Page 1 of 26 Betsi Cadwaladr University Health Board Committee paper: 7.11.13 Item: QS13/217.2 Name of Committee: Quality & Safety Committee Subject: Key Performance Indicators for Risk Management and Risk Management Arrangements within Clinical Programme Groups and Corporate Functions. Summary or Issues of Significance Situation : The Risk Management Sub Committee requires assurance that specific 'Key Performance Indicators' (KPIs) are being developed in relation to Risk functions, and that formal Risk Register arrangements are being undertaken by all Clinical Programme Groups (CPGs) and Corporate Functions (CFs). These KPIs can then be explored and measured to demonstrate progress in relation to risk within specific CPGs and CFs. Background : The Risk Management Policy and Strategy (RM01) and supporting Risk procedures require the Clinical Programme Groups and Corporate Functions to develop their internal Risk processes. Following subsequent reports regarding progress the Risk Manager was asked for an assessment and overview of the progress and arrangements of all Clinical Programme Groups and Corporate Functions to date. Assessment : An initial set of Key Performance Indicators has been developed; this will require consultation and discussion with the Risk Management Sub Committee to ensure a complete list. As specific issues of significance could be ‘lost in averages’ if looked at solely as an overview, these have been presented to demonstrate a BCUHB overview in Appendix 1 with CPG and CF Specific information in Appendix 2. Some KPIs are almost fully implemented within the CPGs and CFs - such as utilising the BCUHB Risk register template. However there are some issues raised by the Risk Management Policy & Strategy (RM01) that would appear to have been overlooked - such as CPG and CF specific Risk Management Procedures (section RA1b, page 6). A core procedure document (template) in line with the Risk Management Strategy & Policy (RM01) has been developed and circulated, so that CPGs and CFs can amend to reflect their specific internal arrangements.
Transcript
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Betsi Cadwaladr University Health Board Committee paper: 7.11.13 Item: QS13/217.2
Name of Committee:
Quality & Safety Committee
Subject: Key Performance Indicators for Risk Management and Risk Management Arrangements within Clinical Programme Groups and Corporate Functions.
Summary or Issues of Significance
Situation: The Risk Management Sub Committee requires assurance that specific 'Key Performance Indicators' (KPIs) are being developed in relation to Risk functions, and that formal Risk Register arrangements are being undertaken by all Clinical Programme Groups (CPGs) and Corporate Functions (CFs). These KPIs can then be explored and measured to demonstrate progress in relation to risk within specific CPGs and CFs. Background: The Risk Management Policy and Strategy (RM01) and supporting Risk procedures require the Clinical Programme Groups and Corporate Functions to develop their internal Risk processes. Following subsequent reports regarding progress the Risk Manager was asked for an assessment and overview of the progress and arrangements of all Clinical Programme Groups and Corporate Functions to date. Assessment: An initial set of Key Performance Indicators has been developed; this will require consultation and discussion with the Risk Management Sub Committee to ensure a complete list. As specific issues of significance could be ‘lost in averages’ if looked at solely as an overview, these have been presented to demonstrate a BCUHB overview in Appendix 1 with CPG and CF Specific information in Appendix 2. Some KPIs are almost fully implemented within the CPGs and CFs - such as utilising the BCUHB Risk register template. However there are some issues raised by the Risk Management Policy & Strategy (RM01) that would appear to have been overlooked - such as CPG and CF specific Risk Management Procedures (section RA1b, page 6). A core procedure document (template) in line with the Risk Management Strategy & Policy (RM01) has been developed and circulated, so that CPGs and CFs can amend to reflect their specific internal arrangements.
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The Risk Register work may be developed using the DatixWeb Risk Register Module – currently being trialled in Anaesthetics CPG along with the draft procedure and user guide. An overview of current progress and analysis can be seen in Appendix 3 with CPG Specific information in Appendix 4. All Clinical Programme Groups and Corporate Functions have slightly different meeting arrangements and internal mechanisms for the review of risk management and Risk Registers. The Risk Management Framework document (RM02) has been amended to advise of minimum review standards and reporting arrangements within CPGs / CFs. Next Steps: • Implement DatixWeb Risk Register Module once pilot in the
Anaesthetics CPG is concluded. • Explore future use of an internal workshop to allow Clinical
Programme Group and Corporate Function Risk leads to share issues and gain further support (once DatixWeb Risk Register Module work is completed).
Strategic Theme / Priority / Values Francis Report recommendations addressed by this paper
Making it Safe Making it Sound
Relevant legislation or Standard for Health Services
Standard 1 – Governance and accountability framework Standard 22 – Managing Risk and Health & Safety
This section is mandatory due to legal requirements Equality Impact Assessment (EqIA)
The Board and its Committees may reject papers/proposals that do not appear to satisfy the equality duty. See http://howis.wales.nhs.uk/sitesplus/861/page/47193 1.Has EqIA screening been undertaken? N (If yes, please supply a copy) 2.Has a full EqIA been undertaken? N (If yes, please supply a copy) 3.Please state how this paper supports the Strategic Equality Plan Objectives: http://howis.wales.nhs.uk/sitesplus/documents/861/sep_0412_e.pdf Development of Key Performance Indicators (KPIs) in relation to Risk Management as have been developed for Equalities issues. The current KPIs include Healthcare Standards for Wales and whilst equalities is a part of this assessment, the Risk
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Management KPIs are in relation to engagement with the whole process, but not specific to this particular strand of governance. 4.Please include a justification if no EqIA has been carried out: I have reviewed the procedure (WP7) and this report is not subject to an EqIA assessment. This report provides data and facts in relation to CPG and CF processes for Risk – there are no patient specific fields within this report.
Recommendations: (e.g for Committee approval or for noting)
To discuss and note the updated information regarding CPG/CFs Risk Management Arrangements.
Author(s) Ken Dawes – Risk Manager Presented by Mrs Angela Hopkins - Executive Director, Nursing & Midwifery
Services Date of report 25th October 2013 Date of meeting 7th November 2013
BCUHB Committee Coversheet v6 June 2013 Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board
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Appendix 1
BCUHB CORPORATE RISK PLANNING: 1. OBJECTIVES
Ref: Objective Current Status Evidence Current Score
Target Score
RA1 Safety Culture is embedded in the organisation at policy and procedural level.
Policies published and reviewed as per established periods: RM01 Risk Management Policy & Strategy RM02 Risk Management Framework (and framework tools) RM03 Procedure for receipt, distribution, action and compliance monitoring of hazard warnings and alerts.
All currently within review dates and accessible through BCUHB intranet http://howis.wales.nhs.uk/sitesplus/861/page/44944
3 3
RA2 Risk Registers have been developed as per BCUHB Procedure.
All CPGs and CFs have a Risk register that complies with the BCUHB procedure and template.
Reports to Risk Management Sub-Committee
3 3
RA3 Risk registers have full mitigation details and any specific risks escalated to the Corporate Register or Assurance Framework
Most CPG level Risk Registers have mitigation and actions against identified risks. Some CPGs and CFs are currently reviewing their risks to clarify these - supported by the Risk Manager.
Reports to Risk Management Sub-Committee
3 3
RA4 Incident Reporting System Operational and implemented across BCUHB
DatixWeb system designed and ready for BCUHB implementation. Piloted in specific areas during 2012. BCUHB wide implementation from 1st January 2013
Reports to Risk Management Sub-Committee
3 3
RA5a Incident Reports are being reviewed.
All CPGs and CFs are now reporting via DatixWeb. The first main identified issue with this system is that incidents once entered need to be reviewed.
Reports to individual CPGs and overview reports to Risk Management Sub-Committee.
3 3
RA5b Incident Reports are being approved and closed on the system
The second identified issue with this system is that incidents are actioned, approved and escalated as necessary by the line management structures concerned.
Reports to individual CPGs and overview reports to Risk Management Sub-Committee.
2 3
RA6 Improvement in Healthcare Standards for Wales assessments for BCUHB -
All Corporate Standards are reviewed by a Star Chamber process on an annual rolling programme of work. This process is now behind schedule due to recent changes to the Board
Programme of work is now in second year.
2 3
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Corporate processes
RA7 Healthcare Standards for Wales CPG / CF implementation Apr - Oct 2013
All CPG's should now have completed the first 6 months pf programme of work. Work to date has declined across many CPGs from previous year.
Quarterly reports provided to Quality and Safety Committee.
1 3
RA8 BCUHB Compliance with Safety Alerts - NPSA, MHRA, WHE, WG
Currently BCUHB fully compliant with 60% of all NPSA Patient Safety Alerts and RRRs etc. (This is an improvement on the previous quarter return of 53%). Corporate Risk Management has a process for the dissemination and collection of feedback in relation to alerts - the exact data regarding implementation can in the main only be supplied by the specific clinical areas.
Quarterly status reports from Welsh Government.A Report has been submitted to Risk Management Sub Committee detailing the areas still outstanding (21 Alerts in total)
2 3
RA9 Welsh Risk Pool assessment - improvement in scores
2012-13 Assessments to be submitted by 28th March 2013 for Clinical areas: CA1 - Maternity CA2 - Operating Departments CA3 - Emergency Departments Full assessment for Corporate 'Claims Standard'
Templates of Afa evidence required sent to all relevant CPGs - evidence collected to be hyperlinked documents to main action plan template. Reports to Risk management Sub-Committee and Quality & safety Committee
3 3
RA10 Number of 'Red' Risks on CPG or CF Level Risk Register
All CPGs and CFs are now utilising the BCUHB Template for Risk Register with specific scoring via the Model Matrix (5x5)
Latest versions received of CPG / CF Level Risk registers
RA10 Number of 'Red' Risks on CPG or CF Level Risk Register
1 0 2 3 1 3 2 1 3 2 1 3 2 1 2 1 2 3 1 3 3
Anaesthetics, Children's & Young People, Primary Care, Women’s Services, Finance and Planning (&OE), had less than 5% of Incidents waiting for review. 1a PCSM have below 20% awaiting review (but 12.7% equates to 1128 incidents) 1b MHLD have above 20% awaiting review (but 25.4%% equates to 1057 incidents)
KEY: BENCHMARK STANDARDS- CRITERIA
Level Requirement - Procedures Specific Numerical Milestones
0 No feedback - or arrangements in place < 30%
1 Structures and Arrangements being reviewed 30 - 60%
2 Arrangements made and becoming established 60 - 80%
3 Achieved or Fully Established 80% +
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Appendix 3 Risk Management Arrangements – Overview June 2013
Clinical Programme Group / Corporate Function
BCUHB Template
CPG Meeting Meeting Schedule
Mitigation details for Identified Risks
Last Formal Review
Comments / Good Practice
Primary, Community & Specialist Medicine
Yes Quality & Safety
Quarterly In Progress Jun -13
Mental Health & Learning Disabilities
Yes Management Team
Quarterly Yes Aug -13
Pharmacy & Medicines Management
Yes Quality & Safety
Bi -Monthly Yes Aug -13
Children & Young People Yes Service Board
Quarterly Yes Sep-13 DatixWeb Risk Register process commenced
Anaesthetics, Critical Care & Pain Management
Yes Quality & Safety
Monthly Yes Jul -13 DatixWeb R isk register Module - pilot
Cancer, Palliative Medicine & Clinical Haematology
Yes Risk Management
Quarterly Yes Oct -13 DatixWeb Risk Register process being discussed
Womens Services Yes Quality & Safety
Monthly Yes Aug -13 DatixWeb Risk Register process commenced
Monthly In Progress Feb-13 DatixWeb Risk Register process recommenced
Finance Yes Management Team
6 Monthly Yes Jul -12
Workforce & Organisational Development
Yes Risk Management
4 Monthly Yes Jul -13 Workshop held in May 2013 with W&OD senior leads.
Public Health Yes N/A N/A In Progress Aug -13
Therapies & Health Science Yes Risk Management (+CESC)
Bi -Monthly Yes Jul -13
All of the Clinical Programme Groups and Corporate Functions are now utilising the BCUHB Risk Register Template. The Risk manager met with the Assistant Director of Public Health in March to devise a register of specific needs, mainly based around the responsibilities of the post and operational issues.
All Clinical Programme Groups and Corporate Functions have a meeting established where the Risk registers can be formally reviewed. There is no clear standard group or meeting for this, but all Clinical Programme Group and Corporate Functions have developed these processes in line with their own internal structures. The Clinical Programme Group and Corporate Functions also all have varying timeframes for reviewing their Risk registers.
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The majority of Clinical Programme Groups and Corporate Functions have ‘existing controls’ details and further actions detailed for all risks within their Risk Registers. Some of the largest Clinical Programme Groups and Corporate Functions are currently working through and completing these mitigating actions as they are putting structures in place and pulling together information from ‘legacy’ processes.
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Some Clinical Programme Groups and Corporate Functions have utilised the Risk registers and Assurance processes to actively manage other projects and risk issues that they do not directly mitigate themselves (i.e. Anaesthetics CPG and monitoring of the RRAILS work and implementation). Many CPGs / CFs are also now developing 'closed' or 'resolved' sections of their Risk registers - to evidence risks that have been mitigated as far as practical. It is important that risks are demoted to a lower level in this way, so that a 'memory' of remedial actions and learning is available and risks can be re-escalated if necessary.
DatixWeb Risk Register Module – Anaesthetics, Criti cal Care & Pain Management CPG The Risk Manager is working with the Anaesthetics, Critical Care & Pain Management CPG to explore the use of the DatixWeb Risk Register Module. As part of this development, the Risk Manager has also drafted a ‘user guide’ which has been sent to the relevant CPG leads to appraise alongside the DatixWeb Risk register Module itself. It is envisaged that this work will then inform a procedure as an appendix that can be utilised by other Clinical Programme Groups and Corporate Functions when the module is ready to be rolled out. Pathology, Radiology, Women’s Services, Therapies & Clinical Support, Children's & young People and Cancer CPGs are also keen to be involved in thi s module. Hospital Management Teams (HMT) – many Health Board procedures and processes in relation to risk utilise a ‘linear’ structure for escalation and de-escalation of risk. As highlighted in the recent circulation of the Risk Management Guidance Template for CPGs / CFs, this does not easily facilitate involvement of specific site management (HMT). There may be an opportunity through the DatixWeb Risk Register module to set up a ‘sharing’ system for risks which involve multiple CPGs or CFs or require sharing or notification to HMT.
Recommendations: • To complete the pilot work around the DatixWeb Risk Register module and produce processes to assist the Clinical Programme
Groups and Corporate Functions with development in this area. • Explore future use of an internal workshop to allow Clinical Programme Group and Corporate Function Risk leads to share
issues and gain further support (once DatixWeb Risk Register Module work is completed).
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Appendix 4 Risk Management Arrangements – CPG / CF Specific in formation
Clinical Programme Groups.
Anaesthetics, Critical Care & Pain Management
Contact / Lead Sue Williams Associate Chief of Staff (Nursing) Dr. Kath Clarke Richard Waterson
Risks rated 15 and above
Contains 24 high level CPG risks with twelve of these rated over 15: 1. HDU within critical care (West) continues to be managed by surgeons – 25 2. Capacity within the critical care units increased from 65% to 100% - 25 3. Insufficient CPG Financial allocation – 20 4. Inability to deliver a closed Critical Care Unit West, due to insufficient funding for Anaesthesia – 20 5. Failure to control Bacteraemia C Difficile, norovirus, and VRE – 16 6. Payments for ILS courses vary across the CPG, based on legacy charges – 16 7. Lack of tier 3/on call anaesthetic trainees. Obstetrics and ITU often covered by single resident doctor – 16 8. Community dental service for children being delivered in premises which do not meet Guidelines – 16 9. Lack of consultant anaesthetic staff for day time obstetric sessions in West – 16 10. Across the three DGHs there is a lack of skilled and competent nursing staff to care for patients with tracheostomies – 16 11. Inability to deliver resuscitation training in Central due to lack of accommodation – 16 12. Arjo-Huntleigh Beds used in all 3 units moving spontaneously and potential for serious harm – 16
Mitigation Measures
Mitigation in place for all identified risks.
Assurance processes
The CPG has established regular Board meetings and produces a Quality and Safety Summary Report. As part of the management team for Anaesthetics CPG, the 'Acutely Ill Patient Steering Group has also developed a Risk register in relation to the implementation and monitoring of 'NEWS' and ‘RRAILS’. Now utilising DatixWeb Risk Register Module and dra ft procedure as part of pilot.
Cancer, Palliative Medicine & Clinical Haematology
Contact / Lead Geraint Roberts - General Manager Cancer Services Risks rated 15 and above
Contains 18 high level CPG risks with two of these rated over 15: 1. Failure to recruit Consultant Oncologists into two vacant posts - 16
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2. Increasing activity and use of high cost cancer drugs resulting in significant budget overspend - 15 Mitigation Measures
Mitigation in place for all identified risks.
Assurance processes
The CPG Risk Register is reviewed at the CPG Risk Management and Health & Safety Group. DatixWeb Risk Register process being discussed
Children & Young People
Contact / Lead Michelle Wright – Interim Governance Lead CPG risks rated 15 and above
Contains 31 high level CPG risks via the programme team registers with four of these rated over 15: 1. Ongoing medical staff shortage could affect clinical delivery of services - 16 2. Staffing levels on Paediatric Wards - inability to meet national standards, complete mandatory training, PDRs,
monitor competencies – 16 3. CAMHS Accommodation in Centre - not fit for purpose and affecting delivery of clinical activity – 16 4. Delivery of financial targets ( CRES) to achieve financial balance at year end 2012/2013 – 15 Escalated to Corporate Risk Register: • Ongoing Medical staff shortage could affect clinical delivery of services – 16 Escalation proforma completed for Corporate Register – already an entry on Corporate and Office of the Medical Director risk registers in regards to Medical Staffing issues.
Mitigation Measures
Mitigation in place for all identified risks. CYP Programme Team risk registers now incorporate a ‘Resolved’ section.
Assurance processes
Training has taken place with Senior teams within the CPG. The CPG has established a Quality & Safety Sub Group and the Risks from the Programme Teams feed into the CPG Risk Register.
Mental Health & Learning Disabilities
Contact / Lead Hilary Owen – Older Persons Service Lead Simon Pyke – Associate Chief of Staff (Operations) Adrian Jones – Associate Chief of Staff (Nursing)
Risks rated 15 and above
Contains 10 High Level Risks identified with eight of these rated over 15: 1. Adequate financial resource within the CPG – 25 2. The Hergest Unit is currently subject to a DSU improvement programme. Various concerns have been raised
about patient experience, communication, controls and process for the Mental Health Measure – 20 3. The CPG as yet, does not have a robust system for Out of Hours cover due to the reduction in the number of junior
doctors and insufficient numbers of Band 6 nurses on the main hospital sites to provide adequate cover – 20 4. Under 18’s admitted into adult environments that are unable to meet the needs of younger people – 20
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5. MDT working, often under the Mental Health Measure is the bedrock on which services are delivered. If this does not work effectively, there is a potential for poorly coordinated care and therefore a risk to patients – 16
6. The CPG has a number of risks relating to IT. Firstly, much of the hardware in place is out of date and not fit for purpose – 15
7. The current structure of CHC is under resourced to meet the demands of patient reviews. An added risk is the number of patients under IRP – 15
8. The Medium Secure Unit has an unfunded nursing, medical and therapies establishment. Patient care is compromised due to restrictions – 15
Escalated to Corporate Risk Register: • The Hergest Unit is currently subject to a DSU improvement programme. Various concerns have been raised
about patient experience, communication, controls and process for the Mental Health Measure – 20 Mitigation Measures
There are controls, actions and assurances identified for the majority of the risk register entries; The CPG Risk Register is undergoing a Quality Assurance exercise within the CPG senior Management Team.
Assurance processes
The CPG has established a Risk Management Group and Quality and Safety Group – the Risk Register developments and current progress is discussed at these meetings, and formally reviewed by the Senior Management Team.
Pathology
Contact / Lead Dr David Fletcher - Associate Chief of Staff (Operations) Arfon Jones - Governance Lead Pathology
Risks rated 15 and above
Contains 10 High Level Risks identified with two of these rated over 15: 1. Fully-integrated IT system to be successful when BCUHB implements the new LIMS system in August 2011, it is
necessary for both the WCP and WPH to be available. This would allow complete end-to-end test requesting and result reporting in Primary and Secondary care across (initially) BCUHB. Failure in the implementation of any part of these projects would compromise the successful implementation of the LIMS, possibly leading to manual input of requests rather than current electronic requesting. Delay in any part of these projects would affect implementation of LIMS, as project timelines would overlap seriously affecting staff resource. BCUHB first to implement new LIMS system. Current slippage in this implementation has increased the risk score – 20
2. Service Out of Hours (OOH) Rotas and payment vary slightly across the three sites. Current CPP systems payments protected nationally until 01/04/2011. Payment has ensured cover in the past, but there have been issues around cover for (e.g.) sickness as system has limited number of staff participating in rotas. Additional staff have been recruited, but are generically trained and require specialist (departmental) experience – 20
Mitigation Measures
Mitigation in place for all identified risks.
Assurance The CPG Risk register is reviewed by the CPG Board.
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processes The Pathology CPG Register has been entered onto the DatixWeb Risk register Module – the Corporate Risk manager has met with the CPG Leads to review the register and explore future opportunities to utilise DatixWeb.
Pharmacy & Medicines Management
Contact / Lead Louise Howard Baker - Clinical Director Pharmacy & Medicines Management (East) Risks rated 15 and above
The combined risk register contains 39 risks covering a wide range of risk issues. There are fifteen risk entries which the CPG has considered to be above 15 and high risk. There are two register entries rated at the highest level of 25: 1. Failure to meet CPG Prescribing budget – 25 2. Lack of capacity to offer adequate clinical pharmacy support to Mental Health & Learning Disabilities CPG, due to
lack of investment. Unable to realise savings due to lack of capacity to make interventions – 25 3. Planned lessening of core pharmacy services at YGC during redevelopment of department – 20 4. Reduced pharmacist staffing due to VERS and resignation. Lack of fulltime cover. Potential for service interruption
and significant delays in provision of chemotherapy – 20 5. Loss of robot due to refurbishment could result in increase in dispensing errors – 20 6. Risk of suboptimal patient care when microbiologist is absent, sole source of specialist guidance – 20 7. Problems with IV fluid deliveries and movement to specified storage rooms – 16 8. Numbers of intrathecal inections fall below safe levels at YGC and YM hospitals 9. Dispensing against a prescribing error in acute sites due to lack of junior doctors; low numbers of junior doctors,
little time, large workload – 15 10. Failure to report / monitor and respond to incidents involving controlled drugs – 15 11. Loss of bulk IV fluid storage at YGC – 15 12. Loss of core dispensing services at YGC during redevelopment project (asbestos) – 15. 13. Lack of patient information leaflets supplied with split packs and venalinks (YMH) – 15. 14. Preparation of injections at ward level – 15 15. Loss of medicines, including controlled drugs from stores at YGC – 15
Mitigation Measures
Mitigation in place for all identified risks, and some further quality assurance work has been undertaken with the Corporate Risk Manager. P&MM risk register now incorporates a ‘Closed’ sect ion with details of nine resolved issues.
Assurance processes
The P&MM CPG risk register is discussed on a quarterly basis by the P&MM Quality and Safety Group. Any significant actions are escalated through the CPG operational plan. The risk register has been discussed and agreed by the P&MM CPG Management Team.
Primary, Community & Specialist Medicine CPG
Contact / Lead Christine Lynes - Associate Chief of Staff (Nursing)
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Lowri Welnitschuk - Deputy ACoS Nursing PCSM David Lankshear – Risk & Health and Safety Lead
Risks rated 15 and above
Contains 18 High Level Risks identified with ten of these rated over 15: 1. Failure to fill Medical vacancies at YG due to recruitment issues (originally 10 vacancies outstanding). Also
significant reduction of senior Medical staff in the Diabetes service - 25 2. Lack of capacity in ED. Unable to off load patients from ambulance – 25 3. Management of Healthcare Equipment for Patients within Residential Homes or their own Home – 20 4. Develop a safe Sexual Health Clinic within the Mold Area – 16 5. Collapse and or failure of equipment not suitable for Bariatric persons - 16 6. Potential risks to outlying medical patients - 16 7. Inadequate Medical and Nursing Staffing levels can deplete the capability of the departments and could
compromise the continuity and safety of care for the Patients - 15 8. No central mechanism for the distribution and audit trail of Alerts within the CPG - 15 9. Failure to recognise and provide timely and appropriate care for seriously ill patients - 15 10. Staff cannot be fully trained and updated to the requirements of the BCUHB. In excess of 72 hrs per member of
staff to facilitate training and updating on all disciplines of mandatory training - 15 Escalated to Corporate Risk Register: • Failure to fill Medical vacancies at YG due to recruitment issues (originally 10 vacancies outstanding). Also
significant reduction of senior Medical staff in the Diabetes service - 25 Escalation proforma completed for Corporate Register – already an entry on Corporate and Office of the Medical Director risk registers in regards to Medical Staffing issues.
Mitigation Measures
There are limited controls, actions and assurances identified for a number of the risk register entries; however much work is required by the CPG with the support of the Corporate Risk Manager.
Assurance processes
A review of the register has been undertaken by the CPG with the Corporate Risk Manager and some further Quality Assurance work has been undertaken with the CPG Risk Lead in January & February 2013. The CPG Quality & Safety Committee is to review all the CPG Major & Moderate risks on a quarterly basis.
Radiology
Contact / Lead Alison Kemp - Associate Chief of Staff (Operations) Helen Hughes - Head of Quality & Governance
Risks rated 15 and above
Contains 23 high level CPG risks via the programme team registers with seven of these rated over 15: 1. Room 2 (West) - Regular fluoroscopy faults, increasing radiation dose to patients. Manufactures cannot rectify
fault in aging equipment (Installed1998). Past manufacturers’ and RCR end of life guidance - 25 2. A&C and ATO staff - Risk of not having sufficient numbers of A&C staff to cope with workload in department.
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Increased risk of potential for radiation incidents due to potential for incorrect information to be entered on to the Radiology information system. (Lapse in concentration) - 20
3. Lapse in patient care. Breakdown in communication and unaccompanied patients. Patients from wards and from A&E are left in the department unaccompanied by staff or relatives. Some are ill and immobile, for example in neck braces. Others are elderly and infirm. There is a risk that patients become ill and no-one responds - 20
4. Capital replacement backlog - the CPG have identifed a significant amount of equipment that is still in operation past its due replacement/end of life date thus not complying with current guidance - 16
5. Incorrect Markers on Radiology Images leading to incorrect interpretation/reporting – 15 6. Lack of dedicated portering support causing delays to imaging and potential increase of length of patient stay - 15 7. Continued Provision of Vascular Ultrasound service in East or Central due to being single handed - 15
Mitigation Measures
Existing controls have been identified for all of the top risks and further action has been agreed to mitigate the risks. The CPG Risk register has undergone a Quality Assurance with the Corporate Risk manager.
Assurance processes
The Radiology Risk Register is a standing item on the CPG Quality & Safety meeting. Monthly reports are presented at the CPG Board which summarises incidents reported, risk management activities, for example statutory and mandatory training, inspections etc.
Surgery & Dental CPG – no update received.
Contact / Lead Meinir Williams – Associate Chief of Staff (Nursing) Helena Blower – Theatres
Risks rated 15 and above
Contains 24 High Level Risks identified with eleven of these rated over 15: 1. Risk to patients and staff due to limited review of urgent adverse and critical events - 20 2. Unsuitable facilities for clinical services including Increased risk of incidents of V&A .Risk of injury to staff when
moving patients/equipment - 20 3. No long resectoscope available for use of patients with large bladder or long urethra - 16 4. Delay in treatment or cancellation of patients requiring major surgery for the treatment of cancer - 16 5. A number of clinics covering Wrexham area do not have appropriate areas to facilitate automated washing system
(HSDU) – 16 6. Instruments not individually identifiable, no traceability on these items.(HSDU) – 16 7. Flexible scope washers x3 situated in inappropriate area (Theatre) – 16 8. ENT uses a large number of clinical scopes (Approx 20 scopes per day) The risks here are associated with only
having one scope cleaning which can clean 3 scopes at a time (ENT) – 16 9. Issue and escalation of non conformance from notified body which could also ultimately lead to suspension of
production and therefore cancellation of procedures (HSDU) – 16 10. Risk of injury to staff due to instable trolleys for use with autoclave and hatch (HSDU) – 15
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11. Eye instrumentation being pre-washed in an ultrasonic bath prior to transfer to HSDU for packing and autoclaving (Ophthalmology) - 15
Mitigation Measures
There are limited controls, actions and assurances identified for the majority of the risk register entries; the Risk Register requires further Quality Assurance processes to rationalise the high level risks and ensure mitigation. The risk register now incorporates a ‘Closed’ secti on with details of seven resolved issues.
Assurance processes
The CPG Risk Register is reviewed at the CPG Quality & Safety Group
Therapies and Clinical Support
Contact / Lead Lynda Owen – Risk Manager Risks rated 15 and above
Contains 19 High Level Risks identified with eight of these rated over 15: 1. H & S, Fire Safety and upgrade of electrics, flooring, radiators, windows and general redecoration required within
the East OPD - 20 2. Lead Specialist Dietician - Nutrition Support – 20 3. Finance - Mutual financial gain through efficiency across CPGs. Potential for savings across CPGs - 20 4. Finance: Full compliance with decontamination legislation - 20 5. Infection Control - No WHB in Clinic Area – 20 6. Infection Control - Specialised Children's' equipment not being decontaminated – 20 7. Decontamination of Podiatry Instruments – 16 8. Decontamination of Sigmoidescopes - 16
Mitigation Measures
Register now contains mitigation measures and actions for the majority of risks. Also included are details of business cases to support actions or information regarding assurance and measures.
Assurance processes
The CPG Risk Management Sub Committee ensures that the risks identified on the risk register are updated at the meeting bi monthly. The Risk Register is then reviewed at a CPG level Quarterly by the CPG Quality & Safety Committee.
Women’s & Maternal Care
Contact / Lead Fiona Giraud Associate Chief of Staff – Nursing and Midwifery Jill Harrison – Lead Manager, Obstetrics & Gynaecology
Risks rated 15 and above
Of the 28 CPG Level Risks identified, eleven have been assessed as over 15: 1. Deliverability of Maternity Services Review and achieving Deanery Requirements– 25 2. 6 Birthing beds urgently need replacing in YGC 2013/14 and 14 beds in YG/MHW in 2014/15 - 20 3. Quality and safety of patient care compromised by the lack of team cohesion and effectiveness in the obstetrics
and gynaecology consultant team in YGC - 16
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4. Induction of Labour rates above 22% - 16 5. C-section rates above 25% - 16 6. Financial situation - break even – 16 7. Labour ward Consultant cover – 16 8. 24 hour cover (including Ultrasound pregnancy scan requests) – 16 9. No adequate Maternity IM&T system available within the Health Board. Data maintained manually – 16 10. Ward Rounds not in place in YGC – 16 11. Midwives performing recovery in obstetric theatres – 15 Escalated to Corporate Risk Register: • No adequate Maternity IM&T system available within the Health Board. Data maintained manually – 16 • 24 hour cover (including Ultrasound pregnancy scan requests) – 16 • Quality and safety of patient care compromised by the lack of team cohesion and effectiveness in the obstetrics
and gynaecology consultant team in YGC - 16 Mitigation Measures
Most risks have full mitigation measures identified; the Corporate Risk Manager has met with the CPG leads and has commenced a Quality Assurance process with the CPG.
Assurance processes
The CPG have established a Quality & Safety Group which meets monthly and risk register review is a standing agenda item. Issues of significance are escalated to CPG Board.
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Corporate Functions. Finance
Contact / Lead Huw Thomas – Assistant Director of Finance Risks rated 15 and above
The Risk Register details 10 top level risks within the Finance function, there are no 'Red' issues identified within this document but six areas assessed as 'amber'.
Mitigation Measures
Mitigation in place for all identified risks.
Assurance processes
All issues under 6 monthly reviews, or by the specific Assistant Director of Finance.
Governance and Communications
Contact / Lead Mary Popplewell – Assistant Director Risk and Assurance Risks rated 15 and above
10 High Level Risks identified with one of these rated over 15: 1. Ineffective management of asbestos during YGC Redevelopment Programme leading to an asbestos exposure and a partial loss of use of YGC – 15. This risk is included on the Governance and Communications register for compliance with the Statutory Duty under Health and Safety Regulations. More detailed risks associated with the management of asbestos are contained within the Operational Estates Risk Register. Also an entry on the Corporate Risk Register.
Mitigation Measures
Mitigation in place for all identified risks.
Assurance processes
Weekly senior management team meetings are held and discussions held in respect of Corporate Function risk issues.
Improvement & Business Support
Contact / Lead Jill Newman Assistant – Director Performance Analysis, Improvement Transformation & Delivery Support Risks rated 15 and above
Of the 8 High Level Risks identified, four have been assessed as having a risk rating above 15. 1. Team Capacity - expectation for programme management and improvement expertise from corporate function to
facilitate significant transformation change and to continue to deliver improvement capability training and small scale improvement support for efficiency gains across all CPGS – 25
2. Violence and Aggression to staff from patients via telephone contact due to length of wait for appointments – 25 3. Inadequacy or inaccuracy of information giving incorrect assurance at Board or board sub committees – 16 4. Human error in management of patient bookings, resulting in information provided to deceased patients, or
incorrect patients causing distress to patients, reputational issues and breaches of Information Governance - 16 Risks associated with work undertaken or supported by the Corporate Function
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• Failure to deliver elective access targets - 25 • Patient Harm due to delays in treatment associated with long waits - 25 • Patient Harm due to follow up backlog waiting list - 25 • Failure to improve access for Unscheduled care resulting in delays in ED and for ambulance handover, with
potential harm for patients - 25 • Failure of the Surgical or Anaesthetic CPGs to deliver the activity to the quality and standard expected within
resource allocated to them - 25 • Failure to deliver Cancer Access requirements leading to harm to patients with Cancer - 16 • Failure to engage clinical teams in 1000Lives plus work programmes - 15
Mitigation Measures
Mitigation measures have been identified against many of the risks. Corporate Risk lead has met with Corporate Function to discuss issues and escalation
Assurance processes
The Corporate Function meets formally and regularly on a monthly basis to review issues and risks.
Medical Director
Contact / Lead Dr Martin Duerden – Assistant Medical Director Primary Care Cathy Mansell – Project Manager (OMD)
Risks rated 15 and above
Of the 19 High level risks identified for the Medical Directors’ office, eight have a risk rating of 15 or above. 1. Failure to Recruit Medical Clinicians in Secondary Care – 20 2. Insufficient Medical Staff to support service provision taking account of changes to Medical training and taking account of the impact of EWTD – 20 3. Failure to commit sufficient resources to contractor performance - requires sufficient expertise and retention of staff with organisational memory and memory of contractor issues to respond with sufficient timeliness – 16 4. Failure to balance adequately knowledge & awareness of poor performance on need to know basis with limiting the extent to which further incidences of poor performance are not identified – 16 5. Lack of sufficient, authoritative support from third parties (future of NCAS, relationships with PHW, Deanery and Access to APT) – 16 6. Failure to locate and provide patient and corporate records to underpin the delivery of safe patient care in a timely manner – 16 7. Failure to ensure that regarding Medical staff - we have the right staff, with the right skills at the right time – 16 8. Failure to put 20% of Doctors, with whom BCUHB have a prescribed connection, through the revalidation process by April 2014 – 15 Escalated to Corporate Risk Register: • Insufficient Medical Staff to support service provision taking account of changes to Medical training and taking
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account of the impact of EWTD – 20 • Failure to locate and provide patient and corporate records to underpin the delivery of safe patient care in a timely
manner – 16 • Failure to put 20% of Doctors, with whom BCUHB have a prescribed connection, through the revalidation process
by April 2014 – 15 There is also a Risk register for Informatics devel oped which sits within the Medical Directors' Corpo rate Function. Of the 51 risks identified for Informatics, eleven have a risk rating of 15 or above. 1. That we may use software and applications past their suitability date e.g., when technology is outdated or support
is no longer available whilst we wait for national product to become available or whilst we secure appropriate funding for replacement products – 25
2. Lack of clarity on delivery of the National Informatics Programme – 20 3. The need to provide multi site care for patients may cause operational difficulties due to processes and logistics
e.g. medical records may be required in various locations and delays with physical delivery may result in case notes not being available when the patient is seen – 20
4. A lack of physical storage space for case notes to be filed may result in increased misfiled records, or poor record retrieval – 20
5. That funding for an EDRMS solution may not be available, that modernisation of services may not be delivered without this – 20
6. To ensure that information is dealt with legally, securely, efficiently and effectively to underpin patient care & safety – 16
7. The demands being placed upon the informatics Service continue to grow, while the resource available to meet these demands diminish or remain the same. There is a risk that service demands may not continue to be met – 16
8. Projects which depend on the resources from the NWIS integration team may be at risk due to resource constraints within the team or due to the 'make up' of the largely based contractor team' – 16
9. A sound disaster recovery strategy may not be available for the organisation to minimise disruption and ensure the continuation of business critical systems in the event of major failures – 16
10. Health and Safety risk to clinic preparation staff currently working from an outside temporary building that was condemned some time ago Risk of injury - through load handling , slips trips or falls through overcrowding Increased risk of fire due to amount of staff, paper and equipment and in a temporary building Risk to patients information due to insufficient space to store all notes in lockable cupboards – 16
11. There may be insufficient Informatics funding to deliver the transformation required for the organisation – 15 Escalated to Corporate Risk Register: • Lack of clarity on delivery of the National Informatics Programme – 20
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• To ensure that information is dealt with legally, securely, efficiently and effectively to underpin patient care & safety – 16
Mitigation Measures
Existing controls have been identified against the majority of risks however there are gaps in the sources of assurance.
Assurance processes
The risk register was developed by the Assistant Medical Directors at one of their regular meetings, and is planned to form part of the regular agenda.
Nursing Midwifery & Patient Services
Contact / Lead Heather Piggott – Assistant Director of Nursing Risks rated 15 and above
Of the 12 High Level Risks identified, three have been assessed as having a risk rating above 15. 1. Compliance with statutory and mandatory training. A failure to comply will lead to a breach on the NMC code.- 20 2. Infection Prevention and Control: Zero tolerance of healthcare associated infections and Effective management of any infections across the Health Board.- 20 3. Failure to achieve safe staffing levels will impact on BCUHB’s ability to deliver safe effective care – 16
Mitigation Measures
Mitigation measures have been identified for all risks.
Assurance processes
The Director of Nursing, Midwifery & Patient Services has regular team meetings where risk issues and progress can be discussed. A subsequent assurance framework has been developed to assesses each identified Corporate Nursing risk against each individual CPG – so that each risk has progress reports that are CPG specific.
Planning & Operational Estates
Contact / Lead Ian Howard – Assistant Director Strategic Analyst & Development Rod Taylor – Head of Operational Estates
Risks rated 15 and above
Planning Contains 7 Top Level Risks, two have been assessed as having a risk rating above 15. 1. Unsustainable service models leading to failure to deliver safe and affordable clinical services – 16 2. Failure to quality assure commissioned services, increasing the risk of poor quality care – 16 Operational Estates Contains 10 Top Level Risks, six have been assessed as having a risk rating above 15. 1. There are large numbers of older air-conditioning units using Refrigirants containing CFC's. This has been banned
and will not be available after 2015 – 16 2. Safe maintained Decontamination systems in Operational Estates – 16 3. To protect visitors, staff, patients & contractors from asbestos fibres – 15 4. Electrical Safety (HV & LV) Injury/loss of life, loss of service and fire risk. HSE are auditing NHS LHBs'
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improvement notices and prosecutions have resulted – 15 5. To ensure that contractors activities do not place the BCU's services, patients, staff or visitors at risk – 15 6. Gas Safe Regulations, Installation and use. training and accreditation – 15 There is also a separate full Risk Register for the YGC Redevelopment Project. This register currently contains a large number of identified issues relating to the Strategic, Design and Commissioning elements of th e project. Currently 19 of these are assessed as bein g 'Red' - not on the BCUHB template as drawn up in partnership with the project management company (GM S).
Mitigation Measures
Existing controls, sources of assurance and improvement costs, as applicable, have been identified against all of the risks.
Assurance processes
Operational Estates, Estates Development and Planning report weekly to the Director of Planning where issues of significance are discussed and Reviewed.
Primary Care Support Unit
Contact / Lead Lynne Joannou - Assistant Director of Primary Care Support Risks rated 15 and above
Contains 17 Top Level Risks, six have been assessed as having a risk rating above 15 1. Failure to recruit and retain PC workforce including GPs and clinical staff. Retiring and insufficient nurse
practitioners - 25 2. High workload and staff capacity due to loss of experienced PCSU staff. Reduced capacity of AMDs. Failure to
deliver operational targets - 20 3. Failure to manage professional & practice performance concerns in accordance with regulations – 20 4. Lack of Integrated Primary Care Strategy - 20 5. Insufficient clinical/nursing support due to lack of capacity delaying / preventing decision-making and delivery of
key objectives- 20 6. Negative impact on LHB managed practices due to lack of practice management skills and general workload
capacity - 20 Mitigation Measures
Existing controls and sources of assurance have been identified against the majority of risks.
Assurance processes
Risk register is formally reviewed and updated through the PCSU Quality & Safety Group
Public Health
Contact / Lead Dr Andrew Jones - Director of Public Health Jo Charles - Associate Director of Public Health
Risks rated 15 Contains 11 Top Level Risks, two have been assessed as having a risk rating above 15
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and above 1. Monitoring and containment of Infectious Outbreaks – 16 2. Lack of sufficient, authoritative support between Public Health and Health Board. Risks will arise from high impact
low frequency events - 16 Mitigation Measures
Existing controls and sources of assurance have been identified against the majority of the high level risks
Assurance processes
The Assistant Director Risk & Assurance and the Corporate Risk manager have met with Public Health Associate Director.
Therapies and Health Sciences
Contact / Lead Adrian Thomas, Assistant Director Therapies and Health Science Julie Jones, Head of Clinical Effectiveness Department
Risks rated 15 and above
Contains 10 high level risks with one of these rated over 15: 1. Inability or delays to appoint to posts funded by NISCHR AHSC grants. has resulted in loss of grant income - 25
Mitigation Measures
All identified risks have mitigation measures in place.
Assurance processes
To be regularly reviewed by Corporate Function Team with support from the Risk Manager.
Workforce & Organisational Development
Contact / Lead Tania Marsden, Head of Workforce Governance and Information Donna Owen, Workforce Governance Officer
Risks rated 15 and above
The register provided contains 14 high level risks. Of the 14 risks there are seven risks scoring 15 or above: 1. Adequate Medical Staffing resources for Health Board – 20 2. To ensure all new staff undergo pre-employment checks and update checks in relation to professional registrations – 20 3. Improvement in Sickness absence rates for BCUHB – 20 4. Reduction and management of Staff stress levels – 20 5. Financial balance in relation to use of locums, agency and bank staff – 16 6. Safety of staff in relation to Major Outbreak – 16 7. To ensure that Staff attend Statutory and Mandatory Training for statutory compliance – 15
Mitigation Measures
All identified risks have mitigation measures in place.
Assurance processes
The W&OD Corporate Function has established a W&OD Risk Management, Health, Safety and Wellbeing Group which is responsible for monitoring the development of the risk register and profile – this meeting will take place every
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four months. The Corporate Risk Manager facilitated a workshop for this Corporate Function in May 2013 where this work was reviewed prior to submission to the W&OD Committee.
Hospital Management Team (HMT) - Central
Contact / Lead Miss Ellen Greer – Interim Site Operational Manager (Central) Dr Brian Tehan - Assistant Medical Director, Central
Risks rated 15 and above
Contains 26 high level risks with ten of these rated over 15: 1. Patient throughput and review within YGC - 25 2. All-Wales Integrated IT system for NHS Wales, based around Welsh Clinical Portal (WCP), Welsh Pathology
Handbook (WPH) and Pathology Laboratory Information Management System (LIMS) - 20 3. Infection Prevention and Control: Zero tolerance of healthcare associated infections – 20 4. Recognition of Deteriorating Patients - 20 5. Agenda For Change compliant "Out of Hours" service for Pathology – 20 6. Missing or Delayed Case Notes -16 7. Laboratory Business Continuity - OOH Blood Science Service – 15 8. Safe Delivery of Site wide Medical gases – 15 9. Correct requesting and follow up of requests and tests – 15 10. Robust Fire prevention and evacuation plans – 15 YGC Redevelopment Risk • YGC redevelopment project: Inability to manage throughput of patients at site if bed numbers reduced during the
project - 16 (Redevelopment Project Board - Risk register entries 1.38 to 1.48) • To protect visitors, staff, patients & contractors from asbestos fibres - 15
Mitigation Measures
Mitigation measures are in place for the majority of risks identified - many from the source CPG risk registers.
Assurance processes
Pilot of a HMT Risk Register commenced and presented to HMT Central in January 2013. The Corporate Risk Manager has met with the Interim Site Operational Manager (Central) and a paper regarding next steps was presented at the June HMT (Central). The HMT Register is in four sections: • HMT Risks • CPG / CF Risks where HMT need an awareness • YGC Redevelopment Project Risks • Resolved Risks
