Ray McKenna MBS OSH Grad IOSH MIFE P G Dip. Fire Safety Practice. Risk Management In Healthcare Seminar

Transcription

1 Ray McKenna MBS OSH Grad IOSH MIFE P G Dip. Fire Safety Practice Risk Management In Healthcare Seminar

2 Introduction Policy Management of Risk Development of a Risk Register Operating Environment Identify Key Risks Assess the Risks Review the Capacity to Deal With These Risks

3 Responsibilities Line Management Responsibility Attention of All Employees Clear & Understandable Manner Line Management Level of Training All Employees Knowledge Risk Register Experience

4 Responsibilities Elimination of Risk Can it be Done? Cannot Eliminate all Risk! Management of Risk Additional Controls Reduce the Level of Risk Acceptable Levels Continual Monitoring Regular Intervals

5 How Risk Registers Contribute to the Process

6 Role of Local Risk Management Facilitate Department Support Line Management & Employees Advise Management of Risks Line Management Function & Responsibility

7 Risk Register Development Process

8 Developing a Risk Register Development with the aid of the Six Step Process

9 Prerequisites before the Process Availability of Risk Expertise Use of Approved Support Materials & Tools Commitment & Ownership Availability of Site Support

10 Step 1. Risk Register Awareness and Organisational Readiness Initial planning by Service Area Manager and Risk Management Support Person. Describe in detail the accountability structure for the management of quality and risk. Describe the Service Area s internal, external and risk management context for managing risk within the healthcare setting. Ensure appropriate communication and consultation throughout the development process. Enlist the help of relevant local and organisational supports.

11 Step 2. Meet with Service Leads and their Management Teams Provide an overview of the purpose of the risk management process Stress the importance of establishing the Service context (external, internal, risk management) Re-enforce the need to review of sources of risk information that may currently lie within the service area Ensure that high quality information/data is used in identifying risks

12 Such Sources of Information Health & Safety Risk Assessments Clinical Risk Assessments Activity Information (e.g. throughput, readmissions, waiting lists) Analysis of Consumer Feedback i.e. complaints, client satisfaction surveys, compliments Audit Reports Incident/accident Reports and Investigation/review (internal and external) Research/Literature Reviews Peer Review Meetings Evaluations Minutes of Team Meetings Occupational Health Surveillance Sickness Absence/Employee Turnover Visual Inspection Speciality Specific Checklists General Checklists

13 Step 4. Development of Risk Registers with Service Management Teams Initial post workshop meeting Consider the issues identified from the workshop Consider any other sources of risk information with a view to identifying the risks to the service Outcome of this meeting should be a Draft Risk List Circulated to the members of the group for final consideration May also be decided to circulate it to other persons who the group may wish to consult

14 Subsequent meetings to complete the Risk Register Purpose is to agree the risk list Complete the risk assessment for each risk identified Documented on a Risk Assessment Form Consider each of the risks separately Agree what controls are required in order to manage the risk effectively Identify and document which of the required controls are currently in place Consider the adequacy of the existing control measures Rate the risk by assessing the likelihood and impact of the risk

15 Consider each of the risks separately Evaluation must be made on whether to accept the risk or that additional controls or other actions are required to mitigate the risk i.e. risk treatment Risks deemed acceptable a process needs to be put in place to monitor and review the risk Risks that are not deemed acceptable, the team need to consider the options available to them to treat the risk Ensure that the additional controls identified in this step of the process Should identify and assign a person who has responsibility for ensuring that these additional controls are implemented additional controls that are identified as not within the span of control of the service to implement the action should be escalated to the person responsible at the next level of management e.g. a speciality directorate to the general manager/ceo of a hospital

16 Each of the risks should be assigned a risk status Open Monitor Closed Categorise the type of risk by assigning a primary, secondary and tertiary risk category At the end of this step in the process the service will have a complete risk assessment form for each risk identified for their service If an improvement plan is not required the agreed timeframe for action should be documented and attached to the risk assessment form At this stage in the process each of the services within the Service Area will have a completed risk assessment form for each risk identified in their services.

17 Step 5. Development of the Service Area Manager s Risk Register Service Area Manager convenes a separate meeting Purpose of this meeting is to evaluate and agree with the service lead the additional controls identified At this meeting the Service Area Manager can: Agree to accept responsibility for the additional control(s) Consider assigning the additional control(s) required to a relevant senior manager on their management team Modify or add additional control(s) and accept responsibility Aggregation of same/similar Risks Creates a new risk onto the Service Area risk register Identifies the additional control(s) and person(s) responsible required to manage the risk

18 Step 6. Sign off and Handover Conduct a final meeting with the heads of Service/Departments To sign off the registers To present feedback from the evaluations carried out to date To advice on the business process for using the registers as a dynamic management tool to manage risk To receive any other feedback that will inform future processes in other areas Updating Risk Registers Monitor & Review

19 HSE Risk Assessment Tool

20 Sample Risk Assessment Exercise

21 Sample Risk Assessment Form

22 Conclusion Points to note:- A risk register should be used to inform the decision making processes within your organisation. The production of a live risk register should be considered an integral element of good risk management practice. Changes in policies, procedures and practices should result in reductions in an organisations highest priority risks! The cultural shift that can be needed is often one of the biggest obstacles to the effective use of a risk register. Thank you!