Annual Report and Accounts - The Great Western Hospital

14.4 The risk and control framework
14.4.1 Risk Management Strategy
The overall objective of the Risk Management Strategy is to ensure that robust risk management
processes are in place which provide assurance to the Board that the Trust is discharging its
responsibilities in ensuring good business and financial decision making leading to improvements in
services and the quality of care provided.
To ensure that risk is identified, evaluated and controlled there are formal structures within the Trust.
In 2011/12 the Risk Management Strategy was reviewed with the reporting process for risk being
formalised. Whilst the Board has overall responsibility for risk management, it delegated the work to
the Executive Committee and the Audit, Risk and Assurance Committee.
The three main tenets of our risk management strategy are:
• Risk assessment
• Risk Register
• Board Assurance Framework
14.4.2 Risk assessment
All trust staff are made responsible for identifying and managing risk. In addition there is a robust
Incident Management Policy in place and at Corporate Induction staff are actively encouraged to
utilise our web-based incident reporting system. A healthy incident reporting culture has been
maintained for a number of years providing assurance that staff feel able to report incidents and risks.
A Being Open Policy, based on National Patient Safety Agency guidance, is in place and regularly
reviewed. An annual audit is undertaken by the Health and Safety Team of all wards and
departments which demonstrates risk assessment and risk management in practice.
14.4.3 Risk Register
In 2011/12 it was agreed that the most significant risks to the Trust, being those which score 15 and
above, should be reviewed monthly at the Executive Committee. A register containing 15 plus risks
is scrutinised and challenged by the Executive Committee (to ensure risks are being managed) and
the Audit, Risk and Assurance Committee (to ensure processes in place to manage risk are
effective). This high-level register is informed both by those risks which scored 15 in the board
assurance framework (top down) and risks identified from within the directorates (bottom up).
14.4.4 Board Assurance Framework
During 2011/12, the Trust undertook a fundamental review of its Board Assurance Framework. The
Board Assurance Framework is set by the Executive Committee and approved by the Trust Board
annually. The assurance framework sets out
• the principal objectives to achieving the Trust’s overall goals,
• the principal risks to achieving those objectives,
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