Robert Jones & Agnes Hunt Orthopaedic Hospital Elements of Risk Management Risk Management Strategy - Lawson Odere 1
1. Introduction 3. Objectives Robert Jones and Agnes Hunt Hospitals NHS The principal objective of the risk management Foundation Trust recognises that effective risk strategy is to provide the Board of Directors management is essential to the overall with sufficient assurance that appropriate performance of the organisation. The strategic structures and processes are in place to approach to risk management as reflected in minimise risks and loss of assets and this document is fundamental to the delivery of reputation and that reporting processes for risk the Trust’s organisational objectives in relation are maintained. to performance, governance and controls assurance. The strategy will also seek to: ensure that the risk management processes 2. Aims are integral to the organisational working practices and culture• the organisation recognises risk management as a key element of integrated governance encourage the reporting of incidents, within a fair blame culture ensuring that lessons are • risk management systems and processes are learned and preventative measures introduced embedded locally across clinical directorates and in corporate services including business ensure that, through the strengthening of risk planning, service development, financial management arrangements there are continualplanning, project and programme management improvements to patient safety and education minimise claims for accident or injury against • all risks are identified that have a potential the Trustadverse effect on the quality of care, safety and support systems which eliminate, transfer or well being of patients, staff, volunteers and reduce risks to as acceptable a level as visitors, and on the business, performance and possible. reputation of the Trust secure the highest possible standards of risk • the organisation adopts a co-ordinated andmulti-disciplinary approach in managing its risks management in terms of external validation, through a systematic process of identification, including the NHS Litigation Authority (NHSLA) analysis, learning, control and management of Risk Management Standards. risk Risk Management Strategy - Lawson Odere 2
The risk management process has five key These systems are electronically linked andelements: networked across the Trust, via an integrated software system. This will enable ready• Identification and management of risk transfer of information across all sources and• Risk evaluation will facilitate local and organisational learning• Risk control from adverse events and risk assessment• Risk reporting processes in addition to supporting an• Monitoring, review and audit. integrated approach to risk analysis. The Trust is committed to ensuring that the risk management processes become embedded in the management of both threats and opportunities, in terms of strategic and operational issues in the functioning of the organisation. In order to underpin an integrated approach to risk management activities across the organisation, the Trust will maintain and continue to develop the single Trust- wide risk management system for: Accident/incident reporting Risk register entry, review and collation of reports Complaints management Litigation and claims management Risk Management Strategy - Lawson Odere 3
Operational Responsibilities for effective risk management The Chief Executive has overall responsibility Executive Team for risk management, on behalf of the Board of Specific responsibilities are delegated to Directors of the Trust. In addition, the Chief members of the Executive Team as follows: Executive is responsible for ensuring that the Trust is in a position to provide an overall The Medical Director has delegatedassurance that the organisation has in place the responsibility for the implementation andnecessary controls to manage its risk exposure. further development of the Risk Management In order to make such a statement, the Chief Strategy. The Medical Director will require Executive and Board of Directors will need to each Directorate to submit an annual Clinical provide evidence that the Trust’s Risk Governance Report to ensure that their Management Strategy is being implemented objectives have been met and reviewed by with systems and processes being regularly the Executive Team. reviewed and that, where deficiencies are identified, developments and improvement The Director of Quality and Effectiveness mechanisms are being put in place with the will support the Directors of the Trust with overall aim of continuous improvement. implementation and development of the Risk Management Strategy.. A Non-Executive Director with a delegatedresponsibility for Risk Management sits on the The Finance Director has delegated Board and chairs the Corporate Governance responsibility for the management of risk in Committee, overseeing on behalf of the Trust relation to finance issues and to supportBoard the organisation’s progress with the Risk implementation and further development of Management Strategy. the Risk Management Strategy. Risk Management Strategy - Lawson Odere 4
. . Strategy Dissemination Implementation andResponsibilities of all employees (including Monitoring:temporary staff) The Risk Management Strategy will beIt is the responsibility of all staff, including Directors and disseminated and made available:Non-Executive Directors to identify, assess and Internally – Directorate and Departmentmanage risk on an on-going basis. The Trust is managers will be expected to communicate thecommitted to learning from mistakes, incidents, Strategy to all relevant staff and it should becomplaints and claims by continually analysing integral to local induction procedures.situations and improving systems. As an employee of Externally – To Monitor, Primary Care Trusts, NHSLA, CQC, Internal and External Auditors,the Trust, everyone has responsibility for and a role to Partner Organisations, and published on theplay in managing risk, which includes: Trust Intranet.• managing risks within their job• alerting managers to any risks within the service areathat require urgent attention However a serious breach of safety regulation• participation in Risk Management training. or negligence causing loss or injury will be regarded as gross misconduct and will beAs a large emphasis within the Risk Management considered within the Trust DisciplinaryStrategy is to develop an environment where the focus procedure Policy.and culture is on reporting and learning from mistakesand near misses. 5 Risk Management Strategy - Lawson Odere
Monitoring An annual risk management report will be provided to the Corporate Governance Committee on progress with implementation of the Strategy and achievements against the Performance Indicators supplemented by ad hoc reports on specific risk management priorities as required. All departments and directorates are required to undertake risk assessments of a range of issues and to demonstrate compliance with this through quarterly Health and Safety Compliance audits. In order to support further development, the Trust will continue to benchmark performance against national and international best practice.Associated Policies and Procedures• Aggregating Data and Learning from •Induction PolicyIncidents, Complaints and Claims Policy • Major Incident Plan• Being Open Policy • Management and Reporting of Accidents and Incidents Policy• Business Continuity Policy •Mandatory Training Policy• Claims Management Policy •Maternity Clinical Risk Management Strategy• Concerns and Complaints Policy •Risk Register-Policy for Management and Use• Disciplinary Policy/Procedure •Serious Untoward Incident Reporting and Management Policy• Dress and Appearance Policy •The ordering, storage and administration of all medicinal• Hand Hygiene Policy substances in The Newcastle upon Tyne Hospitals NHS• Incidents, Accidents and the Trust Foundation Trust policyDisciplinary Process - Guidelines for •Training in the Safe Use of Medical Devices policyManagers, Clinical Directors and •Health & Safety Operational PolicyEmployees. •Procedure for the Prescribing Recording and Administering of Medicines. Risk Management Strategy - Lawson Odere 6
Objective(s) and action Responsibility TimetableDissemination of the Strategy across the organisationPublish the Risk Management Strategy both internally Director of Quality and Effectiveness As indicatedand externally as outlined above.Ensure that all managers are aware of the Risk Director of Quality and Effectiveness As indicatedManagement Strategy and that relevant staff Directorate and Departmentalrecognise their specific risk management management teamsresponsibilities as appropriate to their role.Implementation of the strategy across the organisationEnsure that all Board members, Senior Managers, Corporate Governance Committee As agreedDirectorate Managers and Clinical Directors receive supported by Director of Quality andtraining in risk identification, analysis, control, Effectivenessmonitoring and review including the management ofproject risks, and risk management in businessdevelopment and service delivery.Ensure that all relevant Managers receive training on Director of Quality and Effectiveness As indicatedutilising key risk management information systems forthe management of incidents, complaints, claims,risks and use aggregated risk information in decisionmaking and business planning.Review progress against the Risk Management Director of Quality and Effectiveness Bi-monthly report to CorporateStrategy Performance Indicators. Governance CommitteeTo ensure that all staff groups receive Mandatory Head of Training and Development As indicated intraining/ Risk Management training as defined by the Induction/Mandatory TrainingNHSLA Acute Standards. PolicyDirectorate Risk Management Support• Review of the Directorate self assessment risk Directorate Management Team, As indicatedreviews supported by Risk Risk Management and• Implementation of a standardised approach to risk Safety Manager and Director of Qualityassessment for all identified key risks and Effectiveness• Refinement of action plans to address key risks• Development/refinement of Trust based 7 Risk Management Strategy - Lawson Odere
The Six Million Dollar Questions:1. Is risk assessment, prediction, and management a major priorityin our high security hospitals?2. Is there anyone in senior clinical management in our highsecurity hospitals who is capable of implementing and drivingthrough an organisational-wide combined research and managerialstrategy for risk assessment and management? My Answers:1. YES - and this is the UK government answer also.2. NOT YET. Risk Management Strategy - Lawson Odere 8
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