Presentation to GPDV March 2005

1. Presentation to GPDVMarch 2005 Systems for risk management in leadership and management : what do accreditation reviewers look for? Dr Lee Gruner March 2005

2. ACHS Standards, criteria and elements • EQuIP has six functions • Each function has a number of standards • Each standard consists of criteria • Each criterion has a variety of elements that define the ratings Dr Lee Gruner March 2005

3. Ratings • LA- awareness • SA- implementation • MA- evaluation • EA- benchmarking • OA- best practice • To the end of 2004, only 40% of organisations have obtained MA in all mandatory criteria • 42% of organisations have not achieved MA in 2.2.1 Dr Lee Gruner March 2005

4. The risk management standard in L&M • 2.2:The governing body promotes the safety of all persons within the organisation by its pro- active approach to preventing and managing clinical and non- clinical risks • Criteria: • 2.2.1 (Mandatory) • An organisation wide risk management policy ensures that safety is considered in all activities • 2.2.2 • A risk management system ensures that risks are minimised in all activities Dr Lee Gruner March 2005

5. Risk management criteria in L&M • 2.2.1 • Board signs off on risk management policy that includes clinical and non clinical risk and ways of managing these • Ensures that policy is relevant to health service strategy • Ensures that understanding and implementation of the policy has been evaluated with staff • Ensures policy is regularly reviewed • Is aware of the risk management system and ensures evaluation of this (2.2.2) Dr Lee Gruner March 2005

6. Risk management criteria in L&M • 2.2.2 • Comprehensive incident reporting system • Ways to deal with confidentiality documented • Organisation wide risk management system • Sentinel events reported to the governing body • The risk management system is evaluated • The risk reporting system is evaluated • Incidents/ events/ near misses are trended and information used to decrease risk and improve quality of care and service Dr Lee Gruner March 2005

7. Development of an effective risk management system • Needs to be organisation wide to include risks in all areas- clinical, financial, HR, reputation, OH&S etc • Use a team approach to develop in departments or for whole organisation if small eg by use of a structured brainstorm • Word risks appropriately • Prioritise all risks using a grid that relates likelihood to consequence Dr Lee Gruner March 2005

8. Assessing consequences • Develop a scale to determine if consequences are trivial to extreme. These will depend to an extent on your organisation eg: financial consequence- extreme may be >$1m in a large organisation and >$50K in a smaller organisation • For OHS, a staff death is likely to be extreme in any organisation, but in a small organisation one staff member off for 12 months will be of greater impact than in a large organisation Dr Lee Gruner March 2005

9. Assessing consequences • Beg and borrow consequences tables from other organisations to develop your own • Review the consequences table regularly to ensure it is still current Dr Lee Gruner March 2005

10. Likelihood v Consequence=Risk Moderate High Extreme Dr Lee Gruner March 2005

11. Develop an action plan • Develop clear action plans to minimise risk in all areas of extreme and high risk • Any extreme risks identified need to be acted upon urgently • Any areas of high risk need to be addressed within 6 months • Moderate risks need to be addressed in the medium term. Some may need monitoring only • Low risks need to be monitored Dr Lee Gruner March 2005

12. Problems in risk management systems • Fragmented risk registers with a fragmented structure for reporting • Risks not identified correctly (confusion between cause and effect) eg risk identified is “poor communication”. This risk should be the outcome that this poor communication will lead to • Risks not identified in all areas- particularly non clinical risk • Risk registers not reviewed • Risks not appropriately classified • Framework too complex for staff to understand the process Dr Lee Gruner March 2005

13. Solutions • Fragmented risk registers with a fragmented structure for reporting • Risk registers not reviewed • Establish a single risk register with one oversighting and representative committee • Establish a monitoring system to ensure high and moderate risks are addressed in a timely manner Dr Lee Gruner March 2005

14. Solutions • Risks not identified correctly (confusion between cause and effect) • Ask the right questions Dr Lee Gruner March 2005

15. Developing a risk register • What are we concerned about? • Staff defrauding the system • Why are we worried about this- the risk? • Not enough funds to provide services • How do we manage this risk? • Establishing fail safe systems to minimise fraud • Risk minimised Dr Lee Gruner March 2005

16. Developing a risk register • What are we worried about? • We have a malfunctioning smoke alarm system and Staff don’t take any notice when fire alarm goes off • Why are we worried about this- the risk? • Staff may not address a real fire threat appropriately and are in danger • How do we manage the risk • Fix the smoke alarms • Educate staff in response • Risk minimised Dr Lee Gruner March 2005

17. Developing a risk register • What are we worried about? • Staff walking to their cars at night • Why are we worried about this – the risk? • Staff may be attacked • How do we manage the risk? • Security walks staff to cars (Risk minimised) • All staff leave in daylight ( Risk eliminated) Dr Lee Gruner March 2005

18. Developing a risk register • What are we worried about? • Visitors being injured when they visit our premises • Why are we worried about this – the risk? • They may sue us and we will go bankrupt • How do we manage the risk? • Take out public liability insurance (Risk transferred) Dr Lee Gruner March 2005

19. Solutions • Risks not identified in all areas- particularly non clinical risk • Ensure that risks are assessed in all areas of the organisation- financial/ HR/ OH&S/ information management / clinical/ reputation/programs/ equipment • Use teams to develop risks in the areas • Consultant help may be useful Dr Lee Gruner March 2005

20. Solutions • Risks not appropriately classified • Develop a detailed likelihood and consequence table that defines what is trivial/ minor/ moderate/ major/ extreme • The table should define injury severity/ reputation risk/ financial risk/ program risk/ environmental risk/ facilities or equipment risk at each level • The table should define likelihood of occurrence eg almost certain (occurs weekly) compared with very unlikely (not less than every 3 years) Dr Lee Gruner March 2005

21. Solutions • Framework too complex for staff to understand the process • Pilot the framework with staff • Develop a flow chart of how the process works Dr Lee Gruner March 2005

22. Questions? Dr Lee Gruner March 2005