BÒrd SSN nan Eilean Siar
Western Isles NHS Board
Corporate Risk RegisterNovember2014
The Corporate Risk Register reflects those risks that are of significance to the whole organisation in terms of:
- Clinical Risk
- Financial and Organisational Risk
- Population Health
- Physical Risks
- Human Resources
Corporate Objectives 2013-2016
CO1 To provide person-centred care, focusing on the evidence based health needs of our population, identifying and taking every opportunity to improve our patients’ health and experience.
CO2To protect individuals from avoidable harm by continually learning, and improving the reliability and safety in everything we do.
CO3To pro-actively stimulate and intensify our search and application of effective innovation to improve how we care for patients today and in the future.
CO4To promote and support people to live longer healthier lives.
CO5To specifically target early years, health inequalities, vulnerable and hard to reach groups.
CO6To continually improve and modernise our integrated healthcare services and assurance systems.
CO7To support, develop and sustain a compassionate, confident, competent, flexible and responsive workforce.
CO8To deliver our commitment to partnership working to deliver national standards, targets and guarantees.
CO9To have a sustained focus on prevention, anticipation and support self-management.
This paper outlines the monthly review and update of the Corporate Risk Register detailing its highest risks, those with a score of greater than12, currently on the register.
The following changes have been made:
Risk(s) Added – There have been 3 risks added
- Out of Hours Service Lewis and Harris
- Out of Hours Service Uist
- Out of Hours Service Paediatric Cover
Risk(s) Removed - There have been no risks removed.
Risk(s) Changed–There have been no risks changed.
The Corporate Management Team is asked to:-
- Review the Corporate Risk Register
- Monitor progress made to address risk
BÒrd SSN nan Eilean Siar
Western Isles NHS Board
November2014Corporate Aim / Risk Category / Risk / Owner / Inherent Risk / Further Mitigating Actions to Eliminate/Transfer or Reduce Risk / Current residual Risk / Review Date / Governance/Review Committee
RISK 1To provide person-centered care, focusing on the evidence based health needs of our population, identifying and taking every opportunity to improve our patients’ health and experience. / Financial and Organisational / Sources of financial failure include for example: failure to achieve efficiency targets; high sickness absence necessitating use of bank staff; high levels of unplanned or extra contractual activity with mainland providers; critical equipment failure necessitating costly repair and/or transfer of activity to mainland providers; failure to adhere to standing financial instructions and delegated limits; external changes to regulations such as VAT, pension contributions or national insurance contributions. Any one of the above could cause the organisation to fail to achieve financial balance. For instance the efficiency target for 2014/15 is £2.025 million. If this is not achieved, then the Board is likely to experience a financial deficit. / Director of Finance / 12 / Production of a Financial Recovery Financial Plan.
Regular monthly reporting of performance to budget holder, CMT, HCG, Board and SGHD.
Financial Performance is also closely monitored by CE and DoF at monthly departmental performance review meetings / 9 / Risk updated 1/10/14
Risk rating has changed / Healthcare Governance Committee
RISK 2To protect individuals from avoidable harm by continually learning, and improving the reliability and safety in everything we do. / Financial and Organisational
Population Health / There is a risk that the Board may not be able to respond effectively to a Major Incident (under the auspice of the Civil Contingencies Act (2004)).
Also the Boards current Business Continuity Management System may not be able to continue to provide critical services during failures. / Director of Public Health / 15 / Multi-agency Pandemic Influenza Plan.
Health Board Emergency Planning Group (EPPHIG).
Business Continuity being rolled-out across the Health Board. / 12 / Risk updated October 2014.
Risk rating has changed / Corporate Management Team
RISK 3To protect individuals from avoidable harm by continually learning, and improving the reliability and safety in everything we do. / Financial and Organisational
Population Health / There is a risk that due to non compliance with Infection Control Policies HAI’s may not be reduced to or stay within tolerable levels to meet the HEAT Target projection for CDI and SAB
Added on 19/9/14
Due to rolling total and total number of CDI cases in 2013/2014 it is not possible to achieve this HEAT target therefore any actions within this action plan will be to reduce numbers but will not reduce this risk. / Nurse
Director / 15 / Ongoing Education and Support from Infection Control Team.
As per the Infection Control Team annual plan approved by CMT.
Action plans for CDI’s. / 15 / Risk updated 19/9/14.
Risk rating has changed / Healthcare Governance Committee
RISK 4To deliver our commitment to partnership working to deliver national standards, targets and guarantees. / Clinical
Financial / There is a risk that NHS WI will not meet TTG legal target for inpatient/day cases without increasing capacity. / Nurse
Director / 25 / Weekly Theatre scheduling meeting, ‘Activity, Capacity & Cancer’ Meetings, Service Level Agreement Monitoring Committee, Surgical Clinical Management Team, Delayed Discharge Group, Single Operating Division and NHS Western Isles Escalation Policy. / 20 / Update on 7/11/14
Risk and risk rating remains the same.
December 2014 / Corporate
RISK 5 To protect individuals from avoidable harm by continually learning, and improving the reliability and safety in everything we do. / Clinical
Financial / Risk that staff, patients, public and or resources may suffer avoidable harm, loss and/or damage due to inadequate security system processes / CEO / 15 / Comprehensive internal and external CCTV in place and working effectively.
Further access security to be undertaken at W.I.H. Assessment of HBO & Springfield Road undertaken
CCTV installation by 31/03/15 / 9 / For review
2014 / Corporate Management Team
RISK 6 To provide person-centered care, focusing on the evidence based health needs of our population, identifying and taking every opportunity to improve our patients’ health and experience. / Population Health / There is a risk of unsatisfactory patient outcome because clinicians are unable to (or experience delay in) obtaining specialist laboratory based clinical advice in a timely manner. There is a risk that the organisation could be liable for incidents resulting in an unsatisfactory patient outcome. / Medical
Director / 25 / Develop formal network with laboratory service that is part of a larger mainland health board to satisfy requirement for both professional direction and clinical advice.
Meeting scheduled to progress SLA with NHS Highland / 8 / For review
November 2014 / Corporate Management Team
RISK 7 To deliver our commitment to partnership working to deliver national standards, targets and guarantees. / Clinical
Population Health / There is a risk that due to an increase in delayed discharge patient’s acute capacity has been reduced to levels where waiting times could be breached with cancellation of elective procedures. In addition, there may be insufficient acute capacity to accept emergency admissions. / Nurse
Director / 25 / Discharge Action Group meets weekly (WIH) to review all delayed discharges and potential delays.
Criteria meetings for allocation of care packages now take place weekly.
A&E staff work pro- actively with Discharge Coordinator to avoid
Admission where it is identified that with sufficient support the patient could be safely discharged home from A&E / 20 / Update
7/11/14-There is no change and risk rating remains the same
For review December 2014 / Corporate
RISK 8To protect individuals from avoidable harm by continually learning, and improving the reliability and safety in everything we do. / Clinical
Organisation / OOH Lewis and Harris. It has been established that there is not enough GP capacity to deliver an OOH service every day/night. / Medical Director / 25 / A paper that proposes solutions to the safety, training and remuneration issues and long-term sustainability will be submitted for consideration by CMT as soon as possible. It is intended that an initial paper be presented. / 4 / December 2014 / Corporate Management Team
RISK 9To protect individuals from avoidable harm by continually learning, and improving the reliability and safety in everything we do. / Clinical
Organisation / The Uist Out-of-hours services, both Primary Medical Services and Hospital Services are provided by the 4 partners at Benbecula Medical Practice supplemented by 1 local GP who provides 2 shifts of OOH cover per month and 1 GP from the Lewis OOH service who works 1 week in every 5. As of December 2014, the number of Uist GPs willing to cover OOH will drop to 3 (supplemented by 1 local GP providing 2 shifts). This means an increased commitment of a week from the Lewis OOH GP cohort. The existing support from the Lewis OOH service is already under strain and any increasedcommitment to theUist rota would destabilise the Lewis OOH service. Until the nursing skills in the hospital are addressed no other GPs are willing to join the OOH GP cohort. With no further Uist GPs willing to take part in the OOH service and with no ability to increase our commitment from the Lewis OOH GP cohort, there is therefore a significant risk that the GP OOH service for patients registered with North Uist and Benbecula Practices, and the Uist and Barra Hospital OOH medical provision, will fail at the end of 2014. / Medical Director / 20 / The proposed model is reliant on approval to increase the skills of the nurses within the hospital to support the current OOH GP arrangement. Strengthening the nursing support has the ability to maintain and recruit the current/future GP community to provide OOH support in the knowledge that there is appropriately trained support staff to allow safe and effective working during the OOH period. / 10 / December 2014 / Corporate Management Team
RISK 10To protect individuals from avoidable harm by continually learning, and improving the reliability and safety in everything we do. / Clinical
Organisation / OOH Paediatric Cover. A GP who currently provides OOH cover for Harris (excluding those South Harris patients currently provided for by their own GP) patients is retiring and his replacement has indicated that he is unable to provide OOH cover. / Medical Director / 20 / Until a solution is found and approved, a second GP has been allocated from 1stNovember to the daytime weekend shifts. The additional on call GP will cost £4,376 for every month that passes until we have a permanent solution / 5 / December 2014 / Corporate Management Team
RISK QUANTIFICATION CRITERIA
Likelihood DefinitionsDescriptor / Rare (1) / Unlikely (2) / Possible (3) / Likely (4) / Almost Certain (5)
Likelihood / Can’t believe this event would happen – will only happen in exceptional circumstances
(likely to occur every 5-10 years) / Not expected to happen, but definite potential exists – unlikely to occur
(likely to occur every 2 to 5 years) / May occur occasionally, has happened before on occasions – reasonable chance of occurring
(likely to occur annually) / Strong possibility that this could occur – likely to occur
(likely to occur quarterly) / This is expected to occur frequently / in most circumstances – more likely to occur than not
(likely to occur daily/weekly/monthly)
See next page for Severity Impact consequence Definitions
Risk MatrixLikelihood / Severity of Consequences
Negligible (1)/ Minor (2) / Moderate (3) / Major (4) / Extreme (5)
Almost Certain (5) /
Medium/ High / High / V High / V High
(4) / Medium / Medium / High / High / V High
(3) / Low / Medium / Medium / High / High
(2) / Low / Medium / Medium / Medium / High
(1) / Low / Low / Low / Medium / Medium
Very High: Senior Management Action to confirm the level of risk identified and produce an action plan to eliminate/reduce or transfer the risk
High: Service Head Action to confirm the level of risk identified and produces an action plan to eliminate/reduce or transfer the risk
Medium: Ward/Dept Head to confirm the level of risk identified and produce an action plan to eliminate/reduce or transfer the risk
Low: Ward/Dept Head to confirm the level of risk identified and manage using routine procedures
Severity of Consequence DefinitionsDescriptor / Negligible (1) / Minor (2) / Moderate (3) / Major (4) / Extreme (5)
Patient Experience / -Reduced quality patient experience/clinical outcome not directly related to delivery of clinical care / -Unsatisfactory patient experience/clinical outcome directly related to care provision – readily resolvable / - Unsatisfactory patient experience/ clinical outcome, short term effects – expect recovery less than 1wk
-Increased level of care/stay less than 7 days / -Unsatisfactory patient experience /clinical outcome, long term effects - expect recovery over more than 1week
- Increased level of care/stay more than 7 -15 days / -Unsatisfactory patient experience/clinical outcome, continued ongoing long term effects
Objectives/ Project / -Barely noticeable reduction in scope/quality/schedule / - Minor reduction in scope/quality/ schedule / - Reduction in scope/quality/project objectives or schedule / -Significant project over-run / -Inability to meet project/corporate objectives, reputation of the organisation seriously damaged
(physical and psychological) to patient/visitor/staff / -Adverse event leading to minor injury not requiring first aid
-No staff absence / - Minor injury or illness, first aid treatment required
- Up to 3 days staff absence / - Agency reportable, e.g. Police (violent and aggressive acts)
-Significant injury requiring medical treatment and/or counseling
-RIDDOR over 3-day absence due to injury/dangerous occurrences / -Major injuries/long term incapacity /disability (e.g. loss of limb), requiring, medical treatment and/or counseling
-RIDDOR over 3-day absence due to major injury/dangerous occurrences / -Incident leading to death(s) or major permanent incapacity
Complaints/Claims / - Locally resolved verbal complaint / - Justified written complaint peripheral to clinical care / - Below excess claim.
- Justified complaint involving lack of appropriate care / - Claim above excess level.
- Multiple justified complaints / --Multiple claims or single major claim
-Complex Justified complaint
Service/ Business Interruption / - Interruption in a service which does not impact on the delivery of patient care or the ability to continue to provide service / - Short term disruption to service with minor impact on patient care/service provision / - Some disruption in service with unacceptable impact on patient care
-Temporary loss of ability to provide service
- Resources stretched
- Potentially impaired operating capability
-Pressure on service provision / -Sustained loss of service which has serious impact on delivery of patient care resulting in major contingency plans being invoked
-Potentially impaired operating capability
-Temp service closure / - Permanent loss of core service/ facility
- Disruption to facility leading to significant “knock on” effect --
-Inability to function
Staffing and Competence / - Short term low staffing level temporarily reduces service quality (less than 1 day)
- Short term low staffing level (>1 day), where there is no disruption to patient care / - Ongoing low staffing level reduces service quality
- Minor error due to lack of/ ineffective training/ implementation of training / -Late delivery of key objective/service
/care due to lack of staff
- Moderate error due to lack of/ ineffective training/implementation of training
- Ongoing problems with staffing levels / - Uncertain delivery of key objective/service/care due to lack of staff
- Major error due to lack of/ ineffective training/implementation of training / - Non-delivery of key objective/ service/care due to lack of staff.
- Loss of key staff
-Critical error due to lack of/ ineffective training/ implementation of training
Damage/Loss/Theft/ Fraud / - Negligible organisational/
personal financial loss up to £100k / - Minor organisational/
personal financial loss of £100k - £250K / - Significant organisational/personal
financial loss of £250k - £500k / - Major organisational/personal financial loss of £500k - £1m / -Severe organisational financial loss of more than £1m
Audit / - Small number of recommendations which focus on minor quality improvement issues / -Recommendations made which can be addressed by low level of management action / -Challenging recommendations that can be addressed with appropriate action plan
Improvement Notice / -Enforcement/prohibition action
- Critical report / -Prosecution
- Severely critical report
Adverse Publicity/ Reputation / - Rumours, no media coverage
- Little effect on staff morale / - Local media coverage – short term
-Some public embarrassment
- Minor effect on staff morale/public attitudes / - Local media - long-term adverse publicity
- Significant effect on staff morale/public perception of the organisation
Local MSP/SEHD interest / - National media adverse publicity less than 3 days
- Public confidence in the organisation undermined
- Use of services affected / -National/International media/ adverse publicity, more than 3 days
- MSP/MP/SEHD concern (Questions in Parliament)
- Court Enforcement/Public Enquiry/FAI
Criteria for Escalation- Issues raised through the Risk Register -
Criteria to ensure that the process has been used
- The issue is currently on the appropriate Risk Register.
- The issue has been scored and has been assessed as a high, very high risk.
- All possible controls have been implemented.
- Other sources of funding available have been considered.
- The Management Team believes there is no provision in the current budget to address this risk.
- It is preferable that several options of risk reduction should be presented to the more senior level providing a range of choices.
- The Management Team believes this risk needs to be addressed and are able to demonstrate the reduction of risk from any additional finance made available.
If No to any question the risk requires to be explored further at the current management level to ensure it is a true exception.
If all Yes, pass to more senior management level
Issues to be considered when receiving escalated risks-