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SUMMARY REPORT ABM University Health Board

Health Board 27th March 2014 Agenda item 2(vii)

Subject Risk Management Strategy Prepared by Hazel Lloyd, Head of Quality Assurance Approved by Christine Williams, Acting Director of Nursing Presented by Christine Williams, Acting Director of Nursing Purpose This report provides the Board with the Risk Management Strategy and Corporate Risk Register.

Decision Approval X Information Other

Corporate Objectives Safety Quality Efficiency Workforce Health Governance

X X X Executive Summary The report provides the Board with the Risk Management Strategy, reviewed by the Risk Management Review Group and Audit Committee. The Corporate Risk Register is also provided following a review by the Executive Directors and Quality & Safety and Audit committees. Key Recommendations The Board is asked to consider and approve, subject to final amendments, the Risk Management Strategy and note the contents of the Corporate Risk Register.

Assurance Framework These documents are a key part of the internal control in operation within the Health Board and support the Assurance Framework.

Next Steps The Risk Management Strategy, once approved, will be published via the internet and will be subject of regular review through the Quality & Safety and Audit Committees to ensure they are up to date and take account of changes within the Health Board and NHS Wales.

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Corporate Impact Assessment Quality and Safety The documents relate to a number of Standards,

although the main standards covered include: 1 - Governance & Accountability 6 - Participating in Quality Improvement initiatives 22 - Risk Management and Health & Safety 23 - Managing Concerns

Financial Implications

There are no specific resource impacts in preparing this report.

Legal Implications N/A Equality & Diversity

There are no specific issues related to Equality and Diversity within this report

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Main Report Health Board Meeting On

27TH MARCH 2014 Agenda item 2(vii)

Subject Quality & Safety

Prepared by Hazel Lloyd, Head of Quality Assurance Approved by Christine Williams, Acting Director of Nursing Presented by Christine Williams, Acting Director of Nursing

1 PURPOSE

To provide the Board with key documents, for approval, they will support the internal control assurance framework within the Health Board.

2 INTRODUCTION Risk Management, is a shared responsibility between the Medical Director and

Director of Nursing. The Risk Management Strategy has been in use within the Health Board since

its inception although has been updated to take account of organisational changes and reviewed as a minimum on an annual basis. The Strategy will need to be kept under regular review in 2014/15 to ensure it is updated to reflect changes in the Health Board. The key objectives of the document is to ensure: • consistency in approach to the overall management of risks; and • clear organisational arrangements to enable the Health Board to meet its

strategic aims within a framework of strong, effective governance and risk management.

3 Risk Management

Risk Management is an increasingly important driver in terms of strategic risks and decision making as well as operational management of risks. A process is required to ensure a consistent approach is applied to the management of risks once identified to ensure:

• Risks are understood in terms of achieving objectives; • Overall level of risk is understood within processes and objectives; • There is a mechanism to prioritise significant risks and; • Identify weak controls.

The aim is ensure compliance with regulations and legislation, assurance and enhance decision making.

3.1 Risk Management Strategy The revised Risk Management Strategy, attached as Appendix 1, was subject of review by the Risk Management Review Group and discussed at a Risk Management Workshop held in January 2014. The document has also been

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circulated to Executive Directors, members of the Quality & Safety Committee and reviewed by the Audit Committee in March 2014.

3.2 Corporate Risk Register

The Corporate Risk Register is attached as Appendix 2 and contains risks linked to the objectives (aims and priorities) of the Health Board and is underpinned by high operational risks considered through the Risk Management Review Group. There are a number of risks which are of concern which are highlighted below:

• Unscheduled Care (Risk Ref 1) • Effectiveness of Care (Risk Ref 3) • Service Delivery (Risk Ref 5) • Service Change (Risk Ref 19)

The controls in place and actions being taken to decrease the risk are provided within the relevant entry on the Corporate Risk Register. The top three risks for the Health Board relate to:

• Unscheduled Care (Risk Ref 1)

The performance and improvement actions identified have previously been submitted to the Quality & Safety Committee and are summarised in the Register. An update against the unscheduled care action plan is provided in Agenda Item 4.2.

• Effectiveness of Care (Risk Ref 3) The controls in place and actions being taken to decrease the risk are provided within the relevant entry on the Corporate Risk Register for the risk identified. There are 21 operational risks relating to workforce issues which may impact on effectiveness of care.

• Cardiac Services (Risk Ref 32) Cardiac Action Plan is in place and monitored through the Cardiac Thoracic Directorate Board and reported through to the Quality & Safety Committee to every other meeting. A risk register workshop for the Cardiac Thoracic Directorate was held on 5th February to support the development and integration of their risk register within their core business.

4. RECOMMENDATION

The Board is asked to note the contents of the report and approve the Risk Management Strategy.

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APPENIDX 1

Risk Management Strategy & Policy

This document may be made available in alternative formats and other languages, on request, as is reasonably practicable to do so.

Policy Owner: Quality Assurance Department Approved by:

Risk Management Review Group Issue Date: Review Date: Policy ID:

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Contents

Section Page

1. Risk Management Policy Statement 3 2. Introduction 4 3. Strategy Objectives 5 4. Significant Risks 6 5. Roles and Responsibility 6 6. Risk Management Reporting Structure 8 7. Risk Management Process 13 8. Risk Register 17 9. Risk Management Training 18 10. 11.

Glossary References

19 20

Appendices

Appendix 1 Key Policies 21 Appendix 2 Standards for Health Services in Wales 22 Appendix 3 Appendix 4 Appendix 5 Appendix 6

Scheme of Delegation Executive Lead Groups Risk Management Reporting Structure Specialist Groups/Committees Reporting to the Quality & Safety Forum

23 24 25 26

Appendix 7 Terms of Reference Risk Management Review Group 27 Appendix 8 Risk Matrix 29 Appendix 9 Risk Register Template 31 Appendix 10 Population of Risk Register Flowchart 32 Appendix 11 Process to Request Transfer of a Risk from a Directorate Risk

Register to the Corporate Risk Register Flowchart 33

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1. Risk Management Policy Statement

Abertawe Bro Morgannwg University Health Board (ABMU) is committed to providing safe and effective, high quality healthcare. We mandate a culture and environment, which minimises and actively seeks to reduce risk and promotes the health, safety and well-being of patients, staff, visitors and the general public. ABMU recognises that all health service activity carries risks including harm to patients which need to be managed through a systematic framework. This will ensure that risks to patient safety and the organisations objectives are identified, assessed, eliminated or minimised so far as is reasonably practicable. The aim being to minimise the chance of the risk being realised, although where this has not been possible then we will review, learn and share the learning to minimise the likelihood of reoccurrences in an open and fair culture. All staff have a responsibility for promoting risk management, adhering to ABMU policies and have a personal responsibility for patients’ safety as well as their own and colleagues health and safety. ABMU encourages staff to take ownership of their responsibilities through a two-way communication process, with appropriate training and support, to identify and manage risk. To support the development of good risk management practice in the organisation ABMU aims to ensure: • the risk management process is robust, integral to the day to day operation of the

organisation, consistent and supports the achievements of ABMU’s objectives; • the level of risk tolerance is defined and the appetite for risk is clear to support taking

calculated risks to encourage innovation; • a safe, high quality service is provided to patients and continuous improvement is

promoted; • we have a safe environment for patients, staff and visitors through the identification of

hazards and the management of risks; • awareness of risk management is raised through education/training and guidance to

ensure they are aware of potential hazards/risks and how they can be minimised; • there is a culture of learning from everything we do to improve safety in ABMU,

compliance with legislation and continuous improvement by using the Doing Well, Doing Better Standards for Health Services in Wales as a framework;

• risk management is linked to clinical audit to prioritise risk based audits and risks identified following audit are risk assessed and added to the appropriate risk register;

• roles, responsibility and accountability for risk management is clear and well documented within policies, procedures and Job Descriptions;

• regular review of policies and procedures; • there is an open and fair culture in which staff can highlight and discuss risks openly. Ensuring robust risk management systems are in place will enable the organisation to: - be proactive rather than reactive;

- identify and treat risks within the organisation; - improve identification of opportunities and threats; - comply with legislation and regulations.

…………………………… …………………… Signed: Chief Executive Date

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2. Introduction

The foundation of Risk Management in the NHS is set out in HSC 1999/123 which details the requirements for Controls Assurance which were incorporated into the Welsh Risk Management Standards and are now detailed in the technical guides for the Healthcare Standards. Risk Management is therefore a holistic approach to identify and effectively manage clinical, health & safety, financial and organisational risks based on best governance practice which conforms with the Doing Well, Doing Better Standards for Health Services in Wales and the guidance produced by HM Treasury. ABMU recognises that effective Risk Management plays a pivotal role in ensuring high quality services are provided to its patients from an environment that is safe for patients, staff and visitors within the hospital and the community. This document sets out the Board’s strategy and policy regarding Risk Management confirming the accountability and structural arrangements, resources available and guidance on risk management and levels of risk. Risk Management underpins the governance arrangements for the System of Internal Control. Ensuring risk management systems and processes are in place, which are subject to regular review through internal and external assessment, with evidence that Internal Control is in place and that ABMU is committed to manage itself so as to meet its objectives, identify principal risks and manage them. The Chief Executive carries ultimate responsibility, delegated by the ABMU Health Board, for assuring the quality of the services provided and for ensuring the implementation of effective Governance arrangements. Good risk management awareness and practice at all levels is considered a critical success factor for ABMU as managing risk is inherent in everything that we do: treating patients, determining service priorities, managing projects, purchasing new medical equipment, taking decisions about future strategies, or even deciding where it is appropriate not to take any action at all. This document identifies where accountability and responsibility lie and sets out the framework to follow for the reduction of risks to a minimum. There are a number of policies and procedures which support risk management. These are listed in Appendix 1. For Risk Management to be truly effective, ABMU recognises that it must have a safety culture embedded within the organisation. To support this, the HB promotes an open and fair culture where safety is paramount, encourages feedback to staff and to learn lessons from incidents, complaints and risk identification. A patient safety programme is being developed to .................................

3. Strategy Objectives The objectives of this Risk Management Strategy are: • To ensure risk management becomes an integral part of the organisation’s culture and

is used to identify and manage significant risks to the Health Board’s objectives and operational risks;

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• All aspects of risk management are approached in a consistent and structured manner and Risk Registers are used as the tool to manage risk within ABMU;

• Objectives, responsibilities and accountabilities for risk management are clearly

defined at every level of the organisation; • Staff are aware of their responsibility to minimise and manage clinical, financial and

organisational risks and to discuss risks as part of the individual performance review process;

• Staff are empowered to prioritise patient safety, report hazards, incidents and identify

risks; • Ensure the Doing Well, Doing Better Standards for Health Services in Wales are

implemented across ABMU, within Directorates/Localities/Sites undertaking self assessments against the Standards ensuring benchmarking takes place and action plans are completed to improve quality and safety of services;

• Strategies, policies, structures and processes are constantly reviewed and evaluated to

ensure that patient safety and service quality is continuously improved and that ABMU objectives are being achieved;

• Risk Management process will underpin the Health Boards Quality and Safety agenda.

4. Significant Risks The significant risks facing ABMU are the risks linked to achieving ABMU’s objectives and the operational risks which have been escalated, in line with the risk management process, by Directorates/Localities/Sites mechanisms. The organisational objectives are referred to in the Health Board’s 3 Year Plan referred to as the Integrated Medium Term Plan for 2014-17 (IMTP). The priorities are:

• Public Health • Excellent outcomes • Excellent people • Excellent governance • Sustainable services

The organisational priorities are monitored by the Board and Board Committees through assurance and exception reports. The Executive Team will use the IMTP as the basis for performance monitoring of Directorates/Localities/Sites and Corporate Directorate priorities. Monthly Performance meetings, aligned to the IMTP with the Directorates/Localities/Sites to monitor performance against the priorities and other Key indicators. Details of the Doing Well, Doing Better Standards for Health Services in Wales are provided in Appendix 2. Following the Annual self assessments an Improvement Plan is developed which is reviewed by the Health Boards Standards for Health Services in Wales Scrutiny Panel and a report submitted on key issues to the Quality & Safety Committee, as

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a minimum, on a quarterly basis. The Improvement Plan identifies actions to develop the Standards and ensure they are all scored, as a minimum, Level 3 - DEVELOPING.

5. Risk Management Roles and Responsibility

5.1 Chief Executive As Accountable Officer the Chief Executive has responsibility for ensuring that the Health Board meets all its statutory and legal requirements and adheres to guidance issued by the Welsh Government in respect of governance. This responsibility encompasses the elements of financial control, organisational control, quality, Health & Safety and risk management.

Each year the Chief Executive sets out the risk management arrangements and issues

within the Health Board within the Annual Governance Statement which forms part of the Annual Accounts and is scrutinised by the Audit Committee. The Medical Director and Director of Nursing are responsible for Quality and Safety, ensuring robust systems are in place. They are supported to drive forward the patient safety agenda through their Assistant Directors who have roles in quality and safety, safeguarding, Infection Control and education, all supporting patient safety. 5.2 Director of Nursing and Medical Director

The Director of Nursing and Medical Director have specific responsibilities for Risk Management and will support the Chief Executive by providing competent advice and support in the development of effective systems and arrangements to help facilitate the management of risk, this will include arranging to:

• Produce and regularly review the Risk Management Strategy; • Draft the Risk Management section of the Corporate Plan; • Ensure key risks are co-ordinated and reported to the Executive Board, Board

Committees and Health Board; • Draft the Annual Governance Statement.

In undertaking this role the Director of Nursing and Medical Director are supported by the Head of Quality Assurance.

5.3 Executive Directors

Each Executive Director is responsible for managing risk within their area of responsibility. This means they will:

• Ensure staff are appropriately trained in risk assessment and management. • Ensure there are mechanisms in place for identifying, managing and alerting the

Board to significant risks within their areas of responsibility through regular, timely and accurate reports to the Executive Board, relevant Board Committees and the Health Board.

• Ensure there are mechanisms in place to learn lessons from any incidents or untoward occurrences and that corrective action is taken where required.

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• Provide details of the key risks within their area of responsibility to the Board Secretary every 6 months to coincide with the IMTP development and review process.

• Ensure compliance with Health Board policies, legislation and regulations and professional standards for their functions.

A schedule setting out key areas of responsibility of individual Directors are set out in detail in the Scheme of Delegation appended to Standing Orders and are supplemented by individual job descriptions. A summary of each Executive areas of responsibility are summarised in Appendix 3 and Appendix 4 identifies the main Executive Lead Groups in the Health Board. 5.4 Head of Quality Assurance

The Head of Quality Assurance acts on behalf of the Directors of Nursing and Medical Director to achieve high standards of risk management for the Health Board, including the ongoing review and development of the Health Boards Risk Management Strategy. Responsibilities include continuing development of a proactive risk management culture and practice throughout the organisation; actively promoting and ensuring good risk management practices, an open, just and fair culture and the achievement of national risk management standards and continual improvement through the framework or Standards for Health Services in Wales.

5.5 Head of Health & Safety

The Head of Health and Safety, supported by the Health & Safety Department, are responsible for policy development and implementation. Providing professional advice in respect of health and safety management. Ensuring the Health Boards risk management methodology is applied to Health and Safety issues.

5.6 Specialist Advisors

There are a number of specialist advisers within the Health Board who provide advice on specific areas of risk management. These include: Safeguarding, Fire; Health & Safety; Infection Prevention & Control; Information Governance; Medical Devices; Radiation Protection; Resuscitation and Security Management etc.

5.7 Operational Risk Management Arrangements

Clinical Directors/Locality Directors/Directorate Managers/Site Executive Director, Heads of Nurses and senior managers who have devolved responsibilities for risk are responsible for ensuring that:

• Staff are aware of the Risk Management Strategy, are aware of their

responsibilities, understands the extent to which they are empowered to take risk, and are appropriately trained in risk assessment and risk management;

• The Directorate/Locality/Sites adopts an open and fair culture;

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• Hazards, incidents and risk are identified using a consistent approach in the Directorate/Locality to ensure that a learning approach results in continuous improvement;

• Risks are managed within the Directorate/Locality and significant unresolved risks reported to the appropriate Director;

• Appropriate governance arrangements are established to manage risks, ensure action is taken and lessons learned;

• Staff are released to attend mandatory/statutory training; • Staff receive regular PDR’s/Appraisals; • They have effective arrangements in place to identify and manage risk; • Risks identified outside their control, must be communicated effectively through to

the Chief Operating Officer; • Clearly defined structure to ensure the appropriate management of risk and this

should be communicated to all staff within the Directorate/Locality; • Up to date Risk Register and log of risks they have mitigated to a risk tolerated

level, and together with risks that have been treated; • Staff are aware of the Risk Management Strategy; • Risks are managed and minimised within the Directorate/Locality/Site and

significant unresolved risks reported to the Chief Operating Officer/Site Executive and the Risk Management Review Group;

• Governance forum is established to consider all types of risks, ensure action is taken and lessons learned and review the Directorate/Locality Risk Register;

• Staff are released to attend mandatory/statutory training.

5.5 Ward / Departmental Managers

• promotes an open and fair culture for staff to report incidents; • promptly investigates incidents and supports staff through the process; • completes or ensures risk assessments are completed and, as a minimum,

reviewed on an annual basis; • reports risks identified from risk assessments into the Directorate/Locality/Site Risk

Register; • monitor staff attendance at mandatory/statutory training.

5.6 Independent Contractors

The Localities are responsible for working with independent contractors and ensuring appropriate risk management arrangements and systems are in place.

5.7 All Employees

Everyone working in ABMU has a responsibility to continuously improve patient safety, minimise risk and to ensure that they: -

• comply with policies, procedures, protocols and guidelines; • complete risk assessment and report hazards and incidents; • inform their manager of risks which they have identified; • ensure that there is an open and fair culture in their work place.

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6. Risk Management Reporting Structure

Attached as Appendix 5 is the reporting arrangements and Committee Structure, that details ABMU’s structural arrangements for the risk management process. The remainder of this section sets out the roles and responsibilities of the component parts of this structure and its relationship to the risk management process. Each of the summaries regarding the specific areas of risk management is supported by detailed Terms of Reference.

6.1 Health Board The ABMU Board shall, in relation to risk management: - • Critically review and, when content, endorse the Risk Management Strategy and

associated Policies/procedures/methodologies; • Deliberate annual reports and annual assurance statements; • Consider where lessons may be learnt from clinical/non-clinical incidents to foster

continuous improvement; • Consider any legal claims in accordance with the HB’s Standing Orders and Financial

Instructions; • Consider where lessons may be learnt from significant complaints, "no harm

incidents" and other incidents to foster continuous improvement; The ABMU Board will receive regular progress reports on the implementation of Risk Management and Standards for Health Services in Wales Implementation Plan through the Quality & Safety Committee.

Each Executive Director will produce a high level risk schedule, which is then used to formulate the IMTP and appended to the Plan as a Risk Register. The Plan would then be approved by the Executive Board, Audit Committee and Board. The Plan will be reviewed on a 6 monthly review following the same process. Alongside this key risks will be highlighted through all main plans e.g. for service change proposals and in key reports to the Board, its Committees and the Executive Board as a key element to decision making. The ABMU Board will appropriately delegate its responsibilities and functions in accordance with the arrangements set out in this document and Standing Orders. The ABMU Board is responsible for the system of internal control, including risk management. The Quality & Safety Committee will provide assurance that risk management systems are in place and functioning properly to assure patient safety through the minimisation of risk. 6.2 Audit Committee

The Audit Committee provides assurance that adequate systems are in place to ensure that Action Plans produced and agreed through the delivery of Annual Audit Operational Plans are implemented, reporting mechanisms deliver regular reports to the Board and independent verification is in place. Internal Audit

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Internal Audit will, through a programme of work based on risk, provide ABMU Board with independent assurance of the adequacy of the systems of internal control across a range of financial and business areas in accordance with the Wales Internal Audit Standard. 6.4 Quality & Safety Committee The Quality & Safety Committee is responsible for monitoring the implementation of Quality and Safety across the organisation including the integration of quality activities. The Terms of Reference of this Committee are set out in the Standing Orders approved by the Health Board and available on the Intranet. The Quality and Safety Committee will be supported in its role by a number of key specialty Groups/Committees which are overseen by the Quality & Safety Forum which is an Executive Management Group and Appendix 6 sets out the main specialty groups/Committees reporting to the Forum. The Standards for Health Services in Wales Scrutiny Panel is a formal sub Committee of the Quality & Safety committee chaired by a Non Officer member. 6.4.1 Standards for Health Service in Wales Scrutiny Panel The Scrutiny Panel oversees the implementation of the self assessments against the Standards for Health Services in Wales and scrutinises the core Standards and the performance of:

• Corporate leads; • Directorates/Localities self assessment submissions and • The annual corporate quality improvement plan.

6.4.2 Quality and Safety Forum The Forum is an Executive Lead Group Chaired by the Medical Director established to support the Quality & Safety Committee and oversee the work of the specialist quality and safety groups and committees. 6.4.3.1 Risk Management Review Group This Group will review the Risk Management Strategy and highlight significant risks to the organisation. This is a Management Group, Terms of Reference attached as Appendix 7, which reports to the Committees of the Board which is tasked with the overall responsibility to ensure: • Continuous improvement in patient safety and service quality • The Risk Management Strategy aims and objectives are delivered; • There is effective co-ordination and prioritisation of financial, business, and

organisational risk management issues across the organisation; • There is appropriate awareness of risk management at all levels of the organisation; • Welsh Government requirements are met for the monitoring of progress on the

Standards for Health Services in Wales Improvement Plan; • Overall responsibility for the Risk Management methodology and the integration of

risk management processes across the organisation;

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• Identifying learning through risk management processes and reporting them to the Effective Practice Monitoring Group for consideration in the Clinical Audit Plan.

6.4.3.2 Investigations & Redress Group The NHS Redress legislation received Royal Assent in July 2008 and came into force in NHS Wales in April 2011. The Measure is intended to ensure that patients can seek Redress by means of treatment, support and compensation, if appropriate, for lower-value clinical negligence claims without the need to instigate legal action through the Courts. Regulations setting out the detail of the new arrangements have been developed in close consultation with the NHS, patient groups and Community Health Councils and the Putting Things Right Project. The previous Incident, Complaints and Claims policies and procedures have been reviewed in line with the Regulations and changes made to produce an integrated Putting Things Right Policy and Procedure. Incidents

Incidents will be managed and reported in accordance with the ABMU’s Putting Things right Policy & Procedure. Incidents are analysed for trends and to ensure action is taken and a Root Cause Analysis Investigation of serious incidents. Guidance on Root Cause Analysis is contained within the Putting Things Right Policy as an appendix document.

Incident Reporting is not part of the ABMU’s disciplinary process. However, examples of situations where disciplinary action may be necessary are as follows:

• Criminal Activity (eg theft, assault and fraud) • Professional misconduct • Acts of gross misconduct (eg treating patients under the influence of alcohol) • Malicious activity (eg malicious reporting of untrue allegations against a colleague) • Repeated unreported errors or violations of procedures

Complaints Complaints are managed in accordance with ABMU Putting Things Right Policy and procedure. Each complaint received is risk assessed in terms of the severity of the complaint and likelihood of the circumstances re occurring. The Department of Investigation and Redress grade complaints and ensure that appropriate investigations are instigated. In addition, analyses of serious complaints are presented to the Risk Management Group for inclusion in the relevant Risk Register as appropriate. Action plans produced to reduce the risk of the complaint reoccurring are reviewed and monitored by the Investigation and Redress Group, with lessons learned from investigations shared throughout ABMU via this Group. Claims Claims are managed in accordance with ABMU’s Claims Policy & Procedure. Claims management and trend analysis are reviewed by the Claims Management Sub Committee. Lessons learned, where identified, are disseminated throughout ABMU via the

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Investigations and Redress Group, with high risk issues going to the Risk Management Review Group and signposted within the Risk Management Quarterly Reports.

6.4.3.3 Effective Practice Monitoring Group It is essential that clinical audit and effectiveness and risk are linked to ensure that issues identified are considered for inclusion with the Clinical Audit Plan. A member of the Clinical Audit & Effectiveness Team is a member of the Investigations and Redress Group and the Assistant Medical Director for Patient Safety is both as a member of the Investigations and Redress Group and the Effective Practice Monitoring Group. Issues identified for action, following a clinical audit, will be reviewed in line with the Risk Management Strategy and managed through Directorate/Locality Risk Registers.

6.4.1.4 Patient Safety Work Programme This work programme is committed to reducing harm, variation and waste and thereby reducing harm to patients. Key priorities have been identified, based on high risk areas, and included within the IMTP and excellent patient outcomes.

6.4.1.5 Health & Safety Committee The Health & Safety Committee is chaired by the Director of Planning and is supported by the Head of Health & Safety. The Head of Health & Safety is a member of the Risk Management Review Group and Quality & Safety Forum to ensure there are strong links between the risk management and health & safety agendas within the Health Board. The Health and Safety Committee oversees the development of policy, risk control systems and reviews health & Safety arrangements in the Health Board. The Committee monitors and advises on all health and safety risks detailed on the Corporate Risk Register and operational risks escalated to the Head of Health & Safety to consider whether any further control measures can be implemented to mitigate the risk. The Committee reports quarterly to the Quality & Safety Committee and produce an annual report also reported to the Quality & Safety Committee. 6.4.1.6 Directorate/Locality/Site Governance Forums

The Chief Operating Officer reports directly to the Chief Executive and is responsible for the following Directorates/Localities:

• Clinical Support Services • Neath Port Talbot Locality • Swansea Locality • Mental Health Directorate • Musculo-Skeletal • Learning Disabilities Directorate • Regional Services • Surgical Services • Women & Child Health

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The Executive Director of Princess of Wales Hospital is responsible for all services within the Hospital. Each Locality/Clinical Directorate/Site Executive has a Locality/Directorate Board, which is ultimately responsible for Risk Management, specifically operational risks within the Locality/Directorate. The Locality/Directorate/Site Boards will ensure that risk management issues, which can not be managed at Locality/Directorate/Site level or high level risks, which may impact on strategic objectives, are reported, to the Health Board Governance Group and linked into the performance, planning process and capital planning programme.

There are nine Corporate Directorates:

• Medical Director’s Directorate • Nursing Directorate • Directorate of Therapies & Health Sciences • Finance • Workforce and Organisational Development • Planning • Chief Operating Officer • Public Health Directorate

Each Corporate Directorate has a Risk Register and any risk management issue identified as a high risk is reported to the Health Board’s Risk Management Review Group/Executive Board and linked into the planning process, capital planning programme and Corporate Plan by identifying risks against the Board Objectives with the IMTP and against the Five Year Strategy.

7. Risk Management Process

This section of the document sets out an approach to the assessment of risk and the development of an integrated framework for risk management for the HB. It is a summary of the detailed risk management tools adopted by the HB and should be read in conjunction with the Risk Assessment Management Guidance document. When considering risk management it is important to understand the Health Board’s risk appetite and risk tolerance to specific risks as these will change, as they are not single fixed concepts, and will vary over time, and current influential factors at a strategic, tactical and operational level. Risk appetite is about the pursuit of risk and risk tolerance is about what the Health Board will allow management levels within the organisation to deal with. Both risk appetite and risk tolerance are inextricably linked to performance over time. The Health Board’s Board is explicitly responsible for determining the nature and extent of the significant risks the organisation is willing to take to achieve strategic objectives – risk appetite and tolerance. 7.1. Methodology

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The methodology for identifying risk used within HB is the Australian/New Zealand model AS/NZ; Guidance upon acceptable risk is addressed within this methodology to assist managers to make informed decisions as to the extent of the risk and the application of appropriate action thereafter. For each issue/risk identified the LIKELIHOOD & CONSEQUENCE mechanism will be utilised. Essentially this examines each of the issues and attempts to assess the likelihood of the event occurring (PROBABILITY) and the effect it could have on the HB (IMPACT). This process ensures that the HB will be focusing on those risks which require immediate attention, rather than spending time on areas which are, relatively, a lower priority. The prioritising of risk using this mechanism is detailed in Appendix 8 The Heath Board uses the risk module of Datix to record and monitor all risks with a rating of 16, as a minimum, from an operational perspective and all risks considered to be risks to achieving the organisations objectives/aims referred to as the Corporate Risk Register. The Corporate Risk Register can be accessed through the Health Boards intranet and internet and is updated on a quarterly basis. 7.2 Establish the context

Establish the strategic, organisational and risk management context in which the rest of the process will take place. Criteria against which risk will be evaluated should be established and the structure of the analysis defined. The context can include the financial, operational, competitive, political (public perceptions/image), social, client, cultural and legal aspects of the HB’s functions. Within these areas it is critical to identify the internal and external stakeholders/partners which may include any of the following: Welsh Assembly Government, patients, staff and contractors. Once the stakeholders/partners have been identified it is important to consider their objectives, take into account their perceptions, and establish communication policies with these parties. It is also important to consider these issues when considering relationships inside and outside the NHS the behaviour of the “partners” and the organisation and how this will affect any risks identified.

7. 3 Risk Identification

Risk identification can be undertaken on an individual basis or as part of a multidisciplinary team and can be reactive or proactive and linked to strategic objectives, underpinning the assurance framework, or operational services we provide. Details of how to identify risks are provided within the Risk Management Guidance document which supports the implementation of the Risk Management Strategy.

7.3.1 Strategic Risk and IMTP Plan (associated with the achievement of aims and

objectives of the HB). The IMTP Plan sets out the organisational objectives for 2014/17 the achievement of these objectives will ensure the Health Board effectively manages key organisational risks. This

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will be a "top down" approach, undertaken collectively by the members of the Executive Board. The risk of not achieving the objective and the risks to that objective will be highlighted, as appropriate, to the Health Board, Stakeholders and partners.

7.3.2 Operational Risk (associated with the direct delivery of services by the organisation area i.e. risks arising from operational activities). This will be a "bottom up" approach undertaken by the staff within individual Directorates/Localities/Sites overseen by the Management Boards. Where "operational" issues raise questions over the strategic objectives of the HB, these will be considered in detail by the Governance Group. 7.3.3 Patient/Health & Safety Management Patient and Health & Safety assessment involves identifying the significant risk areas in Directorates/Localities/Sites, prioritising them and deciding what action to take. Significant patient/Health & Safety risks are classified as those:

• that could lead to death, disability or severe distress to patients/staff/visitors; • that are less serious but could occur more frequently or affect large numbers of

patients/staff/visitors should also be included • that could impact on the finances or reputation of the HB.

7.4. Analyse/Evaluate risks

Determine the existing controls and analyse risks in terms of consequence and likelihood in the context of those controls. The analysis should consider the range of potential consequences and how likely those consequences are to occur. This enables risk to be ranked so as to identify management priorities. If the levels of risk established are low, then risks may fall into an acceptable category and treatment may not be required. Consideration should be given to the balance between potential benefits and adverse outcomes of managing these risks. The risk mapping exercise will be based around an analysis of the likelihood of the risk materialising and its impact should it materialise. Whilst there are quite complex models available, a simple model has been adopted and it is important to recognise that discussion of the risks is essential to determine within the risk description what the actual risk level is at the time of identification and review. In addition the description should set out the consequences of not taking the actions identified to support and inform management decisions and the IMTP process. 7.4.1. Acceptable Risk: Risk Score of 1 – 4 (Green) Realistically it is never possible to eliminate all risks, and there will be a range of risks identified within the HB that would require us to go beyond ‘reasonable action’, if any, required to eliminate or reduce them, i.e. the cost in time or resources required to reduce the risks would outweigh the potential for harm. These risks would be considered ‘acceptable’ by the HB. Examples are frequent, low consequence events such as minor property loss or damage, injuries requiring first aid only, or potentially serious events that are unlikely to occur and for which reasonable preventative measures are already in place.

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7.4.2. Manageable Risk: Risk Score of 5 – 9 (Yellow) The risk can be realistically reduced, within a reasonable time scale, through cost effective measures through the purchase of new equipment and or training. Examples are manual handling injury, malicious damage, and injury to staff or patients. Action would normally be the responsibility of the department or directorate. 7.4.3 Moderate Risk: Risk Score 10 – 15 (Amber) The risk will need to be reduced within 6 months, given that it is a moderate risk, action would normally be the responsibility of the Directorate. The Directorate should notify these risks to the HB Risk Management Group with details of the actions planned. 7.4.4 High Risk: Risk Score of 16 – 25 (Red) Significant risks are where the consequences of the event could seriously impact on the organisation and threaten its objectives. As examples accidental death, major fire, and major disruption of services. This category might include risks that are individually manageable but cumulatively serious, such as a series of similar injuries. Risks identified as being serious should be reported to the HB Board via the organisation’s Risk Management Group. 7.5. Risk Management and Control For identified risks, the organisation will agree a programme of actions to manage and control the risks. This will take into account value of money, quality of service delivery, quality and reliability of the evidence to support the identified risk and the impact upon the organisation, stakeholders and partners. Consideration will be given to how to develop and implement specific cost-effective strategies to increase benefits and reduce potential costs. The HB will use the following approaches to risk control:

7.5.1 Risk Appetite and Tolerance

The Chief Executive and the Board encourage the taking of controlled risks, the grasping of new opportunities and the use of innovative approaches to further the interests of the organisation and achieve its objectives, provided the resultant exposures are understood and acceptable. When deciding if a risk should be tolerated it is necessary to consider a number of factors, e.g. legislation, clinical governance, patient experience, requirements of commissioners and the appetite for these risks. Risk appetite and tolerance considers what risks the Health Board is prepared to take in pursuit of achieving its objectives. This document sets out levels of risks and within these levels there is a management structure which supports decision making in terms of risk appetite and tolerance. Risks rated up to 15 can be managed including determining the risk appetite and tolerance within Directorates/Localities/Sites. Risks rated 16 and above will need to be considered at Executive level in terms of the risk appetite and tolerance levels. Each risk must be considered individually to determine the level of risk appetite and tolerance.

17

Organisational policies and written control documents define where there are mandatory processes and procedures, e.g. the Equality and Human Rights Policy etc. Non-compliance with prescribed policies and procedures constitutes an unacceptable risk and possibly a contravention of legislation. Some risks are tolerable provided the prescribed organisational process is followed, e.g. expenditure proposals, staff recruitment, and designated responsibilities/ authorities are adhered to. Managers may take risk management decisions on the basis of their delegated financial authority and the devolved responsibilities set out in the Scheme Delegation within the Standing Orders.

7.5.2 Treat the Risk

Treat by taking action to contain the risk to an acceptable level using internal controls which include:

• Reactive controls – these controls are designed to identify occasions of

undesirable outcomes having been achieved – after the event so only appropriate when it is possible to accept the loss or damage incurred e.g. post implementation reviews to detect lessons to be learnt from projects for application in future work.

• Proactive controls – designed to ensure a particular outcome is achieved or to ensure an undesirable event is avoided e.g. health and safety guidelines etc.

• Preventative controls – limit the possibility of an undesirable event being realised e.g. separation of duties etc

• Corrective controls – to correct undesirable outcomes which have been realised – provide a route of recourse to achieve some recovery against loss or damage e.g. design contract terms to allow recovery of overpayment.

7.5.3 Terminate the Risk

Terminate – decision not to take the risk. This might be where the level of risk outweighs the possible benefits, and the risk is terminated by not doing something or doing something differently thereby removing the risk (where it is feasible to do so).

7.5.4 Transfer the Risk

Transfer – decision is made to transfer the risk to others, e.g., through insurance, contracting out the provision of service or paying a third party to take it on. Overall accountability for the risk may still remain with the HB and therefore assurance would still need to be gained in this area. In addition, many areas of business and reputational risk cannot be transferred at all. Action plans will be developed to set out the steps required to manage each risk and will include the approach chosen to control the risk as detailed above. Where additional resources are required to effectively manage a risk, this will be linked into the HB’s business planning process. 7.6 Communicate and Consult

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Communicate and consult with internal and external stakeholders and partners as appropriate at each stage of the risk management process and concerning the process as a whole. The frequency of the communication will vary depending upon the severity of the risk and should be discussed and agreed with the stakeholders and partners. This process will be led by the person nominated as the lead to manage the risk and for communication with external stakeholders this will be the appointed Executive Director lead for the risk. Effective internal and external communication is important to ensure that those responsible for implementing risk management, and those with a vested interest understand the basis on which decisions are made and why particular actions are required. Internal stakeholders can include any managers which the risk identified may impact on their service or staff. External stakeholders will vary depending on the type of risk and the risk lead for the Directorate/Locality HB will need to consider which external stakeholders will need to be notified. All significant risks will be reported to the Welsh Assembly Government through the weekly brief from organisations and quarterly performance review meetings. 8. Risk Register Once the risk has been identified and analysed the next stage is to ensure the risk is recorded on the Directorate/Locality Risk Register. The principal tool that the organisation will use for managing the risk assessment systems and processes will be the HB Risk Register, template attached as Appendix 9. The HB Risk Register can be described as “a log of all the risks that may threaten the success of the HB in achieving its declared aims and objectives.” Identifying and logging the risk will ensure that the Department/Directorate/Locality are aware of the risk and, following consideration of any existing controls in place, whether other options exist to further reduce or eliminate the risk. Appendix 10. An Action Plan will be approved and monitored by the Directorate/Locality/Site Board setting out action to be taken and priorities within their Directorate/Locality. The Head of Quality Assurance will coordinate the Corporate Risk Register and produce a HB Risk Register Report and action plan, for risks with a risk rating of 16 and above. The HB Risk Management Review Group will oversee and approve the Corporate Risk Register. The HB Risk Management Review Group will also agree the significant risks to be submitted to the Executive Board, and Quality & Safety Committee and HB Board for review and approval of the proposed action and risk treatments recommended Appendix 11. The Departments, Directorates/Localities/Sites and HB Wide Risk Registers will be analysed by the Clinical Director, General Manager/Executive Director and Governance Lead for the directorate/locality/site respectively. Risk profiling will be undertaken to ensure that trends, where appropriate, are identified from a review of information from the risk register, risk assessments, incidents, claims and complaints. The link with the requirements of the core Standards for Health Services in Wales which require the organisation to have a risk register that is populated by data representing all

19

known risks". In order to understand an organisation’s comprehensive risk profile, there must be a repository for all risk information, the risk register.

Risk Registers will continue to be developed to include risks identified from:

• Deficiencies with various Standards for Health Services in Wales; • findings from department specific and organisational wide hazard reports and risk

assessments; • underlying "root" causes of incidents complaints and claims; • underlying causes related to poor trends identified from key performance indicators; • actions to reduce risks which could not be or were not implemented for various

reasons, such as resource limitations; and • any other source of information that could be considered to be threat to patient,

staff, visitors, environmental safety or the organisations well being.

9. Risk Management Training The successful establishment of a risk management culture will require a varying level of training across the HB. Ward/Department Managers will be primarily responsible for implementing process and a minimum of 2 members of staff, including the Manager, will be trained to carry out risk assessments. These staff will be expected to oversee the risk assessments carried out in their area of work and be responsible to cascade this training to their staff with particular reference to:

the general principles and objectives of risk management; the role of staff in the risk management process; reporting systems and the importance of following them; risk register and; risk assessment.

Training will be reinforced by references in the Staff Handbook, posters, etc. Refresher training will be provided at appropriate intervals. All training provided to staff (of whatever grade) is to be recorded centrally and in personnel records with the signature of the recipient.

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10. Glossary Risk Appetite The amount of risk that an organisation is willing to seek or accept in the pursuit of its long term objectives. Risk Tolerance The boundaries of risk taking outside of which the organisation is not prepared to venture in the pursuit of its long term objectives. Risk Universe The full range of risks which could impact, either positively or negatively, on the ability of the organisation to achieve its long term objectives. Risk analysis Systematic use of information to identify opportunities and threats and to estimate the likelihood of occurrence and severity of the impact Risk assessment The approach and process used to prioritise and determine the likelihood of risks occurring and their potential impact on the achievement of objectives. Risk identification Determination of what could pose a risk; the process to describe and list sources of risks (opportunities and threats). Risk Management The process of identifying and assessing risks, assigning ownership, taking actions to mitigate or anticipate them, and monitoring and reviewing progress. This provides a disciplined environment for proactive decision making. Risk & assurance framework As an integral aspect of planning and performance management, sets the context within which risks are managed in terms of how they will be identified, analysed, controlled, monitored and reviewed. Risk management matrix Tool to assess the overall risk rating using a 5x5 matrix based on the impact of the risk and the likelihood of the risk being realised. Risk owner An individual who is in a position to ensure a risk is managed and controlled. Risk rating The overall score given to a risk based on an assessment of both its likelihood of being realised and its potential impact, measured on a scale of 1 (lowest) to 25 (highest). Significant risk Those risks assessed to have an overall rating of 16 or above (using risk management matrix).

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Strategic risk Risk concerned with where the organisation wants to go, how it plans to get there and how it can ensure success. Terminate Remove the risk by termination or doing things differently. Tolerate Continue with a risk as it is at a reasonable level but monitor regularly. Transfer Transfer the risk to a third party such as insurance. Treat Control the risk by taking contingent or containment action e.g. security checks etc. 11. References 1. Building the Assurance Framework: A Practical Guide for NHS Boards (Department of

Health, Gatelog Ref 1054, March 2003) 2. Doing Well, Doing Better – Standards for Health Services in Wales (Welsh Assembly

Government, April 2010) 3. Draft BS ISO 31000 Risk management – Principles and guidelines on implementation

(British Standards Institute, DPC/30182164 DC, May 2008) 4. Getting the Assurance you need:A guide to Boards – Draft (Welsh Assembly

Government, November 2009) 5. Identifying risk, taking action: Monitor’s approach to service performance in NHS

foundation trusts (Monitor, IRREP 02/03,) 6. Audit Committee Handbook June 2012 7. Leading health and safety at work – Leadership actions for Directors and Board

Members (Institute of Directors and Health and Safety Executive, INDG417, 09/09) 8. Risk Assessment Framework: a tool for departments (HM Treasury, ISBN 978-1-84532-625-8, July 2009) 9. Risk Essentials – A Risk Management Framework (Welsh Government, Version 2,

October 2006) 10. Risk Management in the NHS (NHS Management Executive, December 1993) 11. The Orange Book: Management of Risk – Principles and Concepts ( HM Treasury,

ISBN 1-84532-044-1-1, October 2004) 12. Your Risk & Assurance Framework: A structured approach – (Welsh Government,

December 2009)

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Appendix 1

Policies available to assist with Risk Management

Business Continuity Strategy & Policy Consent Policy Communications Policy Drug Administration Policy Fire Policy Health and Safety Policy Risk Assessment Policy & Procedure Health Surveillance Policy Immunisation of Employees Policy Infection Control Policy Putting Things Right Policy Counter Fraud Policy and Response Plan Intravenous Drug Supply and Administration Policy Latex Allergy Policy Manual Handling Policy Medical Use of Ionising Radiation Policy Records Management Strategy Policy and Guidelines on Dealing with Violence and Aggression Policy & Procedure for the Management of Asbestos Policy for Policies Policy on the Segregation and Safe Disposal of Waste Pre Employment Screening Policy Records Management Resuscitation Policy Risk Register Guidance Standing Orders Standing Financial Instructions Violence & Aggression Policy Whistleblowing Policy

23

Appendix 2 Doing Well, Doing Better: Standards for Health Services in Wales*

Standard Executive Lead

Group/Committee Overseeing the Standard

1. Governance & Accountability Framework

Board Secretary

Quality & Safety Forum

2. Equality, Diversity and Human Rights Director of Workforce and Organisational Development

Equality & Diversity Group

3. Health Promotion, Protection & Improvement

Director of Public Health

ABM Public Health Team Meetings

4. Civil Contingency & Emergency Planning Arrangements

Director of Planning

Emergency Planning Group

5. Citizen Engagement and Feedback Director of Nursing and Director of Planning Patient Experience Board 6. Participating in Quality Improvement Activities

Medical, Nursing and Therapies & Health Science Directors

Quality & Safety Forum and ISIS

7. Safe and Clinically Effective Care

Medical, Nursing and Therapies & Health Science Directors

Effective Practice Monitoring Group

8. Care Planning and Provision Director of Planning Executive Board 9. Patient Information and Consent Medical Director Consent Group 10. Dignity and Respect

Medical, Nursing and Therapies & Health Science Directors

Nursing & Midwifery Board Older Peoples Strategy Group Younger Persons Strategy Group

11. Safeguarding Children and Safeguarding Vulnerable Adults

Director of Nursing

Safeguarding Committee

12. Environment Director of Planning Executive Board 13. Infection Prevention and Control (IPC) and Decontamination

Director of Nursing

Infection, Prevention and Control Committee

14. Nutrition

Directors of Nursing and Therapies & Health Science

Nutrition Steering Group

15. Medicines Management

Medical Director Medicines Management Safety Group

16. Medical Devices, Equipment and Diagnostic Systems

Medical Director

Medical Devices Committee

17. Blood Management Medical Director Transfusion Committee 18. Communicating Effectively

Board Secretary Director of Nursing

Patient Experience Board

19. Information Management & Communications Technology

Director of Workforce and Organisational Development

Information Governance Board

20. Records Management

Director of Workforce and Organisational Development

Information Governance Board

21. Research, Development and Innovation Medical Director Research & Development Committee 22. Managing Risk and Health and Safety Director of Planning and Director of Nursing

Risk Management Review Group Health & Safety Committee

23. Dealing with concerns and managing incidents

Director of Therapies & Health Science

Investigations & Redress Group

24. Workforce Planning

Director of Workforce and Organisational Development

Workforce & OD Committee

25. Workforce Recruitment and Employment Practices

Director of Workforce and Organisational Development

Workforce & OD Committee

26. Workforce Training and Organisational Development

Director of Workforce and Organisational Development

Workforce & OD Committee

* Standards in Full are available on the Health Boards Intranet on the Risk Management site or by contacting the Head of Quality Assurance

24

Appendix 3

Scheme of Delegation

25

26

BOARD

Remuneration Committee

Audit Committee

Quality & Safety

Committee

Workforce & OD

CommitteePharmaceutical Charitable

Funds

SHSIW Srutiny Panel

Quality & Safety Forum

Innovation, Support &

Improvement Science Core

Group

Executive Board

Specialist Quality & Safety

Management Committee/

Groups

Directorate Quality Forums

Locality Quality Forums

Tactical Operational

Service Operational

Strategic Assurance

Mental HealthAct

MonitoringCommittee

Mental HealthManagersCommittee

Executive Team

Joint Operational

Board

Health & Safety Committee

Appendix 5

27

28

Appendix 7

Risk Management Review Group

Introduction The purpose of the Risk Management Review Group is to oversee the implementation of the Risk Management agenda within the Health Board, for risks of all kinds, ensuring compliance with all relevant and associated Health Board strategies and policies. The Risk Management Review Group will oversee the development and review of the Risk Management Strategy, and monitor implementation of the Strategy to deliver quality improvement in relation to patient and staff safety and organisational learning.

• To oversee compliance with the Health Board’s Risk Management Strategy and Policy and affiliated policies, as necessary;

• To ensure that responsibilities and assurance arrangements for Risk Management are clear and unambiguous across all levels of the organisation;

• To work in partnership with other organisations where relevant to develop joint Corporate risk control measures in relation to cross boundary risk management;

• To consider the implications of developments that affect Risk Management in the Health Board, including legal developments, and the response needed;

• To oversee the organisation’s approach to the reduction of risk generally and specifically;

• To encourage a systematic assessment of risk in all areas of the HB. • To monitor the Corporate and Operational Risk Register reports from the Localities,

Directorates and Corporate areas on an ongoing basis, and conduct a quarterly review of the Health Board Corporate Risk Register;

• To consider risks brought before the Risk Management Review Group for decisions regarding escalation of risk from operational status to the corporate level.; To ensure that there are effective mechanisms for reporting significant risks to the Board or senior management in a timely fashion (outside the usual reporting mechanism if required);

• To consider risks which require capital funding and agree priorities to be submitted to the relevant operational Group/Committee;

• To oversee the self assessment process and monitor full compliance against the Healthcare Standards in the Health Board at Directorate/Locality and Corporate level;

• To monitor performance against the Corporate and Directorate/Locality Healthcare Standards Improvement Plan;

29

• To consider the outcomes of external inspections, including HIW, HSE and MHRA inspections, receive and as appropriate approve the actions plans and monitor implementation and effectiveness of those actions;

• To receive NPSA alerts and notices and agree actions required for action and monitoring;

• Receive report of all significant Health & Safety matters from the Health & Safety Committee;

• To review the Mandatory/Statutory training core matrix and consider if changes are required and oversee the mandatory/statutory training plan.

Receipt and Approval To receive and endorse risk-related annual reports;

Reporting Arrangements The Risk Management Review Group will report bi monthly to the Quality & Safety

Forum. Administration Arrangements Administration for the group will be provided by the Quality Assurance Department.

Frequency of Meetings Meetings will be held bi-monthly.

Membership Director of Nursing - Chair Board Secretary Medical Director or nominated representative Director of Planning or nominated representative Director of Workforce & OD or nominated representative Director of Finance or nominated representative Head of Quality Assurance Directorate Managers Locality Managers Local Counter Fraud Specialist

Ex-Officio Members Head of Internal Audit or nominated representative

Other staff will be invited to attend meetings, as required.

Quorum To be quorate, one third of the members must be in attendance

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Appendix 8 Risk Matrix

Step 1 – Measure of Consequence The envisaged or actual consequences and likelihood are analysed in the context of any risk controls that have already been put into place using Table 1. It is acknowledged that in practice, both Steps 1 and 2 are subjective and will depend on the knowledge and expertise of the person(s) involved in the risk assessment process. To mitigate this, risk assessment is most appropriately conducted as a group/multidisciplinary activity.

Descriptor Actual or potential unintended impact on individual(s) - Patient, family member, visitor, contractor, staff

Actual or potential impact on the Trust

1

NEGLIGIBLE

Green

No harm, harm prevented or very minor harm. Example(s): Cut or bruise. First-aid treatment only required. Some extra observation required. Unsatisfactory patient experience not related to patient care.

No damage or very minor damage. No direct financial loss or financial loss up to 1k Very minimal impact. No service disruption. Example(s): Wastepaper basket fire

2

MINOR

Yellow

Avoidable short-term, non-permanent harm or impairment of health – full recovery in up to 1 month. Example(s): Minor healthcare associated infection. Temporary avoidable increase in pain experience. Unsatisfactory patient experience – readily resolvable

Short-term damage, remedial within 1 month. Increased length of hospital stay/level of care – between 1 and 7 days. Single failure to meet internal quality standards. Damage or direct financial loss up to £10,000. Staff sickness < 3 days. Low risk of complaint.

3 MODERATE

Amber

Avoidable semi-permanent injury or impairment of health or damage - recovery in up to 1 year. Additional interventions required or treatment needed to be cancelled. Necessary to transfer to another centre for treatment/care. Example(s): Temporary loss of mobility Temporary loss of vision Healthcare associated infection taking up to 1 year to resolve e.g. MRSA Further/new surgical intervention required Mismanagement of patient care

Damage remedial in up to 1 year. Direct financial loss/cost up to £100,000. Increased length of hospital stay/increased level of care – 8 to 15 days. Temporary restrictions on service(s) / service disruption. Repeated failures to meet internal quality standards. Staff sickness > 3 days. Local adverse publicity / moderate loss of confidence in organisation. Risk of litigation with cost up to £500,000. MHRA Reportable. Mental Health Act Commission Assessment. HSE Improvement Notice issued.

4

SEVERE

Red

Irrecoverable injury or impairment of health, having a lifelong adverse effect on lifestyle, quality of life, physical and mental well being. Example(s)/including: Procedures involving wrong patient/ body part. Loss of major body part(s). Retained instrument/material after surgery. Healthcare associated infection, which may result in major permanent

harm e.g. Hepatitis C. Haemolytic transfusion reaction. Radiation dose much greate/less than intended, whilst undergoing a

medical exposure. Mis-diagnosis with poor prognosis of return to health Infant abduction or discharge to the wrong family. Serious concerns re patient experience or clinical service requiring

escalation to executive level for investigation/action.

Adverse national publicity. Loss of confidence in the Trust. Ability of Trust to provide a service adversely affected / temporary service closure/resources needed to remedy situation – up to £1M. Increased length of stay or care over 15 days. Risk of litigation with cost up to £1M. Prohibition Notice / Executive Officer fined. Failure to meet national and professional standards of quality. Example(s): Trust-wide PAS/PIMs failure.

5

MAJOR

Red

Avoidable loss of life or unnecessary shortening of life expectancy. Example(s)/including: Unexpected death of a patient whilst under the direct care of a healthcare

professional. Healthcare associated infection resulting in or with potential to result in

death, e.g. hospital acquired legionellosis. Suicide or homicide committed by a patient being treated for a mental

health condition. Unacceptable patient experience which would lead to an investigation by external bodies eg Mid Staffordshire

Significant adverse national / international publicity. Severe loss of confidence in the Trust. Extended service closure. Risk of litigation with cost over £1M. Criminal prosecution. Direct financial cost over £1M. Example(s): Major loss of healthcare facilities due to fire. Loss/destruction of medical records department and all patient records Screening errors and failure to recall.

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Step 2 – Measure of Likelihood Table 2

Level and Descriptor Description Example

1 RARE

Would only occur/reoccur in very exceptional circumstances; considered a very remote probability that it could happen / happen again.

10 Yearly

2 UNLIKELY

Not expected to occur/reoccur but there is some possibility.

Yearly

3 POSSIBLE

May occur/reoccur at some time / occasionally.

Monthly

4 PROBABLE

Will probably occur/reoccur but will not be a persistent issue.

Weekly

5 EXPECTED

Will occur/reoccur and likely to be frequent.

Daily

Step 3 Risk Rating Multiply the consequence and likelihood together to provide the Risk Rating which determines the overall risk ranking and priority of the risk for action (risk treatments), in accordance with the Risk Matrix: Risk Matrix LIKELIHOOD

CONSEQUENCES 1 Rare

2 Unlikely

3 Possible

4 Probable

5 Expected

1 Negligible 1 2 3 4 5

2 Minor 2 4 6 8 10

3 Moderate 3 6 9 12 15

4 Major 4 8 12 16 20

5 Critical 5 10 15 20 25

1 - 4 LOW

This level of risk is considered acceptable and no additional action is required over and above existing management measures.

5 - 8 Manageable

This level of risk is marginally acceptable and efforts should be made to reduce the risk although the costs of reduction must be carefully considered. Risk reduction actions should be completed within 12 months.

9 - 15 Amber

Moderate This level of risk should have Risk Management Steering Group consideration. Action to reduce the risk should be completed in 6 months.

16 - 25 HIGH

Board level notification/attention of this level of risk is required, via the Risk Management Steering Group. Urgent attention to the risk is required with actions to reduce the risk commencing within 1 month. Close monitoring required. Immediate action may be required, including halting the process although before doing so the risk must be assessed to ensure it is safe to do so..

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Appendix 9 Risk Register Template

Risk Ref

Ward/Department/Directorate

Date of Entry

Type of Risk/ Specific Risk

Description of Risks

Existing Controls in Place

Cons

eque

nce

Lik

eliho

od

Risk

Rate

Potential Solutions

Cons

eque

nce

Lik

eliho

od

Resid

ual R

isk

Treatment

Agreed

Cost/Resource

Target Date/ Action Lead

33

Risk Rate 10 – 15 (Amber)Ø Enter on Directorate /

Locality Risk Register. If solution can be actioned at this level, to remain on Dept / Service Risk Register.

Ø If solution cannot be actioned at Dept / Service level, report risk to the Directorate / Locality Governance Lead.

Risk IdentifiedØ Assess RiskØ AnalyseØ Consider ControlsØ Identify SolutionsØ Rate the Risk using the Risk Matrix

Risk Rate 16 – 25 (Red)Ø Report immediately to

Service Manager / Head of Service for verification.

Ø Verification checked, report to Directorate / Locality Risk Lead for inclusion on Directorate / Locality risk Register.

Risk Management Review GroupØ Verify scores and discuss solutions with

Directorate / Locality. Consider appointment of an Executive Director to review.

Ø Receive and review Directorate / Locality Risk Registers minimum once a year.

Ø Report to Q&SC and Health Board as appropriate.

Risk Rate 5 – 9 (Yellow)Ø Enter on Ward /

Department / Service Risk Register.

Ø Solutions can be actioned at Ward / Department / Service level.

Ø If solutions cannot be actioned at Ward / Dept / Service level notify Line Manager and Directorate / Locality Governance Lead.

Risk Rate 1 – 4 (Green)Ø If no trends have been

identified review and reassess in 12 months or earlier if any circumstances change.

Ø If a trend is identified reassess and notify Line Manager

Head of Quality Assurance to:-Ø Receive risks of 16 and above which

Directorates / Localities cannot treat.Ø Link to Corporate Risk Register.

Directorate Locality BoardØ Receive Risk Register quarterly.Ø Agree Directorate / Locality priorities.Ø Agree action plan to treat the risk.Ø Identify risk of 16 and above or

organisation wide risks which cannot be managed within the Directorate / Locality to the Head of Quality Assurance and report to Risk Management Review Group.

Appendix 10Population of Risk Register

What is the Risk Rate for the next 12 months?

34

Directorate Risk Register

Corporate Director to notify Directorate / Locality Manager / Risk Lead why the risk will not be entered

on the Corporate Risk Register ie possible solutions to be actioned at Locality Directorate level.

Corporate Director to validate the risk score and consider the controls in place and solutions identified and consider whether the Directorate / Locality have

exhausted all possible solutions.

Reported to the Risk Management Review Group to consider and identify a Corporate Director to review

the Risk.

Appendix 11Process to Request Transfer of a Risk from a Directorate Risk Register to the Corporate Risk Register

Is all the above information provided by Directorate?

Directorate / Locality Board identify risk to be transferred to Corporate Risk Register

Provide the Head of Quality Assurance with:-Ø Controls in place to reduce risk.Ø Solutions to reduce the risk to a risk rate of 15 or below.Ø Details of why the risk cannot be managed at a

Directorate level.

No Yes

Corporate Director to decide whether to accept the risk for inclusion on the Risk

Register.

YesNo

Corporate Director to notify the Head of Quality Assurance of the entry for the Corporate Risk Register and provide confirmation to whether the Board will be

asked to TOLERATE, TREAT, TERMINATE, or TRANSFER the Risk.

Entry made on Corporate Risk Register and reviewed by Risk Management Review Group and reported to

the Q&S Committee and the Health Board.

Ris

k to

rem

ain

on L

ocal

ity /

Dire

ctor

ate

Ris

k R

egis

ter

Ref

Ope

ned

Obj

ectiv

e fo

r 13

/14

Domain/Type Description Controls in place

Con

sequ

ence

Li

kelih

ood

Rat

ing

Action Plan Action Lead Option Agreed

Board/ Committee Progress Q1 Q2 Q3 Q4

1 Q1 2012/13 Excellent Patient Outcomes ………………..

Timeliness of Care & Access ………………..…….. Unscheduled Care Access

Difficult to achieve waiting times in A&E and handovers which may lead to delays in assessing and treating patients and a risk of the right care not being given at the right time. Pressures on the service from number of factors which include changing profile of patient, increased demand, major service change in unscheduled care services, reduced opportunities for surge capacity due to refurbishment programme and service change, medical staffing pressures, norovirus.

ABMU and partners Unscheduled Care and Patient Flow Improvement plan for 2013/14 developed and submitted to WG. Additional actions underway regarding winter preparedness in conjunction with LA/WAST and 3rd sector USC and Patient Flow Programme board established, chaired by CEO. Daily Health Board wide escalation process in place. Regular reporting to Executive Team, Executive Board and Health Board/Quality and Safety Committee. External reporting to Welsh Government.

4 5 20 5 key elements of plan focussed on

Pre Hospital initiatives

Effective ED’s

Patient Flow

Efficient operational processes

Improved capacity – acute and community

(Cross refer to detailed plan)

Chief Operating Officer

Treat Q&S Committee Board

Additional capacity of 80 beds and bed equivalents in place at the end of Quarter 2 to deliver sustainable increase in capacity. Quarters 3&4 schemes now being implemented. Winter planning arrangements underway. Redesign of assessment units. Roll out of board rounds to support patient flow

ED Operational processes being reviewed with support of external consultants

20 20 20 20

3 Q1 2012/13 Excellent People ………………. Excellent Patient Outcomes …………..……..

Safety Domain .................... Deliver services effectively through trained competent staff and develop new roles as services change over time. Workforce Planning Compliance with Mandatory and statutory training

National shortages of numbers in some areas can lead to: Unable to recruit sufficient numbers of trainees to fulfil rotas on all sites Unable to attract non training grades to complete rotas Unable to fill Consultant grade posts in some specialties with adverse affects on patient safety and industrial relations

Regular monitoring of recruitment position with reports to Executive Team and Board via Medical Director and Medical Workforce Board. Specialty based local workforce boards established to monitor and control specific issues. The new HB Workforce & OD Committee will seek assurance of medical workforce plans to maintain services. Engagement of the Deanery about recruitment position

5 4 20 HB Workforce & OD Committee to be established. Medical workforce issues are seen as a lever for service planning and factored into C4B and South Wales service plans. Ongoing discussions and communication with Deanery about recruitment position. Recruitment campaigns for additional non training posts to fill gaps .Specific Medical Workforce Group for Integrated Medicine and Paediatrics to develop short term workforce plans .Medical Workforce Board to consider current and future shape of the medical workforce . Review of primary care in terms of recruitment and retention underway. Funding to be secured to increase nurse staffing levels. Number of workforce risks have been identified by NPT Locality relating to staffing issues of therapy staff. Action plans being worked through to ensure appropriate controls are in place.

Director of Workforce and ODMedical Director, Director of Nursing, Director of Therapies & Health Sciences

Treat ABMU Workforce &OD Committee

Regular Workforce & OD Committee meetings now underway on a quarterly basis to provide assurance on WF and OD issues including staffing levels and recruitment. Focus of Changing for the Better and South Wales Programme is to redesign services and roles that take account of recruitment difficulties in key specialties. A number of medical training initiatives are being pursued in a number of specialties to ease junior doctor recruitment. Medical Workforce Board continues to monitor recruitment and junior doctors rotas 1.2m investment for nurse staffing - 44 wte registered nurses commenced employment in July 2013 across the Health Board. Block recruitment arrangements are in place for qualified nursing staff for 2014.

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Name of Register: CORPORATEInitial RA Revised RA -

(2013/14)Date: February 2014 (Q4)

33 Q4 2012/13 Patient Outcomes ………………….. Sustainable Services

Safety Domain Risk to Cardiac surgical population of South West Wales. In the event of this unit being full with no suitable discharges to HDU or other available ITU beds within ABMU Health Board. .

Patients are admitted and treated according to clinical need. Patients are advised to discuss their condition with their GP should they have concerns recording their condition.Patients are formally pre-assessed prior to elective surgery. Emergency admissions are retained until a date for surgery can be provided.Options assessment with architect new build required have been explored for the development and expansion of CITU/CHU unit to increase capacity and flexibility.

4 5 20 Cardiac Action Plan in place. Summary of action taken include: An interim option of increasing CITU capacity has been developed and comments are presently been sought from the clinical staff. The plan is now being finalised. • An interim option of increasing CITU capacity has been developed and comments are presently been sought from the clinical staff. The plan is now being finalised.• A Cardiothoracic Directorate has been established. • Appointment of a Consultant Cardiac Intensivists • Clinical leadership has been enhanced for CITU with the appointment of a Director of CITU.• Regular communication with staff has continued

Chief Operating Officer

Treat Quality & Safety Committee

Cardiac Action plan in place and reviewed by the Q&S Committee every other meeting.

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31 Q4 2012/13 Sustainable Services ………………… Good Governance

Safety Domain The quality of the storage of the records directly impacts on availability of records. Despite continuing with a robust ongoing programme of retention, destruction and removal of records off site - all acute Health Records Libraries have reached full capacity. This leaves the service in a very hazardous position. The unavailability of space threatens the ongoing provision of service and will lead to an inevitable deterioration in the availability of records and patient care

Retention & destruction action plan in place includes destruction of deceased records from 2005; moving non-active notes to the storage unit ; culling current filing areas

4 5 20 Additional resources required to implement further actions across all sites. Proposal includes the leasing of additional off site storage space total costs £70k capital; £24k recurring

Director of W&OD

Treat Informatics Governance Committee

Jan 14 - R&D action plan in place; further funding to be sourced

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2 Q1 2012/13 Good Governance

Efficiency Domain - Finance Achieving financial balance for 2013/14 is a statutory requirement

Number of factors mean that this risk is high and include: * ability to deliver CIPs and cost containment measures * ITU activity levels above funded levels as a result of increased demand * Ability to recruit to medical staff * Investment required in Unscheduled care Capacity and Nurse Staffing levels * Capital Resource limit *Capacity and Demand Issues for Unscheduled Care and cost of Delivery of RTT t t

• Directorate/Locality CIPs are updated and maintained on weekly/monthly basis · Use of risk rating to assess CIPs · Review of CIP delivery through monthly performance reviews · Regular reporting/monitoring of CIPs to Health Board * Counter Fraud specialist in post, Fraud work plan reporting to the Audit Committee * Regular review of

4 5 20 * Review of CIP through monthly performance reviews. * Options for increasing capacity linked to ITU beds being developed. * Target reduction in use of agency, bank staff and overtime. Need to continue to identify further savings. *Structured approach to unscheduled care & RTT delivery plan .* Briefings to WG identifying significant overspend. Options to

Director of Finance and Chief Operating Officer

Treat Audit committee Financial Plans and current £32.5m gap have been presented in detail to WG. WG have issued additional allocation of £20.5m, this leaves the Health Board with a forecast deficit of £12m. . Options to reduce costs further to be considered by Executive Team (JDIs) and Health Board for schemes that impact on service.

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8 Q1 2012/13 Sustainable Services

Safety Domain …………………. Environment Records

The inability to access records stored off site or held in community based settings, particularly out of hours, can present a risk to patient care. GPOOH access to Hospital records.

Staff adherence to policies and procedures for retention and destruction of records, enabling existing storage to be used more effectively and for records to be consolidated.

4 4 16 Development of business case for an off site storage solution.

Director of Chief Operating Officer

Treat Changing for the Better Board

Discussed at Performance meeting and a Task and Finish Group established to consider options to reduce the risk and actions taken in high risk areas. Directorates/Localities requested to review all areas and ensure compliance with the Records Management Policies prior to further actions being considered.

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11 Q1 2012/13 Excellent Patient Outcomes

All 6 Domains …………….…….. Focus on improving Dignity in Care and the needs of older people

Increasing challenge of providing healthcare models for aging population. Over next 20 years care resident population will see a 24% increase in people of a pensionable age and 15% increase in people of non working age. Providing services to enable citizens to live independently at home is a major challenge.

4 4 16 Action Plan to implement 12 key recommendations within the Older People Strategy. Number of Programmes to support delivery of this priority: C4B, South Wales Programme, Delivering Capacity, Workforce and financial plans, Leadership development, Developing infrastructure, Strengthening Partnerships, Public Health Strategy.

Director of Therapies

Treat Q&S Committee Action plan in place and monitored through the Older Persons Group. Full implementation of the Butterfly Scheme and Dementia Training in Place across the Health Board.

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10 Q1 2012/13 Excellent Population Health

Safety & Effectiveness Domain ……………….. Improving Cardiovascular Health

Failure to deliver against this priority and reduce mortality rates for citizens of the HB population.

1000 Lives plus Programme, Localities and Directorates have plans in place for Tobacco Control and obesity, ABM Public Health Team contributed to the Health Improvement Plans.

4 4 16 Number of Programmes to support delivery of this priority: C4B, South Wales Programme, Delivering Capacity, Workforce and financial plans, Leadership development, Developing infrastructure, Strengthening Partnerships, Public Health Strategy.

Director of Clinical Strategy and Director of Public Health

Treat Q&S Committee ABMU Public Health Team supporting the development of an ABMU HB area 2012/13 Obesity Strategic Action Plan. Implementing the actions from the ABMU HB Tobacco Control Strategic Action Plan 2012 - 14 across the Localities

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9 Q1 2012/13 Excellent Patient Outcomes …………..……. Sustainable Services …………………

Access ………………..………..

Insufficient bed capacity to meet demand at peak times can have a major impact on service delivery around access particularly

See Unscheduled Care Access ref 1. Specific Programmes in place for Patient flow and Surgical Pathway Efficiency reporting to the Strategic Change Board.

4 4 16 Comprehensive pre-hospital alternatives programme incorporated into the USC and patient flow programme, building on previous work with partner agencies, to reduce avoidable hospital attendances

Capacity plans will increase acute and community capacity by 286 beds/ bed equivalents) by March 2014 to deliver 85% medical bed occupancy.

Capacity plan in place for critical care.

Surgical Pathway efficiency programme will deliver improvements in emergency surgical capacity.

Chief Operating Officer

Tolerate Board Additional capacity of 80 beds and bed equivalents in place at the end of Quarter 2 to deliver sustainable increase in capacity. Quarters 3&4 schemes now being implemented. Winter planning arrangements underway. Reduction in elective cancellations as a result of bed access issues.

Recruitment underway to support the commissioning of all 28 critical care beds at Morriston on a substantive basis by the end of December ( circa 5 additional beds)

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21 Q3 2012/13 Sustainable Services

Safety Domain ………………...…….. Follow up Not Booked Lists

Length of follow up OPD lists. Patients are waiting over their target dates in numerous specialties. There is potential for patient harm.

Detailed Follow Up Not Booked lists published weekly on the Caldicott Drive. FUNB information with exception reporting is also available via Hypercube. Additionally, Follow Up Not Booked lists and exception reports are provided to Directorates on a weekly basis for review and action. Impact of the actions are reviewed through the monthly performance review meetings as part of the quality scorecard.

4 4 16 Working with Directorates to review clinic capacity, clinic templates/ follow up policy/ virtual clinics/ SOS follow up/validation of lists etc in order to reduce FUNB problem

All Operational Directorates

Treat Changing for the Better Board

Speciality specific action plans being developed and monitored monthly through the performance meetings.

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25 Q4 2012/13 Excellent Outcomes

Safety ……………………..….. Delayed electronic discharge Summaries

Lack of timely discharge information provided to General Practitioners may lead to patient harm - minimum standard of information - specific follow up instructions, medication and diagnosis

Board wide project in place to improve compliance. IT systems in place to assist in streamlining processes. Performance monitored via HB perf report and monthly performance review meetings with each Directorate and locality.

4 4 16 Working Group established to oversee implementation of the actions identified to support increase in compliance.

Chief Operating Officer

Treat Changing for the Better Board - Patient Safety Programme

Single PAS project & rollout of PIMS+portal to Swansea I by March 2014, will provide single solution for creating discharge summaries as part of Admission process

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26 Q2 2012/13 Good Governance

Good Governance ……………………….. Investigation Redress Department

Prolonged period of reduced resourcing within the department, arising through high staff turnover resulting in limited knowledge levels within the team. Increased volume of work entering the department - 50% increase in complaints over past 3 years / continual increases in volumes of incidents reported / increasing Serious incidents and Never Events / increasing litigation / increasing numbers of cases progressing to Ombudsman / NHS Redress requiring far greater input to achieve compliance / changes to HM Coroners requirements demanding greater co-ordination.

Interim Complaints strategist recruited to review complaints arrangements and progress devolvement of work. Interim Operational Manager for Complaints assisting within department to progress backlog complaints and resolve complaints capacity issues through the next 3 months. Former departmental staff assisting undertaking work as external contractors. Executive oversight of Ombudsman correspondence.

4 4 16 Progress restructuring and redesign of corporate functions provided by the existing department to ensure ownership is appropriately allocated to increase awareness and likelihood of improvement actions being realised and more effective in reducing recurrence.

Director of Therapies & Health Sciences

Treat HR Group / Quality & Safety Committee

Anticipated reorganisation and devolvement to be progressed to implementation within 6 months with the assistance of the Interim Complaints Strategist.

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4 Q1 2012/13 Excellent Patient Outcomes …………..…….

Safety Domain ……………………….. Infection Control Reducing Healthcare Acquired infections

Healthcare acquired infection (HCAI) causes patients harm. HCAI also results in increased costs, length of stay and bed losses.

Comprehensive Control of Infection Policies & Procedures / SOPs in place. HB wide ICD appointed. Comprehensive programme of action via the 1,000 Lives Programme being actioned including hand hygiene, antibiotic stewardship, dress code, cleaning standards Regular monitoring of compliance with standards and the identification of hot spots Operational engagement of infection control in site management processes Clear escalation process in place. Operational Infection Prevention Board established chaired by the Chief Executive. Performance Indictors agreed and monitored through the IPB.

5 4 20 Continue with current management arrangements Consider implications of zero tolerance approach Focus backlog maintenance efforts in high risk areas Ensure full compliance with Hand Hygiene requirements. Monitored through Infection Prevention Board. Reviewed monthly through the performance meetings on the quality section of the performance scorecard.

Director of Nursing Chief Operating Officer Medical Director & Director of T&HS

Treat Infection Prevention Board Infection Control Committee reporting to the Q&S Committee

The Infection Control Commitment to Purpose Action Plan is being implemented. Levels of HCA C Diff' and MRSA reducing. Improving levels of hand hygiene compliance. Improved levels of antibiotic stewardship evident Infection Prevention Board chaired by the Chief Executive monitoring monthly compliance in relation to a range of IC standards ward by ward each month. Capital funding linked to IC priorities agreed. Increase in cleaning hours agreed.

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32 Q4 2012/13 Patient Outcomes

Safety Domain Approximately 10 batches of appointment letters not being printed when patients are appointed on Myrddin (affecting about 400 patients) mainly affected POW & NPT since go live on Myrddin (25/11/13) with isolated incidents in Swansea. This issue has caused subsequent delays in booking processes as additional checks being put in place

Fix in place since 13/1/14. Able to reproduce letters for 600 forthcoming appts. Continued monitoring and feedback to NWIS Myrddin Team to identify problem and ensure issues are resolved

3 5 15 Myrddin Team to work with ABM to resolve this issue.

Director of W&OD

Treat Informatics Governance Committee

15Jan 14 - Escalated to NWIS Directors on 21/1/14 in order for resources to be allocated to resolve problems asap

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15 Q1 Excellent Population Health

All 6 Domains Failure to achieve population health improvement targets leading to an increase in preventable disease amongst the population resulting in increased morbidity impacting on operational and financial pressures.

Local Public Health Strategic Framework developed to ensure that work to achieve targets is being delivered and progress reported via the HB performance reviews.

5 3 15 Actions plans and strategic plans in place for actions relating to tobacco control, substance misuse, obesity, falls and injuries, workplace health and sexual health.

Director of Public Health and Chief Operating Officer

Treat Board ABM Public Health Team contributed to the Single Integrated Plan Joint Needs Assessment in Bridgend, NPT and Swansea. Director of Public Health Annual report which will inform the work of the three Localities.

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31 Q3 2012/13 Sustainable Services

All 6 Domains ………………………... Delay in agreeing the way forward for the South Wales Programme

A decision is awaited on the way forward for the service changes required and has been postponed from December 2013. There is a risk that the fragile services may fail and result in emergency changes which may not follow the strategic direction and impact on other services.

Timescales reviewed by each SWP Board meeting. Framework for making recommendations approved by the Programme Board. Health Board has a strategic plan for local services which complements the SWP.

5 3 15 Director of Planning

Tolerate Board 15 15

14 Q1 2012/13 Sustainable Services

Safety and Efficiency …………………. Fragmented and duplicate records

Enterprise Master Patient Index now contains all known numbers for a patient's hospital record (those previously held on PAS systems) Majority of these numbers have physical paper records

i t d ith th Th i till

Guidance issued to staff on how to choose the most relevant number where duplicates exist. The most relevant paper case note is pulled for the patients new consultation ie. the note with any cardiology

ti it ld b ll d f

4 4 16 Implement Informatics Devt plan and move to paperlite outpatients and more electronic ways of working, reducing the need for paper case notes. Medium to long term investigate funding for scanning of hi t i l d t l

Director of Workforce and OD

Treat Informatics Governance Committee

Ongoing programme of duplicate record amalgamation in place where resources allow.

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23 Q4 2012/13 Good Governance

Safety Domain ………………… Business continuity and Disaster Recovery

Large scale system failure may impact the delivery of key services

ICT Business Continuity Task and Finish Group set up to develop coordinated disaster recovery plan.

4 3 12 Business Continuity plans to be developed for key IT and Clinical Systems to be made available across the Health Board via the Emergency Planning Web Site

Director of Workforce and OD and all Operational Directorates

Treat Emergency planning and Informatics Strategy and Governance Board

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13 Q1 2012/13 Excellent Patient Outcomes ………………. Sustainable Services

Safety ……………..……….. Environment - Premises

Accommodation that does not meet statutory/health and safety requirements could have an adverse impact citizens, staff, financial and operational performance. This is a problem in the acute setting as well as across primary care in community clinics and surgeries.

Key areas where performance linked to health & safety/fire issues flagged through Health and Safety Committee and actions agreed to mitigate impacts. Issues raised through site meetings held regarding service changes for all 4 acute hospital sites

4 4 16 Develop a strategy to improve primary and community services estate.

Directorate Managers and Locality Directors

Tolerate H&S Committee Position statement in respect of primary and community services in progress and will be available by end October

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17 Q1 2012/13 Excellent Patient Outcomes

Safety and Efficiency Domains ………………… Equipment Replacement

Inability to replace key pieces of equipment could adversely affect capacity and patient well being

Ensure that asset life information will be produced in the new single EBME system from 2011/12, is consistent with the Fixed Asset Register and will allow equipment replacement programmes to be planned for future years.Ensure equipment replacement requirements are identified within all future capital new build/ refurbishment schemes

4 3 12 Director of Planning

Tolerate Medical Device Committee

Database being developed to support an ongoing equipment replacement programme.

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24 Q4 2012/13 Excellent Patient Outcomes

Safety Domain ………………….. Compliance with NPSA Alerts

NPSA alerts are produced following a review of incidents across England and Wales promoting safer ways of working to limit the risk of a reoccurrence. Non compliance with the alerts exposes the Health Board to safety risks.

Exception reports produced for the RMRG on a bi monthly basis and reported to the Q&S Committee on a quarterly basis. All Wales Group for leads to share practice in compliance with the alerts.

4 3 12 Continuous monitoring Director of Nursing

Treat and Tolerate for the alert re neuralaxial connectors

Risk Management Review Group and Q&S Committee

Action Plans for each notice monitored on an exception basis at each RMRG and T&F Groups set up to oversee implementation of the actions for specific alerts.

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16 Q1 2012/13 Excellent Patient Outcomes

Access, Efficiency & Timeliness Domains ………………….

Failure to achieve compliance with waiting times, failure to ensure Equity planning maps through our access plans.

Weekly information provided to RTT management teams with prospective views of patient booking. Monthly performance reviews track progress against delivery. Flexible resource identified to manage in-year waiting times risks. Weekly executive support meetings in place in high risk areas

4 3 12 Number of Programmes to support delivery of this priority: C4B, South Wales Programme, Delivering Capacity, Workforce and financial plans, Leadership development, Developing infrastructure, Strengthening Partnerships, Public Health Strategy. Two efficiency Programmes (Surgical Pathway and Patient Flow) support the delivery of this work.

Chief Operating Officer and Director of Planning

Tolerate Board and Q&S Committee

Regular Monitoring in place. 12 12 12 12

27 Q1 2012/13 Excellent Patient Outcomes

Safety and Efficiency ………………….

Loss of access to key clinical and support service information due to insufficient level of capital funding for technical system and hardware refresh

Limited discretionary capital (approx £500k pa) is utilised to invest in priority areas. Resilient systems and networks implemented wherever possible. Working closely with Finance to secure additional capital annually on an ad-hoc basis. Ongoing requirement is £2.3 million on an annual basis.

3 4 12 Continue to invest in technology which reduces capital requirement such as server virtualisation and thin client technology. Investigate feasibility of implementing 'bring your own device' (BYOD) facility to improve access for clinicians. Develop strategic outline programme (SOP) for Informatics to bid for capital investment from WG

Director of Workforce and OD

Treat MSP Programme Board; Informatics Clinical Reference Group

Ad-hoc funding of £2.1 million secured in 2012/13 which enabled replacement of out of warranty equipment and some refresh of PCs and laptops. Wireless network installed in Morriston hospital as part of hospital upgrade development. Pilot of BYOD pilot in place to determine risks and benefits. SOP being developed to highlight capital and revenue requirements for investment in technology to support clinical practice and benefit patient care

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28 Q3 2013/14 Good Governance

Safety Domain …………………... Service/Business interruption/ disruption

Unplanned events - such as major infectious diseases; pandemic flu; major incidents; severe weather episodes; mass casualty incidents etc. could have major implications for ABMU in terms of its resilience, service response and financial cost. The likelihood of one of these events occurring is almost certain, however the likelihood of all of them occurring is unlikely. The impact of such an event however could range from minor to catastrophic.

1. Range of Policies and Plans developed on a national, All Wales, South Wales and ABMU basis covering and mitigating against the risks as far as possible.2. Risks such as these are identified on: National Risk Register - http://www.cabinetoffice.gov.uk/national-securitySouth Wales LRF Community Risk Register, NPT and Swansea Joint resilience partnership, chaired by the local authority.3. ABMU participation in the All Wales Health Emergency Planning Advisory Group which is a forum for discussing and promoting NHS emergency preparedness and emergency planning policy. 4. ABMU participation in South Wales Local Resilience Forum and Health Board/Trust Emergency Planners Group.

4 3 12 1. Review of existing local plans to take into account latest UK & National Guidance and lessons learned from actual events.2. Risks associated with health have been reviewed and placed on the South Wales Local Resilience Forum Risk Register and discussed at the Joint Resilience Partnership3. Participation in a range of exercises to test current arrangements and response plans.

Director of Planning & Chief Operating Officer

Treat Emergency Planning Group, Local resilience Forum and all Wales Working Groups

Considerable work has been undertaken to mitigate the impact of a major incident and subsequently the risk score reflects this. The ABMU Major Incident Plan has undergone a major review in 2012 and an annual review for 2013 is complete.Two main community risks are Pandemic Flu and Flooding. 1.Health Board Pandemic Framework and Multi agency tactical plan for the ABMUHB area are now complete and were tested during the measles outbreak; 2013 as the plan guided the emergency response.2. Flooding - All Health Board premises have now been mapped by "Natural Resource Wales". Some community premises have been highlighted as being in flood risk areas and the respective localities are in the process of working with these premises to develop business continuity plans in respect of this.3. Involvement in workshop for Health Prepared Wales (re Pandemic Flu).4. Will participate in multi-agency exercises when planned. 5.A review of FFP 3 Mask procurement and training currently undertaken to ensure appropriate PPE is available and staff are trained in the appropriate use in preparation for a pandemic but also as a business continuity contingency to respond to isolated episodes.

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29 Q3 2013/14 Good Governance

Safety Domain …………………... Service/Business interruption/ disruption

Business Continuity Planning - robust and resilient plans required across the organisation to prevent service disruption and possible financial implications. The impact of any BCM interruption could range from negligible to catastrophic and as such the risk has been scored as a worst case scenario.

1. Existing BCM Plans for each Locality and Directorate.2. Generic HB wide Business Continuity plans 3. Business Continuity Framework.

4 3 12 BCM Planning & Review process to continue across the Health Board, building on the work already undertaken.Individual service support offered via Emergency Planning to assist in development of BCM plans.

Director of Planning & Chief Operating Officer

Treat Emergency Planning Group, Local resilience Forum and all Wales Working Groups

Significant progress has been made in many areas with feedback provided via Healthcare Standards Submissions in terms of the necessity of each Locality and Directorate to have business contiuity plans to mitigate specific risks to their specialities. They are encouraged to follow Health Board Business Continuity framework as consistency is required across the Health Baord. In addition there is a Business Continuity Register for those plans deemed generic to mitigate risk to the Health Board as a whole. Each Locality and Directorate has been asked to submit a register of their specific plans. A number of generic plans have been recently completed e.g Pandemic Framework, Fuel, Contaminated Casualties, Mass Fatalities, Alternative Premises for Critical Care Areas, Distribution of Countermeasures and Telecoms and some additional plans are being progressed e.g Mass Casualties, Receipt of Bomb Threat and Finding of Suspect Package.Emergency Planning group utilised as forum for initiating BCM planning & review.

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