Risk Register National Primary Care QPS Division Risk Register Workshop 12 th Sept 2014
Risk Registers : what s it all about? Principle National Initiatives and Drivers HSE Policy Governance of Health Service Quality and Risk Framework Legislation - i.e. The Safety, Health and Welfare at Work Act 2005 Clinical Indemnity Scheme HIQA etc.
HSE Quality and Risk Standard Statement of Standard Healthcare quality and risk are effectively managed through implementation of an integrated quality and risk management system that ensures continuous quality improvement. Quality and risk are complementary and together they are a key component of healthcare governance
What do effective quality and risk management systems result in? Better patient care and outcomes Systematic identification of organisational weaknesses Improved governance and accountability structures Proactive approach to managing risk resulting/reduction in errors Fewer complaints A more open culture Improved communication with stakeholders Better decision making at all levels and better resource planning and utilisation Compliance with legislation Improved public perception and confidence/improved reputation
What is risk? Risk is defined as; The chance of something happening that has an impact on the objectives of the Organisation.
Risk Registers : what are they? A Risk Register is a summary of risks which threaten the organisation, its staff and service users The risks are rated and intended actions recorded
Why use a Risk Register Systematic process for identifying and managing issues related to risk Provides a prioritised list of identified gaps in quality from which improvement actions can be planned. Assists in decision making. Assists in allocating resources to areas of high risk Provides information for business/project planning. Monitors performance of improvement action plans. Meets your controls assurance requirements.
Quality & Safety Primary Care Division Recent Developments Procedure for Management of Risks Primary Care Division Risk Register Escalation Flowchart National Primary Care Division Risk Register in consultation with ISA s Quality & Risk a core part of business
National Primary Care Division Management Team & Structures
What Level are we looking at today? Location/ Management unit Dingley Dell Ambulance Trust Risk Assessor Bodmin Moore Date 14/10/99 Date of Review 1/12/99 ADEQUACY OF RISK ASSESSMENT Risk EXISTING CONTROLS Consequences Likelihood RISK RATING RISK Ref. DESCRIPTION OF RISK A I U (C) (l) (Cxl) RANKING 1 Back injuries to ambulance staff 3 4 12 3 2 Patient falling out the back of an 4 1 4 6 ambulance 3 Damage (and possible personal 3 5 15 2= injury) to new ambulances with power-assisted steering 4 Dangerous exhaust fume build up 5 2 10 4 in main ambulance depot 5 Trust bankrupcy through policy of 3 5 15 2= not charging for providing cover at local fairs 6 Public outrage at charging for 1 5 5 5 providing local fair cover 7 'Putting people at risk' at fair 5 4 20 1 through inadequate ambulance cover Etc. A = Adequate I = Inadequate U = Uncertain Multiple fatalities 5 Single fatality 4 Major 3 Serious 2 Minor 1 Negligible 0 Certain 5 Likely 4 Possible 3 Unlikely 2 Rare 1 Impossible 0 Information Location/ Management unit Dingley Dell Ambulance Trust Risk Assessor Bodmin Moore Date 14/10/99 Date of Review 1/12/99 ADEQUACY OF RISK ASSESSMENT Risk EXISTING CONTROLS Consequences Likelihood RISK RATING RISK Ref. DESCRIPTION OF RISK A I U (C) (l) (Cxl) RANKING 1 Back injuries to ambulance staff 3 4 12 3 2 Patient falling out the back of an 4 1 4 6 ambulance 3 Damage (and possible personal 3 5 15 2= injury) to new ambulances with power-assisted steering 4 Dangerous exhaust fume build up 5 2 10 4 in main ambulance depot 5 Trust bankrupcy through policy of 3 5 15 2= not charging for providing cover at local fairs 6 Public outrage at charging for 1 5 5 5 providing local fair cover 7 'Putting people at risk' at fair 5 4 20 1 through inadequate ambulance cover Etc. A = Adequate I = Inadequate U = Uncertain Multiple fatalities 5 Single fatality 4 Major 3 Serious 2 Minor 1 Negligible 0 Certain 5 Likely 4 Possible 3 Unlikely 2 Rare 1 Impossible 0 RISK REGISTER Page 1 of? Location/ Management unit Dingley Dell Ambulance Trust Risk Assessor Bodmin Moore Date 14/10/99 Date of Review 1/12/99 ADEQUACY OF RISK ASSESSMENT Risk EXISTING CONTROLS Consequences Likelihood RISK RATING RISK Ref. DESCRIPTION OF RISK A I U (C) (l) (Cxl) RANKING 1 Back injuries to ambulance staff 3 4 12 3 2 Patient falling out the back of an 4 1 4 6 ambulance 3 Damage (and possible personal 3 5 15 2= injury) to new ambulances with power-assisted steering 4 Dangerous exhaust fume build up 5 2 10 4 in main ambulance depot 5 Trust bankrupcy through policy of 3 5 15 2= not charging for providing cover at local fairs 6 Public outrage at charging for 1 5 5 5 providing local fair cover 7 'Putting people at risk' at fair 5 4 20 1 through inadequate ambulance cover Etc. Location/ Management unit Location/ Management unit Dingley Dell Ambulance Trust Risk Assessor A = Adequate I = Inadequate U = Uncertain Multiple fatalities 5 Single fatality 4 Major 3 Serious 2 Minor 1 Negligible 0 Certain 5 Likely 4 Possible 3 Unlikely 2 Rare 1 Impossible 0 Bodmin Moore Date 14/10/99 Date of Review 1/12/99 ADEQUACY OF RISK ASSESSMENT Risk EXISTING CONTROLS Consequences Likelihood RISK RATING RISK Ref. DESCRIPTION OF RISK A I U (C) (l) (Cxl) RANKING 1 Back injuries to ambulance staff 3 4 12 3 2 Patient falling out the back of an 4 1 4 6 ambulance 3 Damage (and possible personal 3 5 15 2= injury) to new ambulances with power-assisted steering 4 Dangerous exhaust fume build up 5 2 10 4 in main ambulance depot 5 Trust bankrupcy through policy of 3 5 15 2= not charging for providing cover at local fairs 6 Public outrage at charging for 1 5 5 5 providing local fair cover 7 'Putting people at risk' at fair 5 4 20 1 through inadequate ambulance cover Etc. Location/ Management unit Dingley Dell Ambulance Trust Dingley Dell Ambulance Trust Risk Assessor Risk Assessor Bodmin Moore Date 14/10/99 Date of Review A = Adequate I = Inadequate U = Uncertain Multiple fatalities 5 Single fatality 4 Major 3 Serious 2 Minor 1 Negligible 0 Certain 5 Likely 4 Possible 3 Unlikely 2 Rare 1 Impossible 0 Bodmin Moore Date 14/10/99 Date of Review 1/12/99 ADEQUACY OF RISK ASSESSMENT Risk EXISTING CONTROLS Consequences Likelihood RISK RATING RISK Ref. DESCRIPTION OF RISK A I U (C) (l) (Cxl) RANKING 1 Back injuries to ambulance staff 3 4 12 3 2 Patient falling out the back of an 4 1 4 6 ambulance 3 Damage (and possible personal 3 5 15 2= injury) to new ambulances with power-assisted steering 4 Dangerous exhaust fume build up 5 2 10 4 in main ambulance depot 5 Trust bankrupcy through policy of 3 5 15 2= not charging for providing cover at local fairs 6 Public outrage at charging for 1 5 5 5 providing local fair cover 7 'Putting people at risk' at fair 5 4 20 1 through inadequate ambulance cover Etc. A = Adequate I = Inadequate U = Uncertain Multiple fatalities 5 Single fatality 4 Major 3 Serious 2 Minor 1 Negligible 0 Certain 5 Likely 4 Possible 3 Unlikely 2 Rare 1 Impossible 0 1/12/99 ADEQUACY OF RISK ASSESSMENT Risk EXISTING CONTROLS Consequences Likelihood RISK RATING RISK Ref. DESCRIPTION OF RISK A I U (C) (l) (Cxl) RANKING 1 Back injuries to ambulance staff 3 4 12 3 2 Patient falling out the back of an 4 1 4 6 ambulance 3 Damage (and possible personal 3 5 15 2= injury) to new ambulances with power-assisted steering 4 Dangerous exhaust fume build up 5 2 10 4 in main ambulance depot 5 Trust bankrupcy through policy of 3 5 15 2= not charging for providing cover at local fairs 6 Public outrage at charging for 1 5 5 5 providing local fair cover 7 'Putting people at risk' at fair 5 4 20 1 through inadequate ambulance cover Etc. A = Adequate I = Inadequate U = Uncertain Multiple fatalities 5 Single fatality 4 Major 3 Serious 2 Minor 1 Negligible 0 Certain 5 Likely 4 Possible 3 Unlikely 2 Rare 1 Impossible 0 Location/ Management unit Dingley Dell Ambulance Trust Risk Assessor Bodmin Moore Date 14/10/99 Date of Review 1/12/99 ADEQUACY OF RISK ASSESSMENT Risk EXISTING CONTROLS Consequences Likelihood RISK RATING RISK Ref. DESCRIPTION OF RISK A I U (C) (l) (Cxl) RANKING 1 Back injuries to ambulance staff 3 4 12 3 2 Patient falling out the back of an 4 1 4 6 ambulance 3 Damage (and possible personal 3 5 15 2= injury) to new ambulances with power-assisted steering 4 Dangerous exhaust fume build up 5 2 10 4 in main ambulance depot 5 Trust bankrupcy through policy of 3 5 15 2= not charging for providing cover at local fairs 6 Public outrage at charging for 1 5 5 5 providing local fair cover 7 'Putting people at risk' at fair 5 4 20 1 through inadequate ambulance cover Etc. A = Adequate I = Inadequate U = Uncertain Multiple fatalities 5 Single fatality 4 Major 3 Serious 2 Minor 1 Negligible 0 Certain 5 Likely 4 Possible 3 Unlikely 2 Rare 1 Impossible 0 Resources/Action/Improvement National Director Primary Care Aggregation Filtering/ Escalation RISK REGISTER Page 1 of? Aggregation Integrated Service Area (ISA) RISK REGISTER Page 1 of? Community Aggregation Departments/ Care Groups Front line RISK REGISTER Page 1 of? RISK REGISTER Page 1 of? RISK REGISTER Page 1 of? RISK REGISTER Page 1 of? Site Specific
Departmental/Site Specific Risk Registers Develop risk register (In line with Developing and Populating a Risk Register Best Practice Guidance documents) http://hsenet.hse.ie/intranet/qualitypatientsafety Manage & monitor risk or treat locally Do controls need to be escalated to management? Are the controls beyond the capacity & resources of staff in the department to manage? Decision?
Examples of Risks on National Primary Care Risk Register Client needs in relation to aids and appliance not being met due to budget restrictions even where they have been assessed as being a high risk category. Risk of medication administration errors affecting Patients. Risk to the safe delivery of services to patients and clients in the community arising from the recruitment moratorium and the non replacement of staff. Risk associated with lack of standardised and integrated ICT systems and structures throughout the health services.
What are the key objectives of your service? Using all of the sources of risk information available to your Service identify the risks that impact or prevent you delivering on the key objectives of your Service?
Sources of Risk Information
Making Risk Registers a Useful tool Must be locally based and easy to use Must be reviewed and updated regularly Must be part of local management arrangements and processes Important that staff across all disciplines and professions are involved
Next steps Collate information from this workshop Meet with management to complete register e.g. Care Group/Division/Hospital etc. Use register as a key tool for monitoring action plans developed Build on register as new risks are identified. Assessment against the standards for Safer Better Healthcare (June 2012).
Next steps Standard 3.1 Standard 3.1: Service providers protect service users from the risk of harm associated with the design and delivery of healthcare. Essential Element: Effective Risk Management System An effective risk management system at all levels of service delivery to protect users and the workforce.
Contact Details National Quality & Patient Safety Division Primary Care Health Service Executive West, St. Mary s HQ, Castlebar, Co. Mayo Ph: 094 90 49059 Ext: 1059 Fax: 094 90 24730 Email: Angela.Alder@hse.ie Rachel.McEvoy@hse.ie Roger.clarke@hse.ie Note: Risk Management Link (for documents and forms) http://www.hse.ie/eng/about/who/qualityandpatientsafety/resourcesi ntelligence/quality and_patient_safety_documents/riskmgmt.html Acknowledgements: QPS DML
QPS Primary Care Division would also like to thank QPS DML for the use of some