Volume 8, Issue 4, April – 2023 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

The Idea of Applying the “Broken Windows Theory”

as Quality Tool to Improve Risk
Management Strategies
1
Nouran Sameh Alsafty
Benha Faculty of Medicine

Abstract:-  Overview of Broken Window Theory:

The broken window theory has now been identified as
 Background: a key factor in how risk management failure can occur in
Broken windows theory (BWT) proposes that hospitals, specifically in the medical field. This is due in
visible signs of crime and disorder, however they are part to the chaotic atmosphere of hospitals and the low
minor can lead to further levels of crime and disorders tolerance for visible errors in the medical field, which can be
and the concept here is to manage and overcome the indicative of poor performance and care. Hospitals and
minor disorder means we save the whole system from the healthcare organizations are often left in a state of disrepair,
dangerous disasters. where staff and patients are accustomed to substandard
services and outcomes, and where a culture of silence is
 Methods: instilled to downplay or cover up significant problems [1].
The study methodology consisted of a literature BWT advocates have therefore argued that by addressing
review in Google scholar and the PUBMed. the Google disrepair and other signs of disorder, a shift in the culture of
scholar search found 10 related papers. PUBMed tolerant behavior and decline of acceptable standards may
database search found 16 related papers. be achieved, allowing an organization to put patient safety
first and make improvements that will ultimately enhance
 Results: the quality of care.[2]
This Review focuses on the Concept of BWT
application in Advancing Risk management in  The Relationship Between BWT and Risk Management in
healthcare system. Hospitals:
Broken windows theory (BWT) proposes that visible
 Conclusion: signs of crime and disorder, however they are minor can
We advance a model of BWT in healthcare system lead to further levels of crime and disorders and the concept
and a proposal of application of this Phenomenon. here is to manage and overcome the minor disorder means
we save the whole system from the dangerous disasters, So
Keywords: Broken Window Theory, Risk Management the BWT can be a powerful tool for risk management. The
Activities, Strategies for Healthcare Risk management, theory suggests that the number of quality issues increases
Benefits of the BWT Application and Hospitals when not enough attention is paid to minor issues. For
Organization. example, an uncorrected broken window in a building is
usually followed by windows breaking more frequently [3].
I. INTRODUCTION BWT was first introduced as a Quality Management Tool in
1980. Since then, it has been used extensively to analyze
The broken window theory (BWT) is an idea proposed risk management strategies. The concept of the theory has
by criminologists James Q. Wilson and George Kelling in also been used in healthcare facilities such as hospitals.it has
1982, which argues that when people are presented with been used as a quality tool within health care systems,
physical signs of disorder, crime and other forms of anti- specifically the Hospital Care system [4]. The problem with
social behavior are more likely to occur. The BWT states the healthcare system is that there are some doctors and
that allowing small windows of opportunity, such as a nurses who get away with dangerous behavior because they
broken window or sign of disrepair, signals to potential think no one is watching. This paper introduces the broken
criminals that no one cares, and as a result they will be less windows theory as a tool for understanding the problem, to
inhibited to carry out criminal acts. In recent years, the make hospitals safer, staff need to be encouraged to speak
BWT has been increasingly used in healthcare settings to up when they notice a situation where they believe their
attempt to reduce risk, improve patient safety, lower costs, colleagues may be deviating from hospital policy or
and increase nurse satisfaction. The goal of this research practice. And the hospital should put strategies for Risk
paper is to analyze how BWT can be strategically Management and Quality all the staff members to deal with
implemented in hospitals to improve the risk management of them [5]. Healthcare environments are not much different
patients. from any other places or organization, like schools, banks,
and jails. Creating a safe environment to function can be

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Volume 8, Issue 4, April – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
achieved through education, screening, and counseling. The improvement of healthcare system. Taking into
“Broken Windows Theory” is an evidence-based theory that consideration that most hospital-acquired surgical errors are
is used to reduce crime in areas where the broken windows from objectively preventable (human factor) causes, this
work. It could be applied easily in healthcare to reduce the could help to be a determining factor, in which baseline
number of incidents that occur inside the hospital [6]. BWT values will be compared and measured. [8]
has been applied to the hospital context for many years and
is supported by much empirical research. It provides a clear  Risk Management on the way of BWT:
framework for behavior that has a negative impact on Risk management, defined as the systematic process of
others, yet this behavior goes undetected. In health care, it is identifying, evaluating, and addressing potential and actual
argued that due to time pressures and staff shortages BWT risk, is proactive in nature and is meant to protect
will continue its prevalence because it is seen to be a low- organizational assets and minimize financial loss. Managing
cost solution that increases staff control at the same time it risk involves taking action to reduce the frequency and
reduces patient safety issues. This paper looks at risk severity of unexpected incidents and promote high reliability
management strategies in health care. It argues that because performance and system design.[9]
of limited resources there needs to be greater consideration
of disorder as an intervention opportunity for safety Risk management activities were inducted into the
improvement, particularly with regards to patients who are health care system in response to the growing national
vulnerable and/or injured [7]. Most healthcare organizations malpractice insurance costs. As of the 1970’s, the risk
have adopted the patient-centered approach in care. With the management function was essentially comprised of Quality
limited resources, health care organizations must consider Assurance nurses performing incident report and trending in
nursing stations as a safety improvement opportunity to acute care hospitals, but there was little to no proactive
minimize the risk factors and reduce patient's vulnerability. prevention of control activities [10]. Risk management
BWT provides a clear framework for behavior that has a should be common practice throughout an organization, and
negative impact on others, yet this behavior goes it is recommended that each employee and volunteer be
undetected. In health care, it is argued that due to time charged with risk management. A person appointed as Risk
pressures and staff shortages BWT will continue its Manager should be responsible for integrating all
prevalence because it is seen to be a low-cost solution that components of the program. In hospitals, this is typically the
increases staff control.at the same time it reduces patient Risk Manager, in inpatient settings, it could be Quality
safety issues. Medical mistakes can be life-or-death events. Manager, and in outpatient settings, it is frequently the Head
They are potentially devastating, so they are serious Nurse or Office Manager [11]. As such, proactive risk
problems that need to be eliminated. Now imagine if management activities have been integrated into the health
medical professionals could implement their daily work care system over the last several decades to lower the
more efficiently and safely? To achieve this goal, a new prevalence of malpractice. The practical application of the
model is necessary. BWT delivers solutions to fix, prevent, BWT has proven to be effective in reducing costs and
and enhance patient safety in health care settings. If the enhancing the quality of health care by preemptively
window is broken and left uncovered, it can lead to further addressing and correcting minor issues.[12]
Risks, fixing up our windows today will offer a long-term

Table 1 The Fruitful Elements of Risk Management Based on BWT Concept

Which involves identifying and evaluating the potential risks associated with a particular environment or
situation. In the context of hospitals, risk assessment can involve identifying and assessing the physical
environment within the hospital, including items such as broken windows, disrepair, and general physical
Risk assessment neglect. It has been argued that neglect of physical maintenance and the presence of physical disrepair can
lead directly to an increase in the rates of medical errors and other negative outcomes. Thus, the presence of
physical disrepair can be seen as a risk factor that must be addressed.[13]
Which involves taking steps to lessen the severity or frequency of specific risks. In the context of hospitals,
one of the key strategies for effective risk management is to minimize the effects of broken windows and
other forms of physical disrepair, as this can reduce the risk of medical errors and other negative outcomes.
This can be achieved by implementing regular maintenance schedules and developing protocols and
procedures to address any signs of deterioration in the physical environment. For example, if a broken
Risk reduction window is discovered, it should be repaired in a timely manner to prevent further damage. Similarly,
regularly scheduled maintenance of hospital equipment can help to identify signs of disrepair and ensure
that any necessary repairs are completed before they become a significant problem.[14]
Developing and enforcing clear Health Care policies can show that the management has a zero-tolerance
Developing Clear approach to any unacceptable behavior. By clearly setting out expectations for staff and patients, health care
Policies: organizations are not just showing their commitment to providing quality care, but also their commitment to
keeping a well-managed, professional environment.[15]

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Create a Culture A professional organization must cultivate an organizational culture of accountability. Health care providers
of should be proactive in setting standards and expectations to help prevent any behavior that could lead to a
Accountability: broken window. This can manifest in appraisals, feedback, or evaluations of team members at all levels in
the organization. Acknowledging that any kind of misbehavior will not be tolerated can help ensure that
everyone is held to the same high standard. [16]

 Main Steps in the Clinical Risk Management Process:

These needs Planned strategies applied with the help of Most of Hospital departments.

 Risk Management Committee will have Representatives from the following Departments:
 Quality Assurance
 Blood Bank
 Medical Audit
 Infection Control
 Safety and Security
 Accreditation
 Education
 Physicians
 Nurses
 Legal Counsel
 Tissue Committee
 Professional Liability Committee
 Professional Practices Committee
 Utilization Review Committee

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Volume 8, Issue 4, April – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
 Strategies for Advancing the Risk Management:
First, good applicable strategies mean good training and Awareness with Strick compliance of the whole staff to these
Strategies, and this is Done By applying the Step-By-step process. [17] [fig 2]

 Step-By-Step Process:
If a health care organization implements a proactive risk management strategy today, it could use a simple seven-step
process like this one: In view of the rapid changes in all facets of the health care industry, there is a need to continually strengthen
both monitoring and evaluation of the risk management program.[18]

Fig 2 Step-By-Step Process

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ISSN No:-2456-2165

Fig 3 Risk Management Program

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 Healthcare Organization Role for Maintenance:  Eligibility Criteria:
The health care organization must ensure adequate Case reports were excluded due to lack of outcome
supervision of the clinical practice of each of its data. clinical and non-clinical Minor errors that developed
professionals. This process is frequently included in the into major disastrious uncontrolled Risks due to Ignorance
organization’s credentialing and peer review programs. of minor Errors have been reported in more than 5 hospitals
Health care organizations must develop and implement , so our study targets this problem by Solutions depending
competency-based performance parameters for each on the concept of BWT and we focused on How to apply it
professional category. The scope of competencies required for advancement of Risk Management in our hospital this
should be in accordance with the regulatory requirements of Survay done from four major hospitals.
each professional group.]25]
 Information Sources:
 Results of Application of BWT in Risk Management of Studies were identified by searching electronic data-
Healthcare System: bases PubMed, Google Scholar, the Cochrane database was
The application of the BWT in risk management of the reviewed, the last search was conducted in 2022.
healthcare system has several benefits:
 Search:
 It provides a detailed view of risk in the healthcare For searching the electronic databases, the following
system, allowing for comprehensive risk management. search term were used: Broken Window Theory, Risk
 Marked Risk Reduction. management Activities, Strategies for healthcare Risk
 Reduce the risk of medical errors and other negative management.
outcomes.
 Improving quality of care provided by physicians.  Study Selection:
 Marked Elimination of needlessly dangerous procedures. First, titles and abstracts were screened for eligibility
 Leads to Brilliant Healthcare System with Successful criteria, then full text availability were checked. Eligibility
rate. was assessed second time based on full texts article if
abstracts were not enough. The search on PubMed provided
II. METHODS 16 article, 10more articles were found on Google Scholar
search and 3 systematic reviews from Cochrane library. A
 Protocol and Registration: sum of 29 articles were identified, through screening based
This review of current studies, dealing with risk on titles and abstracts, 12 articles were excluded because
management strategies according to broken window theory, they didn't meet eligibility criteria. Out of the remaining
was written according to PRISMA statement for reporting 17articles, 4 articles were excluded because full texts were
systematic reviews. not available, 3 articles turned out to be case reports and 2
article didn't contain the appropriate outcome data. [Fig 4]

Fig 4 Flow Chart for the Study Selection

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ISSN No:-2456-2165
III. SUGGESTIONS AND [3]. Ren, L., Zhao, J. S., & He, N. P. (2019). Broken
RECOMMENDATIONS windows theory and citizen engagement in crime
prevention. Justice quarterly, 36(1), 1-30.
 Action in Benha University Hospital: [4]. Ozturk, O. G., Daglioglu, G., & Inal, T. C. (2022).
This can be achieved through specific actions and Idea of Applying “Broken Windows Theory” to
behaviors that embody a commitment to safety: Clinical Laboratories as a Quality Tool to Increase
the Success of Proactive Risk Management
 Provide safety education to front-line staff, managers, Strategies. Journal of Patient Safety, 18(4), e722-
and physicians that includes team training and education e726.
in communication techniques. [5]. Farokhzadian, J., Nayeri, N. D., & Borhani, F.
 Advocate safety as everyone’s responsibility and (2015). Assessment of clinical risk management
incorporate a safety culture initiative into the overall system in hospitals: an approach for quality
organizational patient safety plan; ensure that patient improvement. Global journal of health science, 7(5),
safety initiatives, action plans, and results, as well as 294.
interventions to improve safety, are periodically reported [6]. Li, Jian, et al. "Safety system review in healthcare
to the board of directors. environments: a comprehensive, human reliability-
 Empower staff to identify and ameliorate hazards and based strategy." Safety Science (2019): 198-212.
risks by allocating adequate safety resources and [7]. Perlas, R., & Khanna, P. (2020). Application of the
establishing a non-punitive system for reporting errors Broken Window Theory to patient safety and health
and events. care. BMC Health Services Research, 20(1), 67.
 Implement a reward-based reporting system and ensure [8]. Guo, M. (2019). Window, Window, Who’s There? A
timely feedback to staff on how reports are used to Study on the Impact of Windows in Health Care
improve patient safety. Settings. International Journal of Environmental
 Healthcare leaders and researchers should develop a Research and Public Health, 16(14), 2683.
“code of safe health settings and practices” to keep [9]. Zhang, K. Q., Du, T., & Wang, X. M. (2016). Risk
health practices much safer and up to the required management in organizations: Concepts and
standards. guidance. Boca Raton, FL: CRC Press.
 Healthcare organizations should conduct conferences, [10]. Shaffer, R. M. (2021). Environmental health risk
seminars, and discussions about how to initiate and assessment in the federal government: A visual
maintain safety culture among all working teams while overview and a renewed call for coordination.
providing patient care. Environmental science & technology, 55(16), 10923-
10927.
IV. CONCLUSION [11]. Prop, U.S. (2020). Global Risk Management in
Hospitals and Healthcare.
In conclusion, the ‘Broken Window’ theory has [12]. Robson, M. (2017). Clinical Risk Management in
potential applications in the healthcare sector, and Health Care: Centralising Risk in the Name of
healthcare professionals should consider the implications of Quality Improvement. Journal of Health Services
the theory in terms of risk management and patient safety. Research & Policy, 22(1), 96–101.
By ensuring that all staff are correctly trained and [13]. Haugen, A. S., Sevdalis, N., & Søfteland, E. (2019).
supervised, and by creating a culture of safety and Impact of the World Health Organization surgical
accountability, healthcare organizations will be better placed safety checklist on patient safety. Anesthesiology,
to minimize the risk of medical negligence and errors. The 131(2), 420-425.
practical application of the BWT has proven to be effective [14]. Kannampallil, T. G., Osei-Bonsu, E., & Numer, M.
in reducing costs and enhancing the quality of health care by (2018). Risk management and maintenance
preemptively addressing and correcting minor issues. methodologies: Factors that influence the repair of
broken windows in healthcare facilities. International
REFERENCES Journal of Interior Architecture and Spatial Design,
12(1), 21–30.
[1]. Kyle, M.; Aveling, E.-L.; Singer, S.-J. Establishing [15]. Liebert, S., & Ameringer, C. F. (2013). The health
High-Performing Teams: Lessons from Health Care. care safety net and the Affordable Care Act:
MIT Sloan Manag. Rev. 3. Kyle, M.; Aveling, E.-L.; Implications for Hispanic immigrants. Public
Singer, S.-J. Establishing High-Performing Teams: Administration Review, 73(6), 810-820.
Lessons from Health Care. MIT Sloan Manag. [16]. Byrnes, R. (2018, January 4). 3 Steps for Creating a
Rev.2020, 61, 14–18. 2020, 61, 14–18. Culture of Accountability. HR Bartender. Retrieved
[2]. Konkel, R. H., Ratkowski, D., & Tapp, S. N. (2019). from https://www.hrbartender.com/2018/leadership/
The effects of physical, social, and housing disorder creating-culture-accountability/
on neighborhood crime: A contemporary test of [17]. Cook, S. (2019). Managing Effective Change.
broken windows theory. ISPRS International Journal Oxford University Press.
of Geo-Information, 8(12), 583.

IJISRT23APR017 www.ijisrt.com 394

Volume 8, Issue 4, April – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
[18]. Archer, S., Hull, L., Soukup, T., Mayer, E.,
Athanasiou, T., Sevdalis, N., & Darzi, A. (2017).
Development of a theoretical framework of factors
affecting patient safety incident reporting: A
theoretical review of the literature. BMJ Open, 7(12),
e017155.
[19]. Blegen, M.A., Goode, C.J., Park, S.-H., Vaughn, T.,
& Spetz, J. (2010). Strengthening the organizational
infrastructure for continuing education in hospitals.
JONA: The Journal of Nursing Administration,
40(7/8), 350-356.
[20]. Booth, A., & Walker, E. (2009). Experiential
Learning in Health and Social Care: Theory, Practice
and Perspectives. New York, NY: Routledge.
[21]. Leone, C. (2009). Accident prevention in the
workplace. London, UK: Taylor & Francis.
[22]. Oster, L. (2017). Using quality assurance to improve
healthcare. Philadelphia, PA: American College of
Healthcare Executives.
[23]. Walshe, K., Smith, J., & Baldwin, L. (2009). An
Introduction to Quality in Healthcare. London, UK:
Oxford University Press.
[24]. Yilmaz, S.K. (2010). Strategies for improvement of
quality of care in hospitals. International Journal of
Health Care Quality Assurance, 23(7), 664-679.
[25]. Mattke, S., Huang, E. S., & Bazzoli, G. (2012). The
role of healthcare organizations in maintaining
quality: A systematic review. Journal of the
American Medical Informatics Association, 19(3),
445-451.

IJISRT23APR017 www.ijisrt.com 395