Section: Ensure Program Quality & Effectiveness Number: III-3-i

Transcription

1 Page: 1 of POLICY: NE CCAC is committed to maintaining an effective Enterprise Risk Management Framework to identify, assess and mitigate risks. The Board shall ensure risk management oversight through a systematic approach which embeds risk management within the culture of the organization. 2.0 DEFINITIONS: Risk: The chance or possibility of danger, loss or injury. For health service organizations, this can related to the health and well-being of patients, staff and the public; property; reputation; environment; organizational functioning, financial stability, market share; and other things of value. Risk Management: A systematic approach to setting the best course of action under uncertainty by identifying, assessing, understanding, acting on, and communicating risk issues. Enterprise Risk Management: A continuous, proactive, systematic approach to identify, assess, manage, and communicate risk from an organization-wide, aggregate perspective to minimize the effects of all risks on the organization s ability to meet its objectives. 3.0 PROCEDURE: The ensures risk management oversight by: i) Knowing the extent to which management has established an effective enterprise risk management framework within the organization. ii) iii) iv) Being aware of and understanding the most significant risks and obtaining assurance that the Risk Management Oversight Policy is being adhered to and that appropriate strategies are being used to manage unacceptable risks. Reviewing risk indicators on a regular basis including but not limited to the information in the monthly Report, quarterly risk reports and quarterly Balanced Scorecard. Including Ensure risk management oversight in each in-camera agenda and in each Board and Committee annual work plans.

2 Page: 2 of 6 v) Excluding risk reporting from consent agendas to enable in-depth discussion and follow-up. vi) Delegating specific risk categories for further analysis and follow-up to the Board as a whole or to a specific Board Committee as per Appendix I. vii) Annually reviewing this policy, and its embedded processes and accountabilities. 4.0 RELATED DOCUMENTATION: Provincial Governance Policy III-3 Risk Management Enterprise Risk Management: Operational Framework 5.0 REFERENCES: Government of Canada, Treasury Board Policy Suite, Integrated Risk Management Framework 6.0 REVIEW / REVISION HISTORY: October 2012 Date Reviewed / Revised by Review only ( ) Enterprise Risk Management Working Group NEW Dec 7-12 Approved Sept Governance Committee/ Comments / Modifications Updated to reflect organizational restructuring Approved April 7-14 Reviewed and Reconfirmed June 2015 Policy Review Working Group Assignment of whistleblowing oversight to Board as a whole October 1-15 Approved March-16 Governance Committee Clarification of oversight for miscellaneous or unusual risk categories April 1-16 Approved

3 Page: 3 of 6 BOARD as a whole Enterprise Risk Management Oversight Ensure Risk Management is a Standing (Balancing Interdependencies) Agenda Item (Board In-camera) Exclusion of risk reporting from Consent Agendas Balanced Scorecard monthly reports and urgent s Health System Partnerships and Community Engagement Processes, Alliances Partnerships/Committees with Hospitals/LTCHs/etc. Strategic Plan and Values Top Organizational Risks and Heat Map integrated into Strategic and Operational Planning Cycles Annual Refresh of the Strategic Plan with a major review every 3 years Disaster and Emergency Response Emergency Response Plan and Business Continuity Plans Reputation, Public Image, Media Board and Leadership unity: One Voice, Key /Executive Team /Executive Team /Executive Team Services Sr. Director Strategic Engagement Sr. Director, Strategic Engagement messaging Communications protocol Sr. Director Strategic Engagement Media protocol Sr. Director Strategic Engagement Government Relations MSAA Information, Systems and Technology (E Health Strategy, Infrastructure, Access Control, Data Integrity, User Support NE LHIN/CCAC regular meetings OACCAC/s liaison provincially Shared services provincially with OACCAC, Security Officer and Privacy Officer in place Business Continuity Plan Operational Procedures Whistleblowing Oversight of resolution of issues may be assigned to most appropriate Board Committee

4 Page: 4 of 6 Other matters that may include factors or Oversight of resolution of issues may be circumstances that are unusual, or do not assigned to most appropriate Board fit into the Risk Categories outlined in this Committee, on the recommendation of the policy Chair, Vice Chair and Chair of the relevant committee(s) or most appropriate Senior Director Governance Committee Board Orientation, Education, Development, Evaluation Board Composition, Board Recruitment, Board Leadership, and Board Succession Planning Governance Policies and Procedures, ensuring alignment of Board Committee Work Plans Governance Policies & Procedures Culture, Code of Conduct Code of Conduct, Values, Policy Manual Sr. Director Strategic Engagement Performance and Risk Reporting Balanced Scorecard/MSAA, Top Organizational Risks and Heat Map Reporting Evaluation Committee Performance Management and Compensation Governance Policies and Procedures / Sr. Director Corporate Services Finance Committee Budget Risks, Financial Allocations, Planning, Forecasting, Financial Management & Reporting, Fraud Physical Assets, Capital, Equipment Acquisitions and Replacement and Maintenance, Property Leases Monthly and quarterly Financial and Statistical Sr. Director, Corporate Services Reports, Forecasting Templates, Linkages with NE LHIN, Business Plan submission/approval by NE LHIN Policy and Procedures Sr. Director, Corporate Services Audit Committee Financial Process Risks Annual 3 rd Party Financial Audit Sr. Director, Corporate Services Review of internal controls over accounting and financial reporting systems Legislative Legislation Matrix Executive Team

5 Page: 5 of 6 Insurance HIROC Sr. Director, Quality and Information/ Sr. Director, Corporate Services Any other area of concern to the Board Special Audits, 3 rd Party Sr. Director, Corporate Services French Language Services Committee Provision of patient services in French (Compliance with French Language Services Act and NE CCAC French Language Health Services Designation Plan) Report on FLS Equity Index French Language Health Services Designation Plan, Human Resource policies and procedures Sr. Director, Corporate Services / Sr. Director, Strategic Engagement Relationships with Francophone Communities French Language Health Services Designation Plan, Human Resource policies and procedures Sr. Director, Corporate Services / Sr. Director, Strategic Engagement Patient Services & Quality Committee Performance of contracted service providers Quality of Care delivered by staff clinicians, case managers, other CCAC staff, Patient Safety, Patient Relations, Patient Services Standards & Policies Health Information Management Human Resources and Staff Relations: HR Planning, Competency, Staff Development, Performance Management, Labour Relations, Strike Planning Provincial Template and Performance Management Tools CCAC- Service Provider Relations Framework Quality Improvement Plan, Service Utilization Reports, Waiting Times/Waiting Lists Reports, Quality Risk and Patient Safety Report Shared services provincially with OACCAC, Security Officer and Privacy Officer in place Business Continuity Plan Operational Procedures Union/Employee Agreements, Contracts, Performance Management Policies, Procedures and Tools Business Continuity Plans Sr. Director, Clinical Services Sr. Director, Clinical Services / Sr. Director, Care Coordination Sr. Director, Quality and Information Sr. Director, Corporate Services Environment, Health & Safety: Infection Prevention and Control Framework, Sr. Director, Corporate Services

6 Page: 6 of 6 Hazardous Material Handling, procedures and training Occupational Health and Safety, Infection Control Ethical Ethical Decision Making Framework integrated into operational and governance decision making. Sr. Director, Quality and Information Patient Services Health System Partnerships and Alliances Community Engagement Processes, Partnerships/Committees with Hospitals/LTCHs/etc. Sr. Director, Strategic Engagement / Sr. Director, Clinical Services / Sr. Director, Care Coordination