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Risk Management Procedure

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Risk Management Procedure Is th is polic C y curre heck th nt? e intran to find et the late v st ersion! Risk Management Procedure Version: 2.7 Bodies consulted: Management Team Approved by: Management Team Date Approved: 24 July 2020 Lead Manager: Associate Director of Quality and Governance Responsible Director: Deputy Chief Executive Date issued: July 2020 Modifications: Feb 2021 Review date: July 2021 Intranet? Extranet? Risk Management Procedure v2.7 Feb 2021 Page 1 of 43 Audit trail Date Amendments Name February Section 5.3 H& S Manager responsibilities updated– operational lead for 2021 infection prevent & control, (IPC) with accountability to the Director IPC Section 6 – updated to confirm only staff with risk user permissions can log a new risk. Section 10 -References reviewed and updated Removal of the paper ‘risk assessment pro forma’ June The procedure has been updated throughout to encompass the Marion 2020 processes and procedures required to use the electronic risk register, or Shipman, AD alternatively to continue with the current system. In addition the Quality and governance processes for reviewing education risks is updated in sections Governance 6.8.3 and 6.9.2. March Marion 2019 6.14.2 ….the following work streams to an agreed reporting schedule: Shipman, AD Clinical Quality and Patient Experience Quality and Corporate Governance and Risk Governance Information Governance Patient Safety and Clinical Risk Estates and Facilities Compliance Group Additional group added 6.14.3 The following wording has been removed, ‘All reports submitted to the CQSG by the work streams are first reviewed by the Executive Management Team to ensure that operational risks are being appropriately addressed.’ New section added 6.6.6 ‘The Trust will be moving towards a single electronic risk register during 2019 and this Procedure will be updated accordingly. Relevant reports will be set up for appropriate monitoring.’ 6.9.2 ‘Risks scoring 9-25 must be escalated by the risk owner to the EMT. EMT will review the risk, current and target risk level, proposed treatment plan and risk review date. If considered a strategic risk it will be added to the Board Assurance Framework.’ Additional wording is, EMT will confirm the ongoing monitoring group. ‘Risks scoring 9-12 ….These risks will be managed at director level; monitored by the ongoing monitoring group confirmed by EMT, with assurance to CQSG committees via the relevant work stream. 6.8.2 ‘The Executive Management Team (EMT) will review the strategic risks 15+ on a monthly basis, all strategic risks quarterly and the Operational Risk Register for risks 9+ three times a year.’ This has been amended to 15+ risks…. Section 6.8.3 ‘The Board of Directors will receive 9+ risks on the operational risk register to note three times a year alongside the BAF.’ This has been amended to 15+ risks…. Section 8 Process for monitoring compliance with this Procedure ‘The Operational Risk Register will be reviewed annually by the Executive Management Team and Board of Directors….’ Amend to read, ‘Operational Risk Register risks level 12+ will be reviewed three times a year by the Executive Management Team and Board of Directors….’ Appendix 2 Risk Assessment Pro forma updated Risk Management Procedure v2.7 Feb 2021 Page 2 of 43 Appendix 4 Risk Management Flowchart updated line from EMT to operational monitoring group July Trust NHS graphic updated Marion 2018 Section 5 updated with ‘Training and Education Programme Management Shipman, AD Board’ amended to ‘Training and Education Committee’ Quality and ‘Director for Education’ title amended to ‘Director of Education and Governance Training / Dean of Postgraduate Studies for education and training’ Board and Council Committee Structure added May 2018 Appendix 2 updated Risk Assessment Pro forma Marion Appendix 3 updated Risk Score Definitions and Matrix Shipman, AD New Appendix 4: Risk Management Flowchart, which outlines the who risk Quality and management procedure on a single page Governance Risk Management Procedure v2.7 Feb 2021 Page 3 of 43 Contents 1 Introduction .................................................................................................. 5 2 Purpose ......................................................................................................... 6 3 Scope ............................................................................................................ 6 4 Definitions .................................................................................................... 6 5 Individual roles and responsibilities............................................................... 7 6 Procedure summary and principles .............................................................. 11 Risk Register Management Flowchart .................................................................. 12 6.1 Introduction to risk management .................................................................................. 13 6.2 Identifying risks ................................................................................................................... 13 6.3 Logging risks ........................................................................................................................ 15 6.4 Guidance on risk scores .................................................................................................... 18 6.5 Submitting risks ................................................................................................................... 19 6.6 Approving risks .................................................................................................................... 23 6.7 Updating risks ...................................................................................................................... 23 6.8 Monitoring risks ................................................................................................................... 25 6.9 Reporting on risks ............................................................................................................... 29 6.10 Aggregating Risks ............................................................................................................. 31 7 Viewing Risks: Dashboards .......................................................................... 32 7.1 All Staff Risk Dashboard .................................................................................................. 32 7.2 Operational Dashboard .................................................................................................... 33 7.3 Module Admin Dashboard ............................................................................................... 33 7.4 Monitoring Group Dashboard ........................................................................................ 33 8 Training Requirements ................................................................................ 34 9 Process for monitoring compliance with this Procedure ............................... 35 10 References .................................................................................................. 35 11 Associated documents ................................................................................ 36 Appendix 1: Equality Analysis ............................................................................. 37 Appendix 2: Risk Score Definitions and Matrix ................................................... 39 Appendix 3: Definitions ...................................................................................... 41 Appendix 4: Reporting structures ....................................................................... 43 Risk Management Procedure v2.7 Feb 2021 Page 4 of 43 1 Introduction 1.1 The Tavistock and Portman NHS Foundation Trust (the Trust) recognises that healthcare provision and the activities associated with caring for patients, employing staff, providing premises, managing finances and operating in a public sector environment are all, by their very nature undertakings that involve a degree of risk. 1.2 The Trust is committed to creating a safe and secure environment in which high quality care and education can be provided. As an important step in fulfilling this commitment is that we will ensure that all types of risk (corporate, clinical and operational including health and safety) are appropriately identified, assessed and managed. This procedure should be read in conjunction with the Trust’s Risk Management Policy and Strategy. 1.3 Before the Trust can manage and control the risks it faces, it first needs to identify and then assess them. When completing this process it is important to keep in mind that risks only exist in relation to objectives of the service, directorate or Trust. 1.4 The Trust is moving all risks, with the exception of ‘patient’ and ‘project risks’, to an electronic platform during 2020. Implementation will take place in a structured roll out process alongside training. Until services and teams are moved onto the new platform they should follow the same procedures using the current risk assessment pro forma and centrally held excel risk register. 1.5 Once a service has moved to the electronic risk register it should not use the paper version of the risk assessment form. Risk Management Procedure v2.7 Feb 2021 Page 5 of 43 2 Purpose The purpose of this procedure is To ensure that a consistent approach to the application of risk assessment techniques is applied across all services within the Trust in order to manage and mitigate risks; To create
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