Board of Directors 24 October 2014
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1 Board of Directors 24 October 2014 AGENDA ITEM: Item 16 PRESENTED BY: Richard Jones, Trust Secretary & Head of Governance PREPARED BY: DATE PREPARED: 19 September 2014 Richard Jones, Trust Secretary & Head of Governance SUBJECT: PURPOSE: Risk appetite report and proposals Approval EXECUTIVE SUMMARY: Following a risk maturity audit carried out by Baker Tilley and part of the Board Governance review it was agreed and review the current risk matrix and through this the Trust s risk appetite.. It has been identified that the majority of trusts including WSFT use a simple 5x5 matrix with the risk rating based on a multiplication of the likelihood and consequence scores. This can cause confusion where different risks can have the same calculated score but very different impacts e.g. 3x5=15 (Risk rating = Amber) or 5x3=15 (Risk rating = Amber). One risk has a moderate likelihood and high consequence while the other risk has a high likelihood and moderate consequence. It is proposed that the Trust moves away from the simplistic calculation to derive the Risk Rating and introduces a matrix which differentiates between Risk Ratings for likelihood and consequence, placing greater emphasis on the consequence score when determining the Risk Rating. The risk likelihood descriptors have also been amended, providing a clearer description for those grading the risk. It is anticipated this will provide greater consistency in the scoring for likelihood for risks and incidents. Implementation of the change will be supported by appropriate training and guidance. Appendix A sets out the current and proposed risk scoring and risk matrix. Any changes made to the current risk matrix will have an impact on: - New risk assessments - with risk rating derived using the new matrix - Existing risk assessments, including the BAF (risk ratings may be down or up based on the new descriptors and matrix), The following risk assessments will be targeted for review and update with the responsible leads: o Risks previously scoring 15 (3(L) x 5(C)) which are now Red = 57 o Risks previously scoring 10 (2(l) x 5(C)) which are now Amber = 12 o The risk rating for all other risks remains unchanged and will therefore be reviewed in accordance with their existing schedule - A range of policies and procedures including: Risk Assessment, Incident reporting and Management, Strategy and Policy for Risk Management and Health, Safety and Welfare) and potential harm incident grading. - Datix forms and reporting
2 The revised matrix will not impact any external reporting to agencies or SIRIs as these are based on actual harm which remains unchanged. Appendix B details the implementation plan for the roll-out of the proposed changes. Linked Strategic objective (link to website) Issue previously considered by: (e.g. committees or forums) Risk description: (including reference Risk Register and BAF if applicable) Description of assurances: Summarise any evidence (positive/negative) regarding the reliability of the report Legislation / Regulatory requirements: Other key issues: Recommendation: 6. To deliver and demonstrate rigorous and transparent corporate and quality governance Board workshop (with Internal Audit). Annual governance review. Operational Steering Group and TEG (Oct 14). Failure effectively prioritise, manage and escalate risks within the Trust. Review of national guidance. Internal and External Audit review of the effectiveness of our risk management arrangements H&S regulations require an effective system to be in place to assess and prioritise risks. This is also reflected in the Quality Governance requirements or Monitor and the CQC regulations. The proposal is consistent with these requirements. Implementation plan (Appendix B) sets out the arrangements to implement the proposed changes. 1. To approve the proposal to introduce a revised risk matrix based on actual likelihood and consequence and the implementation plan for this change
3 Appendix A Risk Assessment guidance sheet- Current and Proposed Likelihood Matrix: Current Likelihood Almost certain Likely Possible Unlikely Rare Proposed Likelihood Weekly Quarterly Annually 5-yearly 20-yearly Description Will undoubtedly happen/recur possibly frequently Will probably happen/recur but it not a persisting issue Might happen or recur occasionally Do not expect it to happen/recur but it is possible it may do so This will probably never happen/recur Description Expected to occur weekly Expected to occur quarterly Expected to occur once a year Expected to occur once every 5 years Expected to occur once every 20 years or less The Risk is the likelihood by the consequence, as seen in the matrix below: Current Consequence of harm Likelihood of harm Negligible (1) Minor (2) Moderate (3) Major (4) Catastrophic (5) Almost Certain (5) Likely (4) Possible (3) Unlikely (2) Rare (1) Proposed Consequence of harm Likelihood of harm Negligible (1) Minor (2) Moderate (3) Major (4) Catastrophic (5) Weekly (5) Quarterly (4) Annually (3) yearly (2) yearly (1)
4 Consequence Matrix: Impact on the safety of patients, staff or public (physical/ psychological harm) Negligible Minor Moderate Major Catastrophic Minimal injury requiring no/minimal intervention or treatment. No time off work required Minor injury or illness requiring minor intervention. Requiring time off work for <3 days. Increase in length of hospital stay by 1-3 days Moderate injury requiring professional intervention. Requiring time off work for 4-14 days. RIDDOR / agency reportable incident. An event which impacts on a small number of patients Major injury leading to long-term incapacity/disability. Requiring time off work for >14 days. Increase in length of hospital stay by >15 days. Mismanagement of patient care with long-term effects Incident leading to death. Multiple permanent injuries or irreversible health effects. An event which impacts on a large number of patients Experience / complaints Unsatisfactory service or experience not directly related to care. No impact or risk to provision of care Unsatisfactory service or experience related to care, usually a single resolvable issue. Minimal impact and relative minimal risk to the provision of care or the service. No real risk of litigation. Basic administration error Attitude of staff but with low impact on patient experience Delays in outpatient clinics Lack of communication/ information (administrative/ nursing with low level impact on patient experience) Delays in TTOs ( to take out, medicines to be taken away by a patient being discharged) Problems with facilities/ premises (eg car parking) Unsatisfactory patient experience, readily resolved or easily resolvable Low staffing levels that reduce the quality of service Service or experience below reasonable expectations in several ways, but not causing lasting problems. Has potential to impact on service provision. Some potential for litigation. Attitude of staff has greatly affected patient experience (normally medical/ nursing staff) Serious lack of communication/ information (medical/ nursing which has had significant effect on patient experience/ outcome) Unacceptable delays in treatment whilst an inpatient (eg awaiting emergency surgery/ investigations) Cancelled operations Insufficient pain management Serious problems with facilities/ premises serious risk to patient safety Major changes need to be implemented to systems/ procedures Local media interest likely to go public MP concerns Late delivery of service due to low staffing levels Significant issues regarding standards, quality of care and safeguarding of, or the denial of rights. Complaints with clear quality assurance or risk management issues that may cause lasting problems for the organisation. Possibility of litigation and adverse local publicity. Serious issues that may cause long-term damage, such as grossly substandard care, professional misconduct or death. Will require immediate and in-depth investigation. May involve serious safety issues. A high probability of litigation and strong possibility of adverse national publicity. Serious untoward incident Serious drug errors Delays in treatment which could cause death Clinical negligence/ equivalent Litigation Potential damage to reputation. Adverse media coverage lasting more than three days Serious & totally unacceptable suboptimal care An event which impacts on a large number of patients DOH concern Not compliance with national standards with significant risk to patients if unresolved Non-delivery of key service due to lack or staff Human resources / organisational development/ staffing/competence Statutory duty/inspections Adverse publicity/ reputation Short-term low staffing level that temporarily reduces services quality (<1 day) No or minimal impact or breach of guidance/statutory duty Rumors. Potential for public concern Low staffing level that reduces service quality Breach of statutory legislation. Reduced performance rating if unresolved Local media coverage - short-term reduction in public confidence Elements of public Late delivery of key objectives/ service due to lack of staff. Unsafe staffing level or competence (>1 day). Low staff morale. Poor staff attendance for mandatory/key training Single breach in statutory duty. Challenging external recommendations/ improvement notice Local media coverage - long-term reduction in public confidence Uncertain delivery of key objective/service due to lack of staff. Unsafe staffing level or competence (>5 days). Loss of key staff. Very low staff morale. No staff attendance for mandatory/key training Enforcement action. Multiple breaches in statutory duty. Improvement notices. Low performance rating. Critical report National media coverage with <3 days service well below reasonable public expectation Non-delivery of key objectives/service due to lack of staff. Ongoing unsafe staffing levels or competence. Loss of several key staff. No staff attending mandatory training/ key training on an ongoing basis Multiple breaches in statutory duty. Prosecution. Complete system change required. Zero performance rating. Severely critical report National media coverage with >3 days service well below reasonable public expectations. MP concerned (questions in
5 expectations not being met the house) Total loss of public confidence Business objectives/projects Finance including claims Insignificant cost increase/schedule slippage Small loss. Risk of claim remote <5 percent over project budget. Schedule slippage Loss of percent of budget. Claim less than 10, percent over project budget. Schedule slippage Loss of percent of budget. Claim between 10,000 and 100,000 Non-compliance with national percent over project budget. Schedule slippage. Key objectives not met Uncertain delivery of key objectives/loss of percent of budget. Claim between 100,000 and 1 million. Purchasers failing to pay on time Incident leading >25 percent over project budget. Schedule slippage. Key objectives not met Non-delivery of key objectives/loss of >1 percent of budget. Failure to meet specification/slippage. Loss of contract/payment by results. Claim > 1 million Service/business interruption Environmental impact Loss/interruption of >1 hour. Minimal or no impact on the Loss/interruption of >8 hours. Minor impact on Loss/interruption of >1 day. Moderate impact on Loss/interruption of >1 week. Major impact on Permanent loss of service or facility. Catastrophic impact on
6 Appendix B Action plan for implementation of new risk matrix Description Lead Due Date Completed Date Status * Proposal paper to be RJ 6 Oct 14 Green presented at TEG Proposal to be RJ 24 Oct 14 Green approved and signed off by the Board Update Datix on Test LG/MD Nov 14 Green system with new Matrix. Communication material MD,RJ,SL Nov/Dec Green to be written and 14 disseminated covering risk assessment and potential grading for incidents Revise and update all relevant policies and procedures and training presentations Review new and current Red and Amber risks including the BAF to reflect new matrix with individual leads Update live Datix with new matrix once tested and communication has been disseminated Monitor impact on potential grading of incidents MD, SL, RJ and other as determined Jan 15 Green Comments Includes: articles in the green sheet, Trust wide communications, Corporate Managers, divisional governance meetings, existing training sessions etc MD, RJ 5 Jan 15 Green To be started in November and in place for go live LG 5 Jan 15 Green SL, MD Feb 15 Green Findings incorporated into aggregated report to Board * Status Key Red Amber Green Complete Due date passed and action not complete Off trajectory - The action is behind schedule and may not be delivered On trajectory - The action is expected to be completed by the due date Completed
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