EQUALITY & DIVERSITY IMPACT ASSESSMENT When completed, a copy of this EDIA form should be ed to

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1 EQUALITY & DIVERSITY IMPACT ASSESSMENT When completed, a copy of this EDIA form should be ed to lynsey.fitzpatrick@nhs.net Name of Policy/Strategy Name of Division Names and role of Review Team: Risk Register Policy and Procedure Clinical Governance Andy Howat (Health & Safety Adviser) Cathy Baty (Senior Occupational Health Adviser) Assisted by Kenny Degnan (Risk Co-ordinator) Date(s) of assessment: 21/06/13 PART ONE: RAPID IMPACT ASSESSMENT (INITIAL SCREENING PROCESS) SECTION ONE AIMS OF THE PROGRAMME 1.1. Is this a new or existing Policy/Strategy Existing Policy Version What is the aim or purpose of the Policy/Strategy This is a management tool providing clarity, addressing responsibility and generating action plans. The objectives of a Risk Register are: to achieve greater visibility of exposures and threats that may prevent NHS Dumfries and Galloway from achieving its objectives to implement a rigorous basis for decision making and planning to create a record of the identification and control of key organisational risks to achieve a more effective allocation and use of resources by prioritising risk to respond more effectively when potential risks occur to assess and monitor if management controls or resources are adequate to manage risks to achieve pro-active, rather than reactive, management and therefore reduce the likelihood that risks will occur to continue and further develop the integrated approach to risk management, whether the risk relates to clinical, non clinical, financial or organisational risk to ensure all significant risk management concerns are properly considered and communicated to the Board. This Policy also outlines the assurance mechanisms which will be used to monitor the effectiveness of the Risk Register process.

2 1.3. Who is this policy/strategy intended to benefit or affect? In what way? Who are the stakeholders? This policy is applicable to all patients, staff and independent contractors working within NHS Dumfries and Galloway. NHS Dumfries and Galloway acknowledges that the sound and effective implementation of risk management is considered best business practice at a corporate and strategic level as well as a means of improving operational activities and continually improving patient and staff safety. The continuing development of a comprehensive Risk Register is a core part of risk the Boards management activity. The stakeholders come from all levels of the organisation from the executives and the board via the healthcare governance committee and board management group to the frontline staff What outcomes are intended from this Policy/Strategy The Risk Register is an essential component of the organisation s internal control system and will be used as a systematic and structured method of recording all risks (clinical, financial and organisational) that threaten the objectives of the organisation. This process will form an integral part of day-to-day practices and culture, utilising a single co-ordinated approach to the identification, assessment and management of all types of risk 1.5. How have these people been involved in the development of this policy/strategy? Consultation via Area Partnership Forum and Healthcare governance What resource implications are linked to this policy/strategy? The main resource associated with the implementation of this policy is time as there is a requirement for staff at all levels within the risk roles and responsibilities to be involved and where appropriate complete risk assessments and manage action plans that result from the risk management process. The Datix Risk Management module will be used to capture the majority of Risks. The Datix system will be regularly reviewed by the Risk Management group.

3 SECTION TWO IMPACT ASSESSMENT Complete the following table, giving reasons or comments where: The Programme could have a positive impact by contributing to the general duty by Eliminating unlawful discrimination Promoting equal opportunities Promoting relations within the equality group Taking account of disabilities The Programme could have an adverse impact by disadvantaging any of the equality groups. Particular attention should be given to unlawful direct and indirect discrimination. If any potential impact on any of these groups has been identified, please give details - including if impact is anticipated to be positive or negative. Equality Target Groups Positive impact Adverse impact Reason or comment for impact rating 2.1. a Women 2.1. b Men Yes No All sexes are expected to be involved in the management of risk. For some specific risks there are individual assessments available ie Pregnant workers risk assessments Minority ethnic groups inc gypsy travellers, refugees & asylum seekers Yes No 2.3. Children & Young people Yes No We have a comprehensive work placement and work experience policy which is used to identify any risks associated with these young people within the workplace. The risk assessment process can also be used to consider child protection issues.

4 2.4 People with disabilities (physical or learning) Yes No The risk assessment and risk register can be measures required to ensure compliance with ( The Equality act 2010) 2.5 Religious or faith groups Yes No The risk assessment and risk register can be measures required to ensure all faith groups are treated with respect and are allowed to practice their religion. This may have an impact on service delivery and may need to be considered in a risk assessment. 2.6 Older people Yes No The risk assessment and risk register can be measures required to ensure the safety and welfare of older people either as employees or as visitors and patients. 2.7 Homeless 2.8 Looked after and Accommodated: Children Adults Older People Yes No The risk assessment and risk register can be measures required to ensure the safety of anyone accommodated by NHS D&G. 2.9 Lesbians Yes No 2.10 Gay men Yes No 2.11 Bisexuals Yes No 2.12 Transgender people Yes No

5 2.13 People with language or social origin issues 2.14 Individuals with Mental Health issues 2.15 People in criminal justice system Yes No The risk assessment and risk register can be measures required to ensure that anyone with language or social origin issues is assessed and provided where appropriate with the correct information, instruction and resources to ensure they are safe. Yes No The risk assessment and risk register can be measures required to ensure anyone with mental health issues is safe. Yes No Where prisoners are required to visit the organisation for use of any of our services the risk assessment and risk register can be used to establish any risks and control measures required to ensure the safety of patients, visitors and staff dealing with these patients People in poverty 2.17 Married and unmarried people/civil partnerships 2.18 Staff Yes No NHS Dumfries and Galloway acknowledges that the sound and effective implementation of risk management is considered best business practice at a corporate and strategic level as well as a means of improving operational activities and continually improving patient and staff safety.

6 SECTION THREE CROSSCUTTING ISSUES What impact will the proposal have on lifestyles? For example, will the changes affect: 3.1 Diet and nutrition? Positive impact Adverse impact Reason or comment for impact rating 3.2 Exercise and physical activity? 3.3 Substance use: tobacco, alcohol or drugs? 3.4 Risk taking behaviour? Yes No The continuing development of a comprehensive Risk Register is a core part of risk management activity. The system will not eliminate the risk and cannot be guaranteed to remove all risks as it relies on the people identified in the risk control measures following the safe system of work. 3.5 Education and learning, or skills? Yes No Risk register can be used to improve the awareness of risk within areas and can be used as educational tools to help staff understand the risk aspects of their job. IT access may be an issue in some areas and provision of paper based risk assessments will be considered.

7 3.6 Other SECTION FOUR CROSSCUTTING ISSUES: Does your Programme consider the impact on the social environment? Things that might be affected include: 4.1 Social status Positive impact Adverse impact Reason or comment for impact rating 4.2 Employment (paid or unpaid) 4.3 Social/family support 4.4 Stress Yes No The risk assessment and risk register can be measures required to mange stress and stress related ill health in the workplace. 4.4 Income SECTION FIVE CROSSCUTTING ISSUES Will the proposal have an impact on the physical environment? For example, will there be impacts on: 5.1 Living conditions? Positive impact Adverse impact Reason or comment for impact rating 5.2 Working conditions? Yes The risk assessment and risk register can be measures in connection with the working environment.

8 5.3 Pollution or climate change? 5.4 Accidental injuries or public safety? 5.5 Transmission of infectious disease? Yes No The risk assessment and risk register can be measures required to ensure we are not having a negative effect on the environment. Yes No The sound and effective implementation of risk management is considered best business practice at a corporate and strategic level as well as a means of improving operational activities and continually improving patient and staff safety. Yes No The risk assessment and risk register can be measures required to ensure that all infection prevention and control measures are being followed. 5.6 Other Will the Programme have any impact on Discrimination? Equality of opportunity? Yes No IT access may be an issue in some areas and provision of paper based risk assessments will be considered to ensure there is equal opportunity to manage risk in these areas.

9 Relations between groups? Yes No The establishment of Risk registers will in some cases include cross boundary risks Cross Boundary Risk Registers Traditional Risk Registers are based on the vertical line management structure. However, DATIX also allows the generation of cross boundary Risk Registers from Notification Groups. This will enhance communication on risk between teams Other

10 Will the proposal affect access to and experience of services? For example: Positive impact Adverse impact Reason or comment for impact rating Health care Yes No The sound and effective implementation of risk management is considered best business practice at a corporate and strategic level as well as a means of improving operational activities and continually improving patient and staff safety. The continuing development of a comprehensive Risk Register is a core part of risk management activity. The Risk Register is an essential component of the organisation s internal control system and will be used as a systematic and structured method of recording all risks (clinical, financial and organisational) that threaten the objectives of the organisation. This process will form an integral part of dayto-day practices and culture, utilising a single co-ordinated approach to the identification, assessment and management of all types of risk. Social Services Education Transport Housing

11 PART TWO SECTION SIX EXAMINATION OF AVAILABLE DATA AND CONSULTATION Data could include: consultations, surveys, databases, focus groups, in-depth interviews, pilot projects, reviews of complaints made, user feedback, academic or professional publications, reports etc) This policy and procedure replaces the 2006 Risk Register Policy and is fully compliant with the Australia/New Zealand Risk Management Standards adopted by NHS Scotland. Risk Registers have been used to establish where risks lie in all areas of the organisation. The Datix adverse incident module although a reactive tool allows the collection of a huge amount of data this can thereafter be used to introduce risk reduction measures. Name any experts or relevant groups / bodies you should approach (or have approached) to explore their views on the issues. Risk Management Group; Are responsible for the development and implementation of NHS D&G risk management strategy. The group are accountable to the Board Management Group through the Director of Nursing. The Risk Management Group consists of: Patient Safety and Improvement Manager Adverse Incident Manager Clinical Governance Administrative Assistant Clinical Governance & Risk Management Facilitator Health & Safety Adviser Clinical Governance Facilitator/Risk Module Lead Risk Systems Manager

12 What do we know from existing in-house quantitative and qualitative data, research, consultations, focus groups and analysis? There is mixed understanding of Risk Registers across the organisation and this policy will help raise awareness of the need to improve this understanding across all areas. What do we know from existing external quantitative and qualitative data, research, consultations, focus groups and analysis? From various sources it is widely recognised that sound, integrated risk management will reduce risk and improve safety for all. What gaps in knowledge are there? In relation to the groups identified: What are the potential impacts on health? Will the Programme impact on access to health care? If yes - in what way? Will the Programme impact on the experience of health care? If yes - in what way? SECTION SEVEN HAVE ANY POTENTIAL NEGATIVE IMPACTS BEEN IDENTIFIED? If so, what action been proposed to counteract these? Negative impacts (if yes, state how) e.g. Is there any unlawful discrimination? Could any community get an adverse outcome? Could any group be excluded from the benefits of the Programme/function? Does it reinforce negative stereotypes?

13 SECTION EIGHT MONITORING How will the outcomes be monitored? Regular reviews of risk registers at all levels, Health & Safety reviews and regular reports to Directorate General Managers What monitoring arrangements are in place? 3 Health Safety and Risk groups, APF, Clinical Governance and the Board are responsible for monitoring risk registers and risk management. Who will monitor? Risk facilitators, Health & Safety Adviser reviews What criteria will you use to measure progress towards the outcomes? Priority of risks is used to establish current position ie Red, Amber then Green. Review date is also used to review outcomes. Recommendations (This should include any action required to address negative impacts identified SECTION NINE FOR NEW POLICIES ONLY What research or consultation has been done? What stage is the Programme at? What is the target date for completion? Is a more detailed assessment needed? (It is not necessary to subject all proposals to a detailed assessment.) If so, for what reason? COMPLETED PROGRAMME / Policy Who will sign this off? - APF Area Partnership Forum When? August 2013 PUBLICATION How will this be published? - Hippo and Hard copy if required Carried Out by Title

14 Signature Date Authorised by Title Signature Date