Board of Directors Meeting - 29 March 2012 - Devon Partnership ...

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Board of Directors Meeting, 29 March 2012Agenda Item 139. Assurance Frameworks and Risk Registers9.1. The Trust will hold a corporate combined Assurance Framework and Risk Register. Thisdocument will identify risks to the Trust’s strategic objectives (Safe, Timely, Sustainable,Recovery Focussed and Personalised) and provide assurance of mitigating actions andtimescales for each risk identified.9.2. The combined Trust Assurance Framework and Corporate Risk Register will beadministered by the Assistant Director of Corporate Development and Governance9.3. Each Directorate will hold a combined Assurance Framework and Risk Register and is theresponsibility of the Managing Partner/Clinical Director/Head of Profession and Practice.9.4. Local delivery units and teams will hold a risk register (Appendix B) which is theresponsibility of the local delivery unit manager or team manager.9.5. The main processes involved in the risk assessment process are: (refer to Appendix A formore detail):Establish the Context;Identify the Risks;Analyse the Risks;Evaluate the Risks;Treat the Risks- Develop Treatment or Mitigation Strategies;Monitor the Risks- Review Risk Treatment/Mitigation;Communicate and Consult (with internal and external stakeholders as appropriate).9.6. Assurance Frameworks and Risk Registers are reviewed at the appropriate governancemeeting to discuss addition or removal of risk; also to establish mitigating action plans andtimescales to reach residual risk level.9.7. A record is to be kept of removed risks for audit purposes.9.8. In addition to the risk registers held at team, local delivery unit, directorate and corporatelevels, specific registers are maintained by certain central functions including; MedicinesManagement, Estates, Information Management and Technology. These risk registersinform the other risk registers held through both the committees to whom they report andthe Operational Risk Committee.10. Risk Scoring10.1. The level of risk is assessed in accordance with the Risk Scoring Matrix (Appendix B). Thismatrix identifies both the consequence and likelihood of the risk; the aim of risk scoring is tosystematically establish relative priorities.11. Risk Escalation11.1. Risks will be monitored and escalated in the following way:Team risk registers: risks of 9 and above to be reviewed at the Local Delivery UnitGovernance meeting and escalated to Local Delivery Unit risk register as necessaryLocal Delivery Unit register: risks of 12 and above to be reviewed at the DirectorateGovernance meeting and escalated to Directorate Assurance Framework as necessary.Page 120 of 156
Board of Directors Meeting, 29 March 2012Agenda Item 13Directorate Assurance Framework: risks of 16 and above to be reviewed at the TrustManagement Board and escalated to Trust Assurance Framework as necessary. The Risk Escalation Matrix is given as Appendix D.12. Review of the Assurance Frameworks and Risk Registers12.1. Each Assurance Framework will identify the committee(s) responsible for reviewing,monitoring and escalating individual risks.12.2. Frequency of review of risks on the Assurance Frameworks and Risk Registers is asfollows:12.2.1. Trust (Corporate):All risks of 16+ are reviewed by the Board of Directors monthly.All risks are reviewed twice a year by the Board of Directors.All risks to quality and safety are to be reviewed by the Quality and Safety Committeeon a monthly basis.12.2.2. Directorate:All risks are presented to the Operational Risk Committee on two monthly basis.All risks are reviewed four times a year by each directorate.All risk scores of 12+ are to be reviewed at every directorate governance meeting.12.2.3. Local Delivery UnitAll risks are reviewed four times a year by each local delivery unit.All risk scores of 12+ are to be reviewed at every local delivery unit governancemeeting.12.2.4. Team All risks are reviewed four times a year by each local team. All risk scores of 12+ are to be reviewed at every team meeting.13. Organisational Learning from Investigations/Analysis13.1. Learning from experience is critical to the delivery of safe and effective services. It isrecognised that ‘human factors’ play a significant part in incidents, near misses, complaintsand claims and that such factors cannot ever be entirely eliminated.13.2. The systems and processes which operate must be designed to minimise the risk of humanerror at every stage and therefore each event must be looked upon as a learningopportunity. The Trust is committed to ensuring that lessons learned are embedded into theorganisation’s culture and practice. To achieve this, the following activities are undertaken:The Risk Management Team distributes alerts from the following agencies toappropriate managers for cascading to relevant staffNational Patient Safety AgencyMedical Device AlertsNHS EstatesClinical alerts e.g. contaminated illicit drugsCentral Alert System (CAS)Page 121 of 156
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