, as recommended by the Ministry of Health and Ministry of Labor and Employment; the lack of knowledge about the importance of risk management essential to make care safer for health professionals, patients and hospitals institutions.
Faced with these challenges, it is recommended the implementation of continuous education actions focused on the epidemiological aspects on risk management in hospitals which do not develop this activity and the spread of the subject studied to improve the level of knowledge in the hospitals institutions among the professionals who serve both the public and private sector.

Figure 1 :
Figure 1: Characterization of the surveyed hospitals, according to the National Health Council/MS.Joao Pessoa-PB, Brazil, 2016.

Figure 2 :
Figure 2: Distribution of the strategies used by hospitals institutions for patient safety.João Pessoa-PB, Brazil, 2016.