CET Volume 86
DOI: 10.3303/CET2186046
Paper Received: 2 September 2020; Revised: 17 March 2021; Accepted: 20 April 2021
Please cite this article as: Heinzova R., Peterek K., Hoke E., 2021, Risk Management in Health Care Organizations in the Czech Republic,
Chemical Engineering Transactions, 86, 271-276 DOI:10.3303/CET2186046
CHEMICAL ENGINEERING TRANSACTIONS
VOL. 86, 2021
A publication of
The Italian Association
of Chemical Engineering
Online at www.cetjournal.it
Guest Editors: Sauro Pierucci, Jiří Jaromír Klemeš
Copyright © 2021, AIDIC Servizi S.r.l.
ISBN 978-88-95608-84-6; ISSN 2283-9216
Risk Management in Health Care Organizations in the
Czech Republic
Romana Heinzova*, Kamil Peterek, Eva Hoke
Tomas Bata University in Zlin, Faculty of Logistics and Crisis Management, Studentske nam. 1532, 686 01 Uherske
Hradiste, Czech republic
rheinzova@utb.cz
Risk management in healthcare facilities focuses on processes whose performance is specifically defined in
standards and guidelines that the organization creates according to its needs. The aim is to set up uniform
procedures in the organization for staff providing care to patients and define other indirectly related processes
to the direct provision of health care. The article focuses on summarizing the results of research in the field of
risk management in health care facilities in the Czech Republic. A research team was researched in May -
July 2020. This research responded to the then ongoing pandemic COVID-19. The paper aims to map and
summarize knowledge from risk management and crisis preparedness of medical facilities across the Czech
Republic.
1. Introduction
With the development of technology and global globalization, risk management systems are also developing in
all areas of human activity. Gradually, there is a shift in risk management from the mere implementation of
legislation in specific areas such as safety and health at work or fire protection to complex systems providing
risk analysis and management. Similar to other high-risk systems, the complexity of healthcare systems
generates errors and adverse events if not controlled properly. (Ortiz-Barrios et al., 2018) Unlike industry, risk
management in healthcare does not have a long tradition, but it has now become one of the essential
components of modern management in this area. Historically, healthcare risk management has focused
primarily on two areas: patient safety and loss prevention. (Kuhn and Youngberg, 2002) Nowadays there is a
consensus in the healthcare sectors that the knowledge, experience, and expertise of other industries in Risk
Management can improve the quality of services provided in the healthcare sectors. (Cagliano et al., 2015;
Ferdosi et al., 2018) Processes in a medical facility follow a pre-prepared plan with a wide range of reasons to
consider (human nature, atmosphere often full of emotions and stress, the complexity of modern diagnostic
and therapeutic technologies, the variability of human biology, lack of funds and human resources, obsolete
functional management, spontaneously developing organizational culture, unstable political and economic
background).
Risk management in healthcare is associated primarily with patient safety, which is a global issue. Despite
significant advances, patient safety remains a critical public health concern. (Franklin et al., 2020). Demand
for healthcare is significantly higher than the human capacity and resources available in healthcare
departments (Alhassan et al., 2015). Corresponding to these limits, three interventional approaches have
been developed at various levels of the healthcare organizations: (i) quality management, (ii) risk
management, and (iii) patient safety (Franca, 2008; Ferdosi 2018). Risk management programs and patient
safety improvement has gained significant importance in ICUs (Intensive Care Units) where invasive
diagnostic and therapeutic services are provided for patients with complicated illnesses (Askari et al., 2017).
In general, risk management is a process that prevents the action of already existing or future negative factors
and suggests possible solutions suitable for eliminating the effect of adverse effects. Gladkij and colleagues
described risk management as a systematic process of identifying, evaluating, and performing activities to
prevent or manage clinical, administrative, proprietary, and employee security risks in an organization.
(Gladkij, 2003) Risk management is one of the most relevant aspects of clinical governance and approaches
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put forward in literature highlight the necessity to perform comprehensive analyses intended to uncover root
causes of adverse events. (Cagliano et al., 2011). Levett et al., 2017 state that in particular, risk management
is a process-oriented method providing a structured framework for identifying, assessing, and reducing risk at
appropriate times for healthcare organizations. According to Cagliano et al. 2011 Risk management has been
adopted to cover all healthcare risks, both clinical and non-clinical. It includes the processes concerned with
risk management planning, identification, analysis, response, monitoring, and control.
In the Czech Republic, risk management is enshrined in legislation in Act No. 262/2006 Coll., The Labor
Code, and special decrees of the Ministry of Health. For example, these decrees regulate the conditions for
the prevention of the occurrence and spread of infectious diseases and hygienic requirements for healthcare
facilities' operation. Risk management in health care is based on a well-established quality management
system in the health care facility. In April 2005, the so-called Luxembourg Declaration on Patient Safety was
adopted at the European Union (EU) Summit. The recommendation to implement processes in the field of risk
management in healthcare by creating algorithms and quality indicators within the system of external quality
assessment in healthcare (European Commission, 2020) is given here. It can be stated that quality
management in health care facilities focuses on processes that are characterized by unacceptable variability,
then risk management is focused on the area of processes with unacceptable risks. Risk management
principles are most often implemented by those healthcare facilities that already have a program of continuous
quality improvement. Thus, there is a symbiotic, not a competitive relationship between quality management
and risk management (Škrla and Škrlová, 2008). Many authors state that risk management in healthcare
facilities can be part of a continuous quality improvement program. Quality in a healthcare context means
professionals are continuously improving the patients’ care systematically and qualitatively. (Eriksson, 2017)
They are required to participate actively when efficiency and quality methods are introduced in their regular
work practices. (Brennan and Flynn, 2017) The founder of the Health Care Quality Study, Avedis Donabedian,
described the quality of health care as the care in which the maximum benefit to the patient's health can be
expected and when the benefit obtained is higher compared to the cost at all stages of the treatment process.
(Donabedian, 1966) Hospitals are under increasing scrutiny to improve their performance. This does not only
include the performance in terms of efficiency, but also, and increasingly, the performance in terms of quality
and patient outcomes (Saltman et al., 2011). The implementation of Quality Management Systems is
considered one of the main mechanisms to realize. (Groene et al., 2013)
The Joint Commission sets global standards for quality and safety of care on Accreditation of Healthcare
Organizations. One of this organization's priorities is safer care and risk control, which has been fully taken
over by the Joint Accreditation Commission of the Czech Republic. In 2010, a new standard ISO 31000: 2009
(ČSN ISO 31000: 2010) was issued in the Czech Republic, which sets out general principles and guidelines
for risk management. This International Standard is not intended for certification purposes. The standard
provides principles and guidelines for risk management. The standard is not specific to any industry or sector
and can be used by different organizations. Within healthcare organizations, the standard sets out
requirements for quality and safety standards, diagnostic care standards, patient care standards, healthcare
continuity standards, and patient rights rules. (Šamaj, 2016) Medical facilities in the Czech Republic are
exposed to several factors that threaten the safety of medical and nursing care - overloading of medical staff,
poorly designed and managed processes, lack of financial and other resources, and, last but not least,
questioning or downplaying existing problems and risks by medical staff and the media. The medical facility is,
therefore, a considerable incubator supporting the existence and growth of risks. This fact is gaining in
importance in the current situation when the whole world is affected by a coronavirus pandemic, and the
Czech Republic is one of the countries with a high incidence. The management of these new risks implies the
need to redefine requirements for daily practice using safety criteria and measures and contingency plans.
(Alaluf et. al., 2020). The aim of the paper is to map and summarize the findings of risk management and
crisis preparedness of health care facilities throughout the Czech Republic.
2. Methodology
The literature search was prepared based on the study of domestic and foreign professional literature and the
basic terms related to the issue are defined, and the current state of Risk management in healthcare facilities
is analyzed and evaluated. A questionnaire survey was used to collect information in health care
organizations, which was carried out in March and April 2020. The Survio service was used for the research.
Survio is a tool for creating online questionnaires. The questionnaire was sent online to managers at 45
Health-care organizations in the Czech Republic. The authors received back 34 questionnaires. The
questionnaires that were sent back were completely filled out. Statistical evaluation and data processing were
therefore based on a sample of 34 health organizations.
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The rate of return therefore reaches 75%. Because the questionnaires were sent at the time of the outbreak of
the Covid-19 pandemic, the authors rate this return as very good.
3. Results
Based on a survey two kinds of research questions were analyzed. The questions were verified by the
statistical dependence of individual answers with respect to the size of the medical service. However, a
representative sample for each type of equipment was not obtained. At the same time, the samples in the
individual size categories also could not be marked as sufficient. Therefore, it was decided to categorize the
responses according to the number of hospitalizations per year and to consider this classification as a size
categorization. The first set of research questions is focused on examining the existence of interdependence
between the size of the organization and the implemented Risk Management tools (A-G).
The research questions were defined as:
A. Whether the size of the medical service affects the using (holding) a JCT certificate,
B. Whether the size of the medical service affects the management according to ISO 31000,
C. Whether the size of the medical service affects the established program to increase the quality of
services provided,
D. Whether the size of the medical service affects the quantity and the level of sophistication of applied
methods used in risk management (FMEA, FTA, etc.),
E. Whether the size of the medical service affects the existence of the risk catalog,
F. Whether the size of the medical service affects the setting the authorized department or authorized
individuals in crisis management,
G. Whether the size of the medical service affects the regularly training of employees in risk.
The occurrence of individual answers from the survey were evaluated according to the contingency tables.
These tables were used to summarize the relationship between the variables. A chi-square test can be
conducted on these contingency tables to test whether or not a relationship exists between variables. The
Cramer's coefficient was used to measure the strength of relationship between variables. It could take values
from 0 to 1. Values close to 0 indicate a weak association and values close to 1 indicate a strong association
between the variables. The Cramer's coefficient was used only in cases where the dependence in the
relationship between the variables was found. Due to the page limitation of this paper, only the results of
hypothesis testing are presented in the Table 1.
Table 1: Results of chi-square testing of research questions (A.-G.)
Research question
identifier is
Chi-square statistic is Critical value is p-value is Was the relation between
variables significant?
A. 0.534 5.991 .766 NOT significant at p < .05
B. 1.177 5.991 .555 NOT significant at p < .05
C. 2.072 5.991 .355 NOT significant at p < .05
D 6.885 5.991 .032 significant at p < .05
E. 2.872 5.991 .238 NOT significant at p < .05
F 0.116 5.991 .944 NOT significant at p < .05
G 1.445 5.991 .486 NOT significant at p < .05
Table 1 shows the results of statistical data processing. There were no statistical dependencies in relation to
the monitored phenomena and the size of the medical services in research questions A, B, C, E, F and G. The
only identified statistical dependence can be observed in the quantity and the level of sophistication of applied
methods which are used in risk management of the medical service (research question D.). The frequency of
individual responses is given in Figure 1.
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In addition to the issues mentioned above, dependencies related to risk management in general (without
categorization by size) were also identified. Specifically, it was interesting to find whether the institution has
the authorized department or authorized individuals in crisis management. And if so, what is the role and
position of this element in the crisis management of the institution. The second set of research questions deals
with this dependence (I-H).
It is very difficult to clearly quantify such considerations. For the analysis purpose, the relationship to other
employees (management and training) and to the quality of institution's crisis management (existence of a risk
catalog of the institution) determined. Then the research questions were defined as:
H. Whether the authorized department (or individuals) affects the regular training of employees in the
field of risks,
I. Whether the authorized department (or individuals) affects the existence of the risk catalog.
Table 2: Results of chi-square testing of research questions (H. and I.)
Research
question
identifier is
Chi-square statistic is Critical value is p-value is Was the relation
between variables
significant?
I. 11.000 3.841 .0009 significant at p <
.05
H. 9.977 3.841 .0016 significant at p <
.05
The frequency of individual responses is also shown in Table 3. This table was used for statistical processing
and verification of statistical dependencies.
Table 3: Number of the answers and their distribution in research questions (H. and I.)
Authorized department or
individuals in crisis
management?
Regular training of employees in the field of
risks?
Existence of the risk
catalog?
Yes No Yes No
Yes 17 4 20 2
No 6 5 4 7
There is only one research question (D) showing statistical dependence in the first group of research
questions. In this research question, a chi-square test of independence was performed to examine the relation
between size of medical service and the quantity and sophistication of the choice of methods used in risk
management. The relation between these variables was significant. The null hypothesis can be rejected and it
can be concluded that the larger the medical service (the greater the number of hospitalized) is, the more
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sophistication methods of risk management in medical service are used. The Cramer's coefficient is .464 and
that means mean dependence between variables. The remaining research questions do not show statistical
dependencies and the relations between these variables were not significant.
The last two research questions (H. and I.) showing statistical dependence. The null hypothesis could be
rejected and it could be concluded that the authorized department (or individuals) of the medical service
positively affects the regular training of employees in the field of risk. The same relation could be expected
regarding with the existence of the risk catalog. It means if there is the authorized department (or individuals)
of risk management there will be the risk catalog in the medical service. This trivial statement only supports
the need for professionally oriented individuals in the field of crisis management. The questionnaire shows that
only a third of the addressed institutions have a crisis manager. The Cramer's coefficients of the research
question H. and I. are .577 and .504., thus mean dependence between variables was found.
4. Conclusions
Risk management is one of the essential elements of modern management in healthcare. We consider
healthcare to be risky because it provides a service that brings a range of risks that appear in healthcare
facilities. A clear relationship between risk management and quality management is given in several
professional literature and contributions. Risk management in healthcare is a tool for quality control and deals
with the constant consideration of the possibility of adverse situations and their prevention. Risk management
is one of the essential components of continuous quality improvement and, in a broader context, part of
managed care. In healthcare facilities, compliance with all applicable standards, monitoring, evaluation, and
systemic measures to prevent all errors and non-conformities are paramount in the risk management system.
The paper was created based on research in March and April 2020. Medical facilities in the Czech Republic
were sent using a structured questionnaire survey. This research aimed to summarize the knowledge in risk
management and quality used in these facilities. The first of the research questions were focused on how the
size of the medical facility affects the use of particular methods of risk and quality management. Here,
statistical methods have shown that the larger the medical facility, the more sophisticated the risk
management methods it uses. The second question related to the existence or non-existence of a risk
management department in the facility. Because the source of healthcare risks is often the human factor, we
were interested in whether staff training on this issue is implemented. The statistical analysis showed that if a
risk management department is established, it positively affects employees' training on safety and risk issues.
Currently, benchmarking is underway at the level of regional hospitals. One of the comparative criteria is the
parameters in the area of risk management and quality. The authors assume that they will receive the results
of this process and will be able to use them for professional publication.
Acknowledgments
This research was supported by the project RVO/FLKŘ/2020/02 (Risk Management in Healthcare Facilities).
References
Alaluf M.G., Pasqualini A., Fiszbajn G., Botti G., Estofan G., Ruhlmann C., Solari L., Bisioli C., Pene A.,
Branzini C., Retamar Quintero A., Checkverdemian V., Pesce R., Serpa I., Lorenzo F., Avendano C., Sedo
C. A., Lancuba S., 2020, COVID-19 risk assessment and safety management operational guidelines for
IVF center reopening, Journal of Assisted Reproduction and Genetics, 37, 2669–2686.
Alhassan R.K., Nketiah-amponsah E., Spieker N., Arhinful D.K., Ogink A., Van Ostenberg P., Rinke de Witt
T.F., 2015, Effect of community engagement interventions on patient safety and risk reduction efforts in
primary health facilities: evidence from Ghana, PLoS One, 10(11), 1–20.
doi:10.1371/journal.pone.0142389
Askari R., Shafii M., Rafiei S., Abolhassani M.S., Salarikhah E., 2017, Failure mode and effect analysis:
improving intensive care unit risk management processes, Int J Health Care Qual Assur, 30(3), 208-215.
Brennan N.M., Flynn M.A., 2013, Differentiating clinical governance, clinical management and clinical practice.
Clinical Governance, An International Journal, Vol 18, 114-131.
Cagliano A.C., Grimaldi S., Rafele C., 2011, A systemic methodology for risk management in healthcare
sector, Saf Sci, 49(5), 695–708. doi:10.1016/j.ssci.2011.01.006
Cagliano A.C., Grimaldi S., Rafele C., 2015, Choosing project risk management techniques: A theoretical
framework, J Risk, 18 (2), 232–248. doi:10.1080/13669877.2014.896398
Donabedian A., 1966, Evaluating the quality of medical care, Milbank Memorial Fund Quarterly.
275
Danzi, E., Fiorentini, L., Marmo, L., 2017, A parametric fire risk assessment method supporting performance
based approaches – Application to health-care facilities in northern Italy, Chemical Engineering
Transactions, 57, 301 – 306.
Eriksson N., 2017, Hospital management from a high reliability organizational change perspective: A Swedish
case on Lean and Six Sigma, A International Journal of Public sector Management, Vol 30, 67-84.
European Commission, Patient safety: Luxembourg Declaration on Patient Safety, European commision,
[online]. accessed 25.11.2020.
Ferdosi M, Rezayatmand R, Molavi Taleghani Y., 2018, Risk Management in Executive Levels of Healthcare
Organizations: Insights from a Scoping Review, Risk Management and Healthcare Policy, 215 – 243.
Franca M., 2008, Quality, risk management and patient safety: the challenge of effective integration, World
Hosp Health, 44(4), 21.
Franklin B. J., Gandhi T.K., Bates D.W., Huancahuari N.,Morris C.A., Pearson M., Bass M.B., Goralnik E.,
2020, Impact of multidisciplinary team huddles on patient safety: a systematic review and proposed
taxonomy, BMJ QUALITY & SAFETY, 29 (10), 844-853.
Gladkij I., at al., 2003, Management in healthcare, Computer Press, Brno, Czech Republic. ISBN 80-7226-
996-8 xii, 380 s.
Groene O., Botje D., Suñol R., Lopez M.A., Wagner C., 2013, A systematic review of instruments that assess
the implementation of hospital quality management systems, Int J Qual Health Care, 25(5), 525–541.
Kuhn A.M., Youngberg B.J., 2002, The need for risk management to evolve to assure a culture of safety,
Qual Saf Healthc, 11(2), 158 – 162.
Levett J.M., Fasone J.M., Smith A.L., Labovitz S.S., Labovitz J., Melott S., Dotan D.B., 2017, Enterprise Risk
Management in Healthcare, Surgical Patient Care, 67–86.
Ortiz-Barrios M., Herrera-Fontalvo Z., Rúa-Muñoz J., OjedaGutiérrez S., De Felice F., Petrillo A., 2018, An
integrated approach to evaluate the risk of adverse events in hospital sector: from theory to practice,
Manag Decis, 56(10), 2187-2224.
Saltman R.B., Durán A., Dubois H.F.W., 2011, Governing Public Hospitals: Reform strategies and the
movement towards institutional autonomy, World Health Organization, on behalf of the European
Observatory on Health Systems and Policies.
Šamaj M., 2016, Crisis management in healthcare, Risk management. Univerzita Palackého v Olomouci,
Olomouc, Czech Republic. ISBN 978-80-244-5086-5.
Škrla P., Škrlová M., 2008, Risk management in healthcare facilities, Grada, Praha, Czech Republic. ISBN
978-80-247-2616-8.
276