Report by Lesley Anne Smith, Head of Quality on behalf of Elaine Mead, Chief Executive

Transcription

1 Highland NHS Board 3 April Item 4.4 NHS HIGHLAND STRATEGIC RISK REGISTER Report by Lesley Anne Smith, Head of Quality on behalf of Elaine Mead, The Board is asked to: Approve the NHS Highland Strategic Register. Agree to the process for integrating risks associated with Adult Social Care Services. Agree the management and assurance arrangements for NHS Highland s Strategic s. Note the ongoing review of the risk management process within NHS Highland. 1. Background 1.1 In order to be effective, risk management should be embedded throughout the organisation in such a way as to facilitate the timely identification and mitigation of the risks to the achievement of business objectives. This means that risk registers should be based on NHS Highland s strategic and operational plans, and in particular those risks that would prevent the achievement of strategic and operational objectives. 1.2 NHS Highland s Internal Auditors, Scott Moncrieff, carried out a review of our risk management arrangements in August 2011.This review has built on that previous work to examine whether the arrangements for identifying and managing risk at a departmental and regional level are robust and consistently applied across the organisation, and that risks are both escalated upwards and delegated downwards as appropriate within the risk management hierarchy. 1.3 The main findings of the review were that there is a clear commitment to improving the risk management framework within NHS Highland. The Management Steering Group has identified the need to develop a consistent approach to risk management across NHS Highland, and recognises the benefit in doing so. 1.4 The Internal Auditors concluded that the arrangements surrounding the risk management process require improvement. However, the issues highlighted in the report had, to a large extent, been self-identified by those currently involved in the management or application of the risk management process at NHS Highland. 1.5 The management response to the review confirmed that the risk management system is currently being reviewed by the Management Steering Group. This review is led by the Head of Quality and will ensure that risk management is integrated into NHS Highland s decision-making arrangements to create an environment for learning and continuous improvement. This will include the development of a Management Strategy and update of the Management Policy. 2. Register 2.1 A Register is: A management tool that enables an organisation to understand its risk profile A log of risks of all kinds that threaten an organisation s success in achieving its aims and objectives The hub of the organisation s internal control system

2 2.2 NHS Highland s Corporate Register is made up of the following: strategic risks linked to corporate objectives and delivery of the local delivery plan, operational risks which have an organisation-wide impact on the provision of safe, effective patient care significant risks escalated from the Operational Units on account of their significance for the organisation and the requirement for the organisation to be involved in the management of the risk This can be shown diagrammatically as follows: COMPONENTS OF CORPORATE RISK REGISTER STRATEGIC RISKS s associated with the strategic direction of an organisation. Strategic risks are often a function of uncertainties that may be driven by government policy, competition, court decisions or a change in stakeholder requirements. OPERATIONAL RISKS pertaining to the delivery of services. These would include risks involving human resources, controls and processes. Organisation-wide s s which have an organisation-wide impact on the provision of safe, effective patient care Unit specific s Significant risks escalated from the Operational Units on account of their significance for the organisation and the requirement for the organisation to be involved in the management of the risk 3. Current position in relation to the Strategic Register 3.1 Following the last meeting of the Management Steering Group the Head of Quality, of Human Resources and the Clinical Development Manager met on several occasions and reviewed the existing corporate risk register, the feedback on current risks which had been identified when speaking with s, the Service Delivery Characteristics and the Corporate Objectives 2011/12 and the NHS Grampian approach. 3.2 A draft Strategic Register has been prepared which is structured in the following way: Title with a link to NHS Highland aims of Better Health, Better Care, Better Value, the Service Characteristics and the Corporate Objectives Description of the Owner Initial Acceptable Current Source of Assurance Last Review Date 3.3 A Owner is the named with overall responsibility for a particular risk albeit the management of the risk may be delegated to another person. 2

3 3.4 In particular, in their role as Owner, the has overall responsibility for: Ensuring that the risks they own are managed appropriately; Monitoring progress against action plans established to support the management of identified risks; Ensuring that the review process is carried out timeously within their areas of responsibility; Responding to any risk register actions that have been assigned to them by the Management Steering Group; and Providing specific reports on request from any of the s. 3.5 The Strategic Register has been completed by the Team/ Owners and was discussed at the Audit on 13. It is attached as Appendix Operational Registers 4.1 Each of the Operational Units has a Register that records the risks that threaten the achievement of their objectives. In addition there are a number of other operational risk registers including: Healthcare Associated Infection Dental Services Facilities Planning for Integration Project 4.2 Review of these registers is underway as part of the wider review of risk management arrangements detailed in paragraph 1.5 above. 5. s relating to Adult Social Care Services 5.1 The current Strategic Register identifies a risk in relation to Planning for Integration (as part of the wider integration agenda). In addition there is a specific Register in place for the Planning for Integration Project which is being monitored regularly by the Planning for Integration Project Board. 5.2 The Audit meeting on the 13 identified the need for the NHS Highland Register to also contain risks relating to Adult Social Care Services transferring from the Highland Council on 1 April. 5.3 The NHS Board meeting on 21 discussed a number of these risks and it was agreed that the Head of Adult Social Care would work with colleagues to ensure that any risks identified in the Highland Council Strategic Register relating to Adult Social Care Services are reflected in NHS Highland s risk register documents from the 1 April. 5.4 In addition, any risks in respect of issues relating to integration which remain to be finalised over the coming year will also be reflected in the Strategic Register as appropriate. 5.5 The Operational Units will also be required to ensure that operational risks relating to the services transferred from Highland Council are reflected in Operational Registers and managed as appropriate (see section below). 5.6 The updated Strategic Register, including risks relating to Adult Social Care Services will be presented to the June meeting of the NHS Board. 3

4 6. Arrangements 6.1 For the risk management framework to be fully effective, robust monitoring arrangements and clear lines of responsibility and accountability must be in place for the management of risk registers. 6.2 The NHS Board management is the responsibility of the board of each NHS body. Each board must satisfy itself that the organisation for which it is responsible is pursuing risk management in an appropriate manner, i.e. that the activities which support the delivery of risk management are in place, and that information is flowing and action is being taken at appropriate levels, up to and including board level, on safety and quality of care issues both routinely and specifically when problems are identified. The Board discharges this responsibility through the appropriate governance committees. The Board is required to ensure that it conducts a review of its systems of internal control, including in particular its arrangements for risk management, at least annually. 6.3 s The NHS Board has delegated the function of risk governance to the s. Each committee has a responsibility to provide assurance to the NHS Board in respect of the risks that fall within its specific remit. Each committee has further responsibility to encourage managers to ensure the dissemination of learning across NHS Highland from adverse events and near misses. In some cases the NHS Board itself is the assurance source. This requires each to use the Corporate Register and Management Reports issued by the Management Steering Group to consider risks that may require further scrutiny (for example, risks evaluated as very high) and seek assurance from individual risk owners regarding the management of these risks including the adequacy of existing control measures and progress against any actions required for improvement. 6.4 Management Steering Group NHS Highland has a Management Steering Group whose role is to provide reassurance to the NHS Board that all systems, processes and procedures relating to Management are operated in an appropriate manner. This duty is discharged through directing and integrating the relevant work within the Board s s, with input from Groups. The Management Steering Group is responsible for monitoring the effectiveness if the system of controls over risk management throughout NHS Highland. It does this by continually reviewing NHS Highland s risk management system to ensure it is fit for purpose and is delivering the main aim of the risk management strategy. The Management Steering Group will provide six-monthly reports on strategic and operational risks to the s in order to provide assurance that risk management systems for all areas of the organisation are in place and are effective. The Chair of the Management Steering Group will submit an annual Activity Report to the Audit and on to the NHS Board. 4

5 7. Contribution to Board Objectives management is about the culture, processes and structures that are directed towards realising objectives and potential opportunities whilst managing adverse events. The risk management system and its associated risk registers supports the NHS Highland Strategic Framework and the Highland Quality approach, driving forward quality improvement in all aspects of the healthcare agenda. It supports the achievement of NHS Highland s objectives through effective risk management and consistent application of risk management methodologies. 8. Implications NHS Highland recognises that risk is inherent in the delivery of healthcare and that risk management should be part of an organisation s culture. This Strategy is based on the philosophy that the management of risk should be holistic, supporting clinical, corporate, public and staff governance. The Board, managers and staff have a duty of care to integrate risk management in their activities to enhance the quality of service and drive risk management effectively. 9. Assessment. The Strategic Register is a risk based approach which will ensure than any implementation plans are prioritised using the agreed risk management assessment process. 10. Planning for Fairness The Strategic Register is a component part of the NHS Highland risk management system. This latter is currently under review and the resulting Management Strategy and Procedures will be subject to the Planning for Fairness Process. 5

6 11. Engagement and Communication The Strategic Register has been completed in consultation with the Team and has been discussed by the Audit. Lesley Anne Smith Head of Quality 23 6

7 NHS HIGHLAND STRATEGIC RISK REGISTER - EXCLUDING RISKS RELATING TO ADULT SOCIAL CARE RELEVANT FROM 1 APRIL Appendix 1 ID Title Serv Char. 1 Meeting expectations of the heath improvement agenda (Better Health) 2 Impact of the ageing population (Better Health, Better Care) 3 Failure to deliver on the integration agenda ( Primary Care/Secondary Care: Planning for Integration Health and Social Work; Integration of Argyll and Bute 4 Difficulty in measuring effectiveness and quality of interventions and services 5 Sustainability of services in the Rural General Hospitals ( Better Care) Corp Obj. Description Owner Consequence 1 5 There is a risk that the Board does not focus sufficiently on continuing to improve the health of the Highland population or on reducing the inequalities gap 1,3 6 Failure to take account of the impact of the ageing population when planning services may put at risk the ability to deliver on the strategic objectives 4 6 Failure to deliver on the fundamental reconfiguration of health and social care services across the Highland area will put at risk the ability to deliver on the NHS Highland Strategic Framework within the increasingly limited financial resources available 2 2 There is a variety of information available that may not be used to support the delivery of strategic objectives particularly in relation evidencing the delivery of high quality, safe and effective care 3 2 Failure to maintain clinical skills will put at risk the sustainability of services at RGHs of Public Health Transitions Medical Medical Acceptable Consequence Assurance Source Major Likely HIGH MEDIUM Mod. Likely HIGH Improvement Major Likely HIGH MEDIUM Mod. Unlikely MEDIUM NHS Board Last Review Major Likely HIGH MEDIUM Major Possible HIGH NHS Board February Mod. Likely HIGH MEDIUM Mod. Possible MEDIUM Clinical Major Likely HIGH MEDIUM Mod. Possible HIGH Clinical February 5a Sustaining workforce in the Rural General Hospitals 6 s associated with anti-coagulant monitoring 3 2 Failure to recruit and retain staff in RGHs and sustain services 2 2 There are potential delays relating to Warfarin patient dosing requirements being fed back to GPs to enable appropriate communication to patients and the effective management of patients coagulation status HR Mod. Likely HIGH MEDIUM Mod. Likely HIGH Staff Medical Major Possible HIGH MEDIUM Major Possible HIGH Clinical Nov 2011

8 ID Title Serv Char. 7 s associated with current CAMHS provision 8 Ensuring that achieving financial balance has no detrimental effect on quality and patient safety Corp Obj. Description Owner Consequence 2 2 The capacity to support young people with severe mental illness and complex mental health issues is often less than optimal due to lack of capacity within CAMHS, difficulty in delivering intensive services across a wide geographical area, limited access to specialist assessment and treatment services and poor access to inpatient beds in a timely fashion when required 2 2,3 There is a risk that given the financial pressures on NHS Highland to achieve financial balance there will be a reduction in the quality and safety of patient care of Public Health Medical Acceptable Consequence Assurance Source Last Review Major Possible HIGH LOW Major Possible HIGH NHS Board? Major Possible HIGH MEDIUM Major Possible HIGH Clinical 9 Insufficient funds to fully implement the Equipment Replacement Strategy ( Better Value) 10 Inability to fully implement Property Strategy (Better Value) 11 Failure to deliver the Financial Strategy through failure to deliver agreed efficiency programme or through additional expenditure 6 1,2 Reduction in availability of capital funding has resulted in a gap between known equipment replacement requirements and funds available meaning essential clinical equipment may not be replaced as planned 6 1,2 NHS Highland has a significant level of backlog maintenance resulting in buildings that are dilapidated and require urgent maintenance. There is a significant capital programme for investment in the asset base but due to limited resources not all buildings are fit for purpose 7 3 There is a risk that NHS Highland fails to break even due to an inability to deliver the agreed efficiency targets, reliance on non-recurring funding or increased expenditure Finance Major Unlikely MEDIUM MEDIUM Major Likely HIGH NHS Board October 2011 Major Possible HIGH MEDIUM Major Likely HIGH NHS Board October 2011 Major Possible HIGH MEDIUM Major Possible HIGH NHS Board/ Improvement (Better Value) 8

9 ID Title Serv Char. 12 Impact of the capital reduction (Better Value) 13 Failure to comply with Health and Safety Legislation (Better Value, Workforce) 14 Failure to meet HEAT targets (Better Health, Better Care, Better Value) 15 Lack of an information strategy to support delivery of the strategic objectives (Better Health, Better Care, Better Value) 16 Failure to effectively engage stakeholders in the way services will be delivered in the future Corp Obj. Description 6 1 There is a significant capital programme for investment in the asset base including equipment but due to limited resources not all buildings are fit for purpose and some equipment is coming to the end of its useful life 5 7 There is a risk of failure to fully implement the health and safety policy due to lack of ownership throughout the Board and competing priorities. All 4 There is a risk that the Board fails to deliver on the key objectives detailed in the Local Delivery Plan 2 1,2 There is a variety of information available that may not be used to support the delivery of strategic objectives particularly in relation evidencing the delivery of high quality, safe and effective care ALL 1 There is a risk that if there is insufficient involvement and engagement with the large scale projects and service redesign, the projects may be more difficult to deliver. Owner Finance HR Consequence Acceptable Consequence Assurance Source Major Possible HIGH MEDIUM Major Possible HIGH NHS Board/Asset Management Mod. Possible MEDIUM LOW Medium Possible MEDIUM Health & Safety Mod. Unlikely MEDIUM MEDIUM Mod. Unlikely MEDIUM Improvement Last Review Likely Major HIGH MEDIUM Likely Major HIGH NHS Board Dec 2010 Likely Extreme VERY HIGH MEDIUM Likely Extreme VERY HIGH NHS Board February2 012 (Better Health, Better Care, Better Value) 17 Failure to ensure sustainable workforce (Workforce) 18 Failure to protect staff from injury or illness as a result of work (Workforce) 5 7 There is a risk that there will be a reduction in service quality due to the financial constraints requiring a reduction in workforce costs and an ability to sustain the workforce in the future 5 7 There is a risk that we fail to effectively focus on the health and wellbeing of our staff that subsequently leads to illness and injury at work. HR HR Mod. Possible MEDIUM LOW Medium Possible MEDIUM Staff Mod. Possible MEDIUM LOW Mod. Possible MEDIUM Staff / Health and Safety 9