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The Risk Management Process (AS/NZS 4360, Chapter 3)
Identify risks Establish the context Analyse the risks Evaluate the risks “Treat” risks Communicate and consult Monitor and review No changes
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Risk Management Process Risk Assessments & Risk Registers
Establish the context Monitor and review Communicate and consult Identify risks Assess Risks Analyse the risks Evaluate the risks Treat the risks No changes
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Identifying risks: where?
Service User Organisation Support Systems Environment of Care No changes How to tackle risk management? Structure - times of risk - clinical - standards of care, personal well-being, health and safety, control of infection, waste management, fire, security, occupational health organisation - information, personnel finance, contracting
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Risk Identification: how?
External Audits External Inspections New legislation and policy Mental Health Commission Hospital Advisory Service Health & Social Services Regulation & Improvement Authority Internal Incidents Complaints Sickness absence / staffing levels Risk assessments Audits Team meetings / workshops No changes
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Risk Analysis Using information to determine the likelihood of reoccurrence and severity of impact
Almost Certain Likelihood Rare No changes Insignificant Severity Catastrophic
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The response: Controlling / Treating Risk
Risk Mitigation Reducing the Impact Likelihood Risk Prevention No changes Severity of Impact
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Risk Treatment Options
TRANSFER ELIMINATE or AVOID REDUCE ACCEPT No changes
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The Role and Responsibility of the Trust
Organise for risk management Establish policies and procedures Training and education Gather information Share information Manage incidents, claims and complaints Learn from these Prevent future adverse incidents No changes Explaining what is involved - reassuring that much of this is ongoing. Organising involves ensuring that there is a CO-ORDINATING reasponsibility in each area, and that all the various groups and functions they will hear about actually talk to each other. Establishing policies etc gives the opportunity to talk about examples (waste handling, theatre procedure, contractors procedure, food handling etc etc) Training and education - eg lifting technique ---- risk assessment Information - incident reporting - and near miss reporting These poijnt s should reinforce the initial point of the importanc eof how reporting and RM in general is organised. The last 2 points refer to the panoply of control mechanisms - you can expand on this dependent on time - eg physical controls like security and fire measures, through equipment maintenance and training programmes to training and policies on good communications with patients.
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The Role and Responsibility of Managers
Risk Management Strategy and systems Promoting Risk Management awareness Ensuring Risk Assessments completed and communicated Encouraging adverse event / incident reporting, near miss, and learning Releasing staff for training Identify and release staff to act as risk assessors Monitoring professional/clinical and social care standards Ensure compliance with standards and legislation No changes This should say - who this will be (what level - how to workt out who it is!!), what they will be co-ordinating and, possible, who this will be reported to.
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Your Role and Responsibility
Report incidents and near misses Report concerns/risks Get involved in assessing risk Learn from complaints Maintain confidentiality Be aware of professional standards and legal responsibilities Deliver safe professional/clinical and social care Be familiar and comply with the Trust Risk Management policies and systems No changes We need 2 or 3 bullet points for each level
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The Trusts’ commitment to you: Trust Policy Statement – Incident Reporting
The Trust believe that the systematic identification, analysis and control of risk will be facilitated by effective incident recording, which will be afforded a high priority within the Trust. An educational process and the establishment of a supportive, open and learning culture that encourages staff to report mistakes, incidents and near misses through the appropriate channels will underpin this. Amend slide to reflect local arrangements
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Trust Policy Statement – Incident Reporting
The Trust supports an open and fair culture that means: Staff who make a prompt and honest report in relation to an incident, near miss or mistake will not be disciplined except under the following circumstances : Where the member of staff acted in a criminal deliberate or malicious manner Where the member of staff is guilty of wilful or gross carelessness or neglect contravening the Trust policies and procedures and/or professional codes of conduct and could reasonably be expected to appreciate the direct consequences of his/her behaviour Where an incident follows other similar incidents of a similar nature and the Trust has provided all necessary training, counselling and supervision to prevent a reoccurrence Amend slide to reflect local arrangements
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Flow of information Incident/Near Miss identified Serious Incident
Inform manager immediately. Out of hours inform Manager On Call Incident form completed by member of staff or departmental supervisor Send White copy form A to CEO for data entry Send blue copy A and B plus white copy form B, to departmental manager for investigation, risk classification and action. Leave Pink copy in the book Amend slide to reflect local arrangements Send white copy form B to CEO for completion of data entry
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Complaints review Committee Trust Board Audit Committee
Executive Management Board Clinical & Social Care Governance/Risk management Committee Miscellaneous risk groups . Controls Assurance Leads Group Clinical & Social Care Governance/Risk Management Action Team Mental Health Elderly Physical Health and Disability Family and Child Care Primary care/ AHPs, Dental, Nursing Health Visiting Family Planning Learning Amend slide to reflect local arrangements Corporate Support Functions
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Learning lessons: a practical example
Community equipment Elderly lady injured Incident investigated Multi-disciplinary review team Implement service changes Share learning Amend slide to reflect lessons learnt relevant to your own Trust
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If in doubt – contact your line manager!!
Not sure what to do ? incident hazards/risk ? claim ? If in doubt – contact your line manager!! near miss ? complaint
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Thank you ?'s
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