CHHS16/176

Canberra Hospital and Health ServicesOperational Procedure Risk escalation and closure Contents

Contents....................................................................................................................................1

Purpose..................................................................................................................................... 2

Scope........................................................................................................................................ 2

Section 1 – Risk escalation and closure process from Divisions to the CHHS Risk Register.......2

Risk Identification..................................................................................................................2

Ongoing monitoring, management and closure of risk.........................................................3

Implementation........................................................................................................................ 4

Related Policies, Procedures, Guidelines and Legislation.........................................................4

Reference..................................................................................................................................4

Definition of Terms................................................................................................................... 4

Search Terms............................................................................................................................ 5

Attachments..............................................................................................................................5

Attachment A: Divisions to CHHS Risk Escalation and Closure Flowchart.............................6

Doc Number Version Issued Review Date Area Responsible PageCHHS16/176 1 27/09/2016 01/10/2019 CSQU 1 of 6Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS16/176

Purpose

To provide all staff within Canberra Hospital and Health Services (CHHS) with a process for the identification, escalation and closure of risks in accordance with the ACT Health Risk Management Policy, Procedure and Framework.

Scope

This procedure applies to all staff within Canberra Hospital and Health Services for the escalation and closure of risks that impact on the achievement of key, endorsed business objectives.

Section 1 – Risk escalation and closure process from Divisions to the CHHS Risk Register

For further information on the table below refer to Attachment A

Action ResponsibilityRisk Identification1. Staff member proposes a risk to a line manager by providing a full

risk description including what can happen, why and how (context).A risk may be reported in various ways including verbally and by email. Enough information needs to be provided to allow for a full risk assessment to occur.

All Staff

2. Fully document the potential risk using the approved Risk Assessment Template

Line Manager

3. Complete preliminary risk assessment to assess the initial risk rating.Risk Assessment discussed and risk rating assigned together with Executive Director (ED). Risks identified as being either extreme or high risk may need to be escalated to senior management immediately.

Executive Director to initially determine if proposed risk and rating is accepted as a Divisional risk, if so, it is to be added to relevant divisional risk register.If the risk is not accepted/declined/rejected, then it is to be managed at unit level.

Line Manager and Executive Director

4. Risks identified for Divisional management are to be presented and discussed at the highest level of Quality and Safety meeting within the specific Division. To be formally accepted as a Divisional risk, the risk assessment, and current and target risk rating need to be discussed and accepted.

5. If accepted as a Divisional Risk, an action plan is to be developed and Responsible Manager identified.

Line Manager and Divisional Executive Meeting

Doc Number Version Issued Review Date Area Responsible PageCHHS16/176 1 27/09/2016 01/10/2019 CSQU 2 of 6Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS16/176

Discussion and decisions made around the management of risks in these Committee meetings should be clearly minuted and added to the Divisional Risk Register.

Risk escalation6. If Divisional Quality and Safety or Executive Committee determine the

risk needs to be escalated to CHHS wide Level, the risk assessment must be presented by the relevant ED at the monthly Quality, Governance and Risk - CHHS Strategic Executive meeting.

7. It is the responsibility of Strategic Executive to accept the risk at the CHHS wide (tier 2) level and determine the responsible manager.

8. If accepted as a CHHS wide Risk, an action plan is to be developed and the Responsible Manager previously identified to oversee this. Determined responsibilities, actions and timelines are to be added to the CHHS Risk Register.Risks declined to be escalated to tier 2 (CHHS wide) level will continue to be managed at tier 3 (Division) level until the risk rating has reached the target.

ED and Strategic Executive

9. The Responsible Manager is accountable for completing timely updates to documentation for each risk on Riskman.The Responsible Manager may delegate responsibility for Risk Register updates if appropriate

Responsible Manager

Ongoing monitoring, management and closure of risk10. Update and maintain the relevant CHHS wide or Divisional Risk

Register to reflect current risk ratings and action plan status.Updates for CHHS wide risks to be provided at least quarterly to Strategic Executive.Updates for Divisional risks to be provided at least quarterly to the highest level of Quality and Safety meeting in the relevant Division.

Responsible Manager or Director, Clinical Risk Management

11. Evaluate actions, risk status and review risk rating. (This includes risk closure.)Once the risk rating has reached it’s target, the DDG, CHHS Strategic Executive or the ED may decide to close the risk from the risk register.

The Responsible Manager should provide a submission to the CHHS Strategic Executive outlining the reasons for closure of risks off the CHHS Risk Register e.g. actions have been implemented to address all root causes, the current risk rating has been reduced to the target level. The decision should be minuted in the meeting minutes and documented in the Riskman risk register (in the journal section) before the risk can be closed.

DDG or ED

Note:

Doc Number Version Issued Review Date Area Responsible PageCHHS16/176 1 27/09/2016 01/10/2019 CSQU 3 of 6Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS16/176

For risks identified by National Standards Committees, a risk assessment using the risk assessment template must be completed and escalated to the National Standards Governance Committee (NSGC). The NSGC will identify the most appropriate operational governance structure to consider the risk.

Back to Table of Contents

Implementation

This procedure will be implemented through Executive Directors on CHHS Strategic Executive, Division level Committee’s where risk is discussed, National Standard Groups and incorporated into existing CHHS education and training.

Back to Table of Contents

Related Policies, Procedures, Guidelines and Legislation

PoliciesRisk Management Framework Risk Management Policy

Guidelines Risk Management guidelines

Back to Table of Contents

Reference

1. AS/NZS ISO 31000:2009 Risk Management – Principles and GuidelinesBack to Table of Contents

Definition of Terms

Responsible Manager – The person/position responsible for coordinating and managing the implementation of the identified risk treatment action plan, inclusive of risk documentation in the risk register.

Quality and Safety Meeting or Executive Committee –The Division’s regular executive meeting where Risk Management is an agenda item for regular discussion and consideration.

Target level – The risk rating determined by the relevant risk management governance committee as being the ‘acceptable’ risk level.

Back to Table of Contents

Search Terms

Doc Number Version Issued Review Date Area Responsible PageCHHS16/176 1 27/09/2016 01/10/2019 CSQU 4 of 6Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS16/176

Risk, Risk closure, Risk escalation, Risk management, Risk register

Back to Table of Contents

Attachments

Attachment A: Divisions to CHHS Risk escalation and closure flowchart

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval09/01/2017 Procedure amended to

reflect divisional name changes and reporting lines

Deborah Browne, ED, CSQU

CHHS Policy Committee

This document supersedes the following: Document Number Document Name

Doc Number Version Issued Review Date Area Responsible PageCHHS16/176 1 27/09/2016 01/10/2019 CSQU 5 of 6Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS16/176

Attachment A: Divisions to CHHS Risk Escalation and Closure Flowchart

Doc Number Version Issued Review Date Area Responsible PageCHHS16/176 1 27/09/2016 01/10/2019 CSQU 6 of 6Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register