Strategic Framework for Risk Management
Strategic Framework for Risk Management 2007-09
Reference Number: / 210 2008Author / Manager Responsible: / Paul Russell
Head of Patient Safety
Deadline for ratification:
(Policy must be ratified within 6 months of review date) / January 2009
Review Date: / July 2008
Ratified by: / Clinical Governance Committee
Date Ratified: / January 2008
Related Policies
/ Serious Adverse Incident PolicyRisk and Incident Management Policy
Major Incident policy
Infection Control Policies
Information Management Policy
Complaints Policy and Procedure
Policy and Procedure for the Management of Claims
Health, Safety and the Environmental Policy
Fire Precautions Policy
Introduction of New Procedure policy
Author: Paul Russell / Date: September 2007
Position: Head of Patient Safety / Version: 2
Page 25 of 60 / Review Date: July 2008
Royal United Hospital Bath NHS Trust
Strategic Framework for Risk Management
INDEX
Section Page
Consultation Schedule ------4
1. Introduction ------5
2. Key risk areas ------5
3. Definitions ------6
4. Objectives for Managing Risk 2007-09 - - - 6
5. Structure and Communication - - - - - 7
6. Risk Management and the Trust Planning Process - - 10
7. External Standards, Monitoring and Reporting - - 11
8. Internal review of performance- - - - - 12
9. Responsibilities ------14
10. Raising Concerns ------18
11. The Risk Management Process - - - - 19
12. Acceptable Levels of Authority for Resolving Risks/Incidents - 23
13. Lessons Learned and Communication in Changes of Practice - 24
14. Education and Training - - - - - 24
15. Contact Details for Risk Management - - - 25
16. References ------25
Appendix 1
Governance Framework ------26
Appendix 2
Risk Management Decision and Escalation Pathway - - 27
Appendix 3
Governance Committee Membership and Terms of Reference 28
Appendix 4
Operational Governance Committee Terms of Reference - 30
Appendix 5
Recommended Divisional Clinical Governance Committee Terms
Of Reference ------32
Appendix 6
Trust Heath and Safety Committee Terms of reference 2007 - 38
Appendix 7
Health and Safety at Work Sub Group Terms of Reference - 40
Appendix 8
Health and Safety Work Environmental Sub group Terms of
Reference ------42
Appendix 9
Strategic Learning Committee Terms of Reference- - - 43
Appendix 10
Clinical Audit Review Committee Terms of Reference - - 45
Appendix 11
Departmental Governance Committee Exemplar- - - 47
Appendix 12
Directorate Clinical Governance Framework - - - 49
Appendix 13
PEG Terms of Reference ------50
Appendix 14
Medical Equipment Committee - - - - - 51
Appendix 15
Equality and Diversity Committee - - - - - 54
Appendix 16
Medical Gas Committee ------56
Appendix 17
Risk Assessment Form ------57
Consultation Checklist ------60
CONSULTATION SCHEDULE
Name and Title of Individual / Date ConsultedFrancesca Thompson, Director of Nursing / September ‘07
James Scott, Chief Executive / September ‘07
John Waldron, Medical Director / September ‘07
Lynn Vaughan, Director of Human Resources / September ‘07
Catherine Phillips, Director of Finance / September ‘07
Diane Fuller, Director of Patient Care Delivery / September ‘07
Brigid Musselwhite, Director of / September ‘07
Catherine Williams, Acting Divisional Manager & Assistant Director of Nursing (Medicine) / September ‘07
Jan Lynn, Assistant Director of Nursing (Surgery) / September ‘07
Andy Newton, Deputy Divisional Manager (Medicine) / September ‘07
Cathy Caple, Deputy Divisional Manager (Surgery) / September ‘07
Sharon Preston, Assistant Director of Nursing / September ‘07
Mr Chris Gallegos, Divisional Lead (Surgery) / September ‘07
Dr William Hubbard, Divisional Lead (Medicine) / September ‘07
Dr Tim Craft, Deputy Medical; Director and Divisional lead for Specialties / September ‘07
David Robinson, Health & Safety Manager / September ‘07
James Brind, Health & Safety Advisor / September ‘07
Vivienne McHale, Head of Clinical Effectiveness / September ‘07
Glynn Young, Information Governance Manager / September ‘07
Stephen Roberts, Complaints Litigation Manager / September ‘07
Amy Shortridge, Head of Education Training / September ‘07
Vivienne Versis, Clinical Governance & Risk
Co-ordinator / September ‘07
Sharon Bradley, Clinical Governance Systems Administrator / September ‘07
Name of Committee / Date of Committee
Clinical Governance Committee / 23 January 2008
1 Introduction
1.1 The business of healthcare is by its nature, a high-risk activity and the process of risk management is an essential control mechanism. Risk management processes are central to providing part of the Board Assurance Framework for clinical, non-clinical and corporate governance.
1.2 Failure to implement a strategy for managing risk could severely impact on the Trust’s reputation and services and could have serious financial consequences.
1.3 The Trust Board recognises that complete risk control/avoidance is impossible, but that risks can be minimised by making sound judgements from a range of fully identified options.
1.4 This document and related policies clearly set out the processes by which all risks are identified and controlled. It identifies the resources for managing risk and how they relate to each other. It describes the roles and responsibilities from the individual employee up to Trust Board.
1.5 This document is the overarching strategy for risk which links directly to the following policies;
· Risk and Incident Management Policy
· Serious Adverse Incident Reporting Policy
· Complaints and Claims Management Policies
· These appear as appendices with electronic links on the intranet.
2 Key Risk Areas
2.1 Clinical risk covers anything related to the diagnosis, treatment and outcome for each patient. Clinical risks generally arise from sub-optimal governance in standard setting, evidence based practice, limitations in human and equipment resources and knowledge gaps arising from individual or corporate training issues.
2.2 Non-clinical risk relates to security, health and safety, environmental issues. These may affect patients, visitors and staff.
2.3 Strategic risks include risks associated with strategic management, planning and organisation within the trust.
2.4 Financial risk covers the management of finance in accordance with standing financial instructions but also covers strategic decisions made which might not be financially robust.
2.5 Human Resource risk relates to adherence by staff to robust policies and issues that arise from the staff/management relationship.
2.6 Information risk covers the management of information in the Trust but key areas are those of confidentiality, data quality and the security of information systems.
3 Definitions
Refer to the policy for Risk and Incident Management for a full list of definitions.
3.1 Root Cause Analysis (RCA) is a system of investigation that uses process mapping to identify potential causes of an adverse event and to identify controls to reduce the likelihood of an adverse event happening or recurring.
3.2 Fair Accountability or Fair Blame are terms that are often used in conjunction with incident reporting. It is self evident that where there is an individual or corporate responsibility there is necessarily an associated expectation for the responsible person, clinician or manager, to be held to account for the delivery or non-delivery of that responsibility. It is impossible to completely remove the possibility that the fault may lie with an individual but the Trust makes it clear that an event will be properly analysed before the organisation concludes what caused it by fully considering the process weaknesses within which fallible human agents work.
4 Objectives for Managing Risk 2007-09
The Risk Management Strategy is integral to the Chief Executive’s objectives for 2008/10. The primary objective of the strategy is to identify and manage the risks that may prevent the achievement of Trust objectives. The key objectives for managing risks are as follows:
4.1 To have a continually updated and monitored action plan for Risk Management and Clinical Governance in general. (The current Clinical Governance Objectives, including the risk development plan can be found in Appendix 12 of this document
4.2 To have a single well established system for assessing, reporting and investigating risk across the Trust.
4.3 To establish effective communication of risk management functions and improvements across the Trust.
4.4 To establish and review the risks inherent in the Trust’s Corporate Objectives.
4.5 To establish and regularly review risks at Clinical Specialty and Divisional level by the development of a robust local risk register
4.6 To collate and prioritise Trust risks on a corporate level Risk Register in order to facilitate the Board’s discussions regarding the assurance they may take from existing safeguards, instruct and monitor improvements or accept the risk as currently acceptable within the existing level of risk.
4.7 Organisation-wide communication of Trust risks.
4.8 To deliver a comprehensive training programme for risk.
4.9 To achieve external accreditation.
5 Structure and Communication
5.1 The Trust Board has ultimate responsibility and accountability for the quality and safety of services provided by the Trust. Risk management in the overarching framework of governance is therefore the principle role of the Board, as reiterated by Department of Health documents such as ‘An Organisation with a Memory (2000)’ and more recently ‘Safety First’.
BOARD ASSURANCE
5.2 There are 3 Committees with responsibility for assuring the Board that safe and effective healthcare is being delivered and that the Trust is meeting its statutory duties. Each Board committee will be chaired by a Non Executive Director who will provide a written report to the Trust Board on the key issues being addressed by each committee. The committees responsible for assurance are:
5.2.1 Clinical Governance Committee – responsible for clinical issues and risks.
5.2.2 Non-Clinical Governance Committee – responsible for non clinical risks.
5.2.3 Audit Committee – responsible for financial and governance processes
Cross membership between committees will ensure that there is a corporate view of clinical and non-clinical issues together with meeting strategic objectives. The risk register is a standing agenda item between the 3 committees in conjunction with the assurance framework.
The key standing committees reporting into the Board Committees are detailed in Appendix 1.
As this structure is new, the Terms of Reference for all new committees will be drafted when the previous structure is replaced.
RISK MANAGEMENT DELIVERY
5.3 The Management Board will have responsibility for the operational success of the hospital. An essential part of its remit will be to manage the operational risks to the organisation.
The Management Board will be the key decision taking sub-committee in the Trust. Currently, there is a perception that the Executive Team meeting is where key decisions are taken; this will no longer be the case. The Management Board will approve all business cases with a financial cost as it is the committee that will have to manage and balance all operational issues including, finance, performance and managing risk.
The Executive Team, Divisional Chairs and Managers, Assistant Directors of Nursing and the Deputy Medical Director will sit on the Management Board. This will ensure that each key decision has a balanced operational and corporate perspective. The Chief Executive will chair the meeting.
5.4 Divisional Boards underpin the Management Board in being responsible for the day to day delivery of health care. The revised Standing Orders and Standing Financial Instructions, which will be presented to the Board in January, will increase the autonomy and decision taking powers of the Divisions by reducing bureaucracy and increasing self management. The development of service line reporting will further develop this. Increasing the autonomy of the Divisions will allow the Executive Team and Management Board to focus on performance, risk management, corporate operational issues and strategic developments.
5.5 Divisional Governance Committee: In recognition of the large operational clinical governance agenda to be delivered within Divisions, each Divisional Board has delegated responsibility and authority to a Divisional Clinical Governance Committee, as a Divisional Board Committee. The Committee deals with clinical governance and risk issues on behalf of the Divisional Board. The Divisional Clinical Governance committee is chaired by either the Divisional Board Chair or a senior clinician or manager. There will be a substantial shared membership between the Divisional Board and the Divisional Clinical Governance Committee.
5.4.1 A key function of the Divisional Governance Committee is to review any risks escalated to it from the departmental risk/governance meetings, for the purpose of resolution at divisional level or instructing the owner of the risk to enter the risk onto the Corporate Risk Register for Management Board and Trust Board decision.
5.6 Specialty/ Departmental/ Directorate Governance and Risk Committees: The Divisional Clinical Governance Committee will ensure that every Directorate/ Specialty/ Department is involved in a local Risk and Governance Committee. Each department will manage the agenda differently depending on the size of the department and the clinical risk agenda. Larger departments may choose to operate a risk/incident management meeting separate to the overview Governance Committee, whilst smaller departments may have one overarching committee. The departmental governance/risk meeting minutes will be fed up to the relevant Divisional Governance Committee and the Divisional Committee will periodically seek a verbal and written report on departmental governance activities.
5.5.1 A key function of the Departmental Risk/Governance Committee is to review and resolve incidents reported locally, to utilise the Trust’s PRISM database to analyse trends and the develop a departmental Risk Register. In accordance with the Trust’s Risk Escalation Flowchart (Appendix 2) risks that are not resolved locally must be escalated to the Divisional Governance Committee.
5.7 The Operational Governance Committee acts as the operational arm of the Clinical Governance Committee for clinical risk issues. The committee resolves trust-wide clinical risk issues amenable to control by policy and procedural change at a corporate wide level and recommends action to the Clinical Governance Committee and thence to the Board, where there is a financial implication for the resolution of the risk. The Deputy Medical Director is the operational executive lead for governance.
5.8 The Operational Governance Committee receives reports from the following committees with a clinical risk management or resolution function Infection Control, Drug Policy Group, Clinical Ethics, Clinical Audit Review Group, Transfusion Committee, Resuscitation Committee, Medical Records Committee, Research & Development Committee) and the Strategic Learning Committee.