risk management enhancement framework in ntwc on risk … · 2017. 7. 26. · risk management...

Risk Management Enhancement Framework in NTWC on Risk Register Development and Performance Monitoring Process

Bonnie WONG Cluster Manager (Quality & Safety) Quality & Safety Division New Territories West Cluster Hospital Authority, Hong Kong

HA Convention 2017 16 May 2017

New Territories West Cluster (NTWC), Hong Kong Hospital Authority 1

Risk is everywhere in a hospital…

Delayed handling of investigation reports

Retention of materials

Wrong prescription of medication

Procedure performed in a wrong body part

Blood transfused to a wrong patient Loss of an important specimen


To manage risks, it is all people’s responsibilities

Hospital Chief Executive

Senior Management

Middle Management

Frontline Colleagues

Information Resources

Actions Improvement



Risk registers (RRs) are developed for communication among different levels


What information do staff base on in developing RR?

Gaps are identified…

Is the linkage of RR among cluster, hospital and department

levels strong enough?

Are we talking about the same risks but different names?

Reviewed and enhanced the:

• Risk management framework

• Risk register (RR) development process 2014

Aim to effectively identify, monitoring,

report and treat risks



Department Risk Register

Hospital Risk Register

Cluster Risk Register

Department Management Committee

Hospital Management Committee

Cluster Management Committee

HA (Corporate) Risk Register

Endorsed by

consolidate

consolidate

submit to

Clinical Non-clinical CQSC

CMSC & CNMC

Prioritise

Endorse

Consult

CQSC = Cluster Quality & Safety Committee CMSC = Cluster Medical Services Committee CNMC = Cluster Nursing Management Committee

Strengthened risk register (RR) development & endorsement processes 1

New Territories West Cluster (NTWC), Hong Kong Hospital Authority 8 8

Developed an NTWC Risk Taxonomy 2

50 risk categories & 244 sub-categories

• Referencing to EQuIP numbering system

• Review and update regularly


Provided department incident reports 3 • Quarterly incident reports sent to departments since 2Q 2014 • Facilitate review by dept head, incidents • Categorised by risk category, severity index & incident location


Developed an Electronic RR System (ERRS) 4

transform

Paper format (old)

Electronic format (new)



Aims: • Provide a structured system to facilitate

reporting • Timely review / update by Dept Head

anytime • Adopt a structured list of common risk

categories



Data can be easily exported to Excel for analysis


Provided training to departments 5


Developed Key Risk Indicators (KRIs) 6 • Enhance monitoring of risk performance (e.g. incident trends)

• Present in rate-based, e.g. per 1000 IP BDO

• 19 KRIs were developed


Monitored risk by “Risk Control Sheets” 7 • Work with Risk Custodians in planning and updating progresses of

risk mitigation actions

• Timely update performance of each risk, i.e. KRIs

• Report to cluster / hospital management regularly


NTWC was invited to support the development of Corporate Risk Management with KPMG

by HAHO Group Internal Audit in 4Q 2014

Summary

• Adopted both bottom-up & top-down approaches in the development of RRs

• Provided risk performance data for considering the priority of risks more objectively

• Piloted an Electronic Risk Register System to facilitate data input and aggregation

• Developed an NTWC Risk Taxonomy to standardise communication of risk terms among staff

• Developed Key Risk Indicators to monitor risk performance

• Used Risk Control Sheets to document progresses of risk mitigation actions and facilitate reporting to senior management


Thank You!


risk management enhancement framework in ntwc on risk … · 2017. 7. 26. · risk management...

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