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

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Board of Directors Meeting, 29 March 2012Agenda Item 13Appendix A - The Risk Assessment ProcessEffective risk management processes are applied both strategically and operationally at all levels.The risk management process model is based upon the following key concepts/steps: -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;Establish the Context:Establishing the specific risk management issues pertaining to the Trust can provide anunderstanding of the environment in which the risk of harm might take place.Identify the Risks:There are many methods of risk identification within an organisation. The following is a list of riskidentifiers:Health & Safety Inspections:Any risks identified from health and safety inspections should be documented andreported to the Health & Safety Committee for consideration.Audit – Clinical (including walkaround audits), Financial and Internal Audit:The co-ordination of clinical audit is the responsibility of the Co Medical Directors’portfolio; any risks identified by this method will be documented and risk assessed.Financial audit responsibility will rest with the Director of Finance who will bring internalaudit reports and any counter fraud investigation reports to the attention of the AuditCommittee.Legislation/Policy:All staff have a duty to understand their responsibilities under current legislation. TheTrust would be at risk of complaint or litigation where any legislation had beenbreached.Reports from Assessments/Inspections by External Bodies:All members of staff have a duty to highlight risks identified within external body reports.Surveys and Questionnaires:A summary of the feedback from patient, staff and external stakeholder surveys shouldbe reported on annual basis to the Board in order to identify common trends or riskissues. The responsibility for this lies with the Director of Nursing and Practice.Issues arising from routine Patient and Public Involvement activities:The Trust leads or participates in a range of activities to learn from patients and theircarers, including specific focus group work, e.g.Network Action GroupsLearning Disability County Carers ForumLocal Involvement Networks (LINks)The responsibility for identifying issues arising from this work and reporting these to theDirector of Nursing and Practice is the Patient Experience Lead.Page 124 of 156
Board of Directors Meeting, 29 March 2012Agenda Item 13Incident, Complaints, Claims and PALS Reporting:The risk management department provides copies of individual incident forms torelevant specialist managers e.g. in respect of medication errors, violence & aggressiontowards staff, safeguarding incidents etc.Summaries of the data relating to incidents, complaints, claims and PALS (PatientAdvice & Liaison Service) are reported regularly to the Quality & Safety and Safety andRisk Committees.Provider Compliance Assessments:Managers will identify any risks in their review of these assessments.Training:Managers will monitor any risks in meeting compulsory training requirements set by theTrust.National Reports:The Trust will consider all national reports and policies for action.Media:All staff have a duty to alert the communications team of any events that could generatemedia interest for the Trust.Central Alert System (CAS):Hazard/safety notices are received by the designated Central Alert System (CAS) andcascaded to teams for action by the Risk Management Team.Information RiskInformation risk is inherent in all administrative and business activities. Informationrisks are managed in accordance with the Information Risk Procedure (GV00) producedby the Information Governance Dept which can be found on the Trust intranet.Freedom Of Speech (Whistleblowing):Risk issues identified form whistleblowing should be communicated in a confidentialmanner and dealt with according to the Freedom of Information (Whistleblowing) Policy(Ref HR No.21).Grapevine and Intuition:Some pertinent risk management issues can be picked up through ad hoc comments,hearsay or intuition. All staff have a responsibility to discuss issues of concern witheither their line manager or a senior manager.Trade Unions:All union representatives are required to feedback risks, which have been identifiedboth locally and/or nationally to the risk management team or through the LocalPartnership Forum (LPF) or the Health and Safety Committee.Exit Interviews with Staff:Exit interviews could include issues pertaining to training, line managementsupervision/support, working practices, etc which could put the patients, staff and/or theorganisation at risk.Page 125 of 156
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