QUALITY, SAFETY & RISK COMMITTEE ORGANISATIONAL RISK REGISTER

Transcription

1 AGENDA ITEM 2.1 QUALITY, SAFETY & RISK COMMITTEE ORGANISATIONAL RISK REGISTER Executive Lead: Board Secretary/Director of Corporate Services and Governance Author: Board Secretary/Director of Corporate Services and Governance Contact Details for further information: Robert Williams, or Purpose of the Health Board Report The purpose of this report is for the Quality, Safety & Committee to review and discuss the organisational risk register and consider whether the recorded risks are appropriately assigned. The Organisational Register was last considered by the Executive Board in. Governance Link to Health Board (s) Supporting evidence The Board s key role is to ensure its Strategy Cwm Taf Cares and the related organizational objectives aligned with the Institute of Healthcare Improvement s (IHI) Triple Aim are being progressed, these in summary align with: To improve quality, safety and patient experience. To protect and improve population health. To ensure that the services provided are accessible and sustainable into the future. To provide strong governance and assurance. To ensure good value based care and treatment for our patients in line with the resources made available to the Health Board. The report focuses on providing strong governance and assurance. There are a number of assessments that help inform the content of the organisational risk register. The content of this report is informed by the University Health Board s (UHB) Management Strategy. Organisational Register Page 1 of 10 Quality, Safety & Committee

2 Engagement Who has been involved in this work? The information contained within this report has been developed following engagement with senior staff, Executive Directors and Sub Committees of the Board. Executive Board Resolution (insert ) To; APPROVE ENDORSE DISCUSS NOTE Recommendation Summarise the Impact of the Report The Committee is asked to; NOTE the update provided within this report. Equality and There are no equality & diversity implications. diversity Legal implications It is essential that the Board has robust arrangements in place to assess, capture and mitigate risks faced by the organisation, as failure to do so may have legal implications for the UHB. Population Health No impact. Quality, Safety & Patient Experience Ensuring the Board has robust risk management arrangements in place that ensure organisational risks are captured and mitigated actions are taken, is a key requisite to ensuring the quality, safety & experience of patients receiving care. Resources The risks outlined within this report have resource implications which are being addressed by the respective Executive Director leads and taken into consideration as part of the Board s IMTP processes. s and Assurance Health & Care Standards Freedom of Information This report and the organisational risk register is an integral element of the Board s risk and assurance arrangements. It should be noted that this work continues to develop. The 22 Health & Care Standards for NHS Wales are mapped into the 7 Quality Themes but within a Governance Framework. This report focuses mainly on Governance & Accountability but also spans many of the 7 quality themes. No impact Open Organisational Register Page 2 of 10 Quality, Safety & Committee

3 ORGANISATIONAL RISK REGISTER 1.SITUATION / PURPOSE OF REPORT The purpose of this report is for the Quality, Safety & Committee to review and discuss the organisational risk register and consider whether the recorded risks are appropriately assigned. The Organisational Register was last considered by the Executive Board in and is currently being updated to reflect the recent submission of the Integrated Medium Term Plan. 2. BACKGROUND / INTRODUCTION The organisational Register summarises the key live extreme risks facing the Health Board and the actions being taken to mitigate them. The Health Board manages risk through its Directorate structures and in close alignment with the Board s approved Assurance Framework. The Assurance Framework reports into the Audit Committee for periodical review, monitoring and scrutiny. It is also important for members to note that the Executive, as risk owners, are appropriately sighted and involved in the development of the organisational risk register, providing updates, including reports on mitigating actions. The organisational risk register is reviewed and where appropriate updated on a bimonthly basis with input from the Executive lead as required. All organisational risks have a lead Executive Director and the risk aligned to either the Board, or as appropriate, a sub committee of the Board to ensure appropriate review, scrutiny and where relevant updating. Each Director is responsible for the ownership of the risk(s) and the reporting of the actions in place to manage/control and/or mitigate the risks. The organisational Register is reported routinely to Committees of the Board, including on occasion to the Integrated Governance Committee for information and where appropriate, scrutiny of any risks will be considered by the appropriate sub committee. Whilst this report summarizes the detail, this report is informed by a more detailed excel based document. This is currently under review following receipt of a recent Internal Audit review of the Board s Management arrangements, which provided generally positive feedback of the Board s arrangements and a Reasonable Assurance rating (which was reported to Audit Committee. We have also recently transferred all the organisational risks onto the Datix Module. Improvement continues to be made with directorates and localities routinely completing integrated risk reporting templates that are used for exception reporting to this Committee, until a Quality, Safety & Assurance sub group is fully established, following which the appointed Chair will report into the Committee. Organisational Register Page 3 of 10 Quality, Safety & Committee

4 3. ASSESSMENT OF GOVERNANCE AND RISK ISSUES Overall analysis The organisational risk register currently includes 30 Extreme / High risks. The risks are categorised into the following groupings: Categories / Rating Extreme (rated 15-25) High (rated 8-12) Business objectives / 6 3 projects Impact on Safety 9 1 Statutory duty / 4 2 inspections Finance (including 1 1 claims) Human Resource / 2 0 Organisational Development / Staff Competence Service / Business 0 1 Interruptions Total s 22 8 High / Extreme s (Rating 20 and above) In considering the robustness of a developing organisational risk register, Board Members need to consider whether the top recorded risks are those that Members of the Board can relate to and indeed evidence that they are informing the work of the Board and its Sub-Committees in delivering its related Strategy. In this case the top risks outlined within the Organisation s risk register are; Failure to recruit medical & dental staff and its related impact on rotas going forward (also aligned with South Wales Programme outcome) Reduction in medical staff training posts Failure to recruit registered nursing staff Increasing dependency on agency staff to cover nursing and medical gaps DoLS mainly associated with the volume / backlog of related assessments Fire Safety compliance and issues with Prince Charles Hospital site (Ground & First Floor) Lack of control and capacity to accommodate all hospital follow up outpatient appointments Producing and delivering a viable 3 year integrated plan Achieving financial break even Organisational Register Page 4 of 10 Quality, Safety & Committee

5 Of the categorised risks, these have been broken down under one of our existing s. Members will also be aware of a number of changes to the organisational risk register since it was last reviewed by the Board. These include risks and also changes to ratings / levels of control and can be summarized as follows; There are currently 22 extreme and 8 high risks; The majority of assessed risks are linked with workforce shortages and the related impact, which includes GP shortages and Primary Care Sustainability; More recently, a new risk relating to the development and delivery of an Information Management & Technology (IM&T) Strategy has been added to the register. As part of the current review and update taking place, members of the Primary Care Committee have raised the risks associated with anticoagulation and also CAHM Services. Organisational Register Page 5 of 10 Quality, Safety & Committee

6 Register Category Business s / Projects (10 risks) Setting the Direction and Performance and Operational Efficiency Description of risk identified Producing a viable balanced/break even 3 year integrated plan. Reputational damage & potential legal challenge on the decision making on FNC. Failure to provide adequate capacity to ensure safe and secure storage for patient records. Initial 15 (was 20) Current Trend Controls Last Scrutiny Committee Reviewed Health Board Health Board Quality, Safety & Failure to invest in and develop Primary Care Services, across RCT and Merthyr Tydfil but particularly in the Rhondda Valley. Primary Care - Recruitment and sustainability Primary Care Committee Primary Care Committee Failure to continue to provide GP Out of Hours Services as currently configured. Failure to achieve Referral to Treatment targets (was 20) Primary Care Committee Finance, Performance & Failure to achieve the 4 hour emergency access targets and 8 hour targets. Implementation of SWP outcomes Finance, Performance & Health Board 023 Deterioration in the timescale relating to issuing concerns (complaints) responses to patients and/or carers Quality, Safety & Organisational Register Page 6 of 10 Quality, Safety & Committee

7 Register Category - Impact on Safety (10 risks) To improve quality, safety and patient experience. 007 Description of risk identified Failure to recruit medical & dental staff. Increasing dependency on Agency Staff cover in Medical and Nursing areas, which has the potential to 034 impact on continuity of care and patient safety and is actually impacting on the UHB financial position. 035 Failure to recruit registered nursing staff Reduction in training posts within various specialities & capacity to meet workload demands. Lack of control and capacity to accommodate all hospital follow up outpatient appointments. Initial Current Trend Controls (was 16) Last Reviewed Scrutiny Committee Quality, Safety & Quality, Safety & Quality, Safety & Quality, Safety & Finance, Performance & Failure to achieve Red 1 Ambulance targets. Sustainability of a safe & effective Ophthalmology Service Finance, Performance & Quality, Safety & 005 Failure to sustain services as currently configured to meet cancer targets Finance, Performance & 033 Sustaining CAMH Services Primary Care Organisational Register Page 7 of 10 Quality, Safety & Committee

8 037 New Ensuring the development, approval and implementation of a Strategy for IM&T, that is clinically led and supports staff in care delivery Health Board Register Category Statutory Duty / Inspections (6) Statutory Compliance 017 Description of risk identified Failure to meet Fire Safety Standards on ground and first floor PCH. Initial Current Trend Controls Last Reviewed Scrutiny Committee Quality, Safety & 021 Staff Competency/ Compliance with mandatory training requirements Quality, Safety & 025 Failure to meet Fire Safety Standards across the UHB Quality, Safety & Failure to achieve statutory and mandatory planned preventative maintenance (PPM) programme. Failure to appropriately apply Deprivation of Liberties Safeguards (DoLS) legislation following the West Cheshire court judgement (was 12) 016 Management of Asbestos Quality, Safety & Quality, Safety & Quality, Safety & Organisational Register Page 8 of 10 Quality, Safety & Committee

9 Register Category Finance / Including Claims (2) Financial Viability 011 Description of risk identified Failure to achieve financial balance. Initial Current Trend Controls Last Reviewed Scrutiny Committee Health Board 012 Failure to Deliver Major & Discretionary Capital programmes Capital Programme Board Register Category Human Resources / OD / Staff Competency (1) Sustainability / Organisational Development and Innovation 019 Description of risk identified Failure to achieve the Management of Absence target. Initial Current Trend Controls Last Reviewed Scrutiny Committe Finance, Performance & Register Category Service / Business Interruption (1) Business Continuity 006 Description of risk identified Discharge Delays from Acute Hospitals Initial Current (Was 16) Trend Controls Last Reviewed Scrutiny Committee Finance, Performance & Organisational Register Page 9 of 10 Quality, Safety & Committee

10 Quality, safety and patient experience The Health Board s risk management arrangements are in place to ensure risks are assessed and mitigating actions taken to improve the quality, safety and experience of patients and where appropriate escalation arrangements are in place to inform the Board via its key sub-committees. Use of resources There is a significant risk to the service if robust risk based assessment arrangements are not in place. Good governance arrangements, including effective risk management help to ensure the effective use of resources. Its important to note that routinely as part of the internal audit and assurance annual plan, 3 clinical and 1 corporate directorate undergo a governance review each year, which includes a review of its risk management arrangements. This is in addition to the organizational related audit reviews. Compliance with Legislation There may be an adverse effect on the organization if arrangements are not in place to manage and mitigate risks. Performance Assessment and monitoring of risks within the Health Board is undertaken within Directorates/Localities/Departments. The extreme / high organizational risks will be monitored by the Executive Team / Board and through the relevant Sub-Committee of the Board. As a general rule the top organizational risk register will be routinely reviewed by the Audit, Quality, Safety & and Integrated Governance Committees, although all sub Committees of the Board have a role to play in ensuring risks assigned to a sub Committee are considered as part of its work. management arrangements will also be a key element of internal audit work and key risks will help to inform the annual internal audit plan. 4. RECOMMENDATION The Quality, Safety & Committee is asked to; NOTE the update provided within this report; and DISCUSS the organisational risk register, which reflects changes suggested by the Health Board at its January 2017 meeting and that the risks are appropriately assigned to its sub Committees. Freedom of Information Open Organisational Register Page 10 of 10 Quality, Safety & Committee