NHS Highland Board 27 March 2017

Item 4.10

NHS HIGHLAND STRATEGIC RISK REGISTER

Report by Mirian Morrison, Clinical Governance Development Manager on behalf of Elaine Mead, Chief Executive

The Board is asked to:

• To note the NHS Highland Strategic Risk Register as at March 2018

• To note the Issue Log as at March 2018

• To note the Risk Management and Assurance and Escalation Routes

1. Background and Summary

At the April 2015, Board meeting the NHS Highland Risk Management Policy was approved. The policy conforms to British Standard (BS ISO 31000:2009) Risk Management Principles and Guidelines.

Risk Management arrangements are overseen by the Risk Management Steering Group, chaired by the Chief Executive and meets on a quarterly basis. The group provides reassurance to the NHS Board that systems, processes and procedures relating to risk management are in place and provides the lead role in advising on and managing all risks to an acceptable level. The group oversees the Strategic Risk Register.

2. NHS Highland Strategic Risk Register 2017/18

The Board is responsible for ensuring that there is a clear and appropriate management structure for ensuring that NHS Highland has effective systems which enable risk to be identified and decisions to be taken at an appropriate level.

To support the Board in discharging its responsibilities, it had delegated aspects of risk governance to the Governance Committees. Each committee has a responsibility for providing assurance to the Board in respect of the risks that fall within its specific remit. In some cases the Board itself is the assurance source.

This requires each Governance Committee to use the Strategic Risk Register to consider risks that may require further scrutiny (for example, risks evaluated as very high) and seek assurance from individual risk owners regarding the management of these risks, including the adequacy of existing control measures and progress against any actions required for improvement.

The Strategic Risk Register is reviewed and updated on a quarterly basis by the Risk Management Steering Group. The strategic risk register is attached in Appendix 1.

3. NHS Highland Issues Log 2017/18

In November 2017, it was agreed that an issues log be set up to capture any risks that had been an issue and hence required close monitoring on weekly/monthly basis.

Following discussion at the Risk Management Steering Group in November 2017 it was agreed that risk ID 448 (risk of not delivering the savings plan) should be taken off the risk register and added to the issues Log.

In February 2018, it was agreed that the specific risk of Raigmore Hospital Radiology Staff should be added to the issues log.

The issues log is attached in Appendix 2.

4. Risk Management and Assurance and Escalation Routes

To ensure appropriate assurance, escalation and de-escalation of risk a flowchart has been developed and continues to be reviewed as structures change. This is shown in Appendix 3.

On an annual basis each of the Operational Unit Risk Registers are considered by the Risk Management Steering Group to give assurance the risks are being appropriately managed. Operational Units can escalate risks to the Risk Management Group for consideration of inclusion onto the strategic risk register.

A Corporate Services Risk Group has been set up to review the risk registers of each of the corporate functions. This meets on a quarterly basis, two weeks before the Risk Management Steering Group and escalates any risk for consideration for inclusion onto the risk register.

Since April 2017, the following risks have been escalated and following agreement added to the strategic risk register.

• The risk of new members of staff contracting Hepatitis B infection because of a national storage of the Hepatitis B vaccine

• The risk of not delivering the savings in plan in full

The risk of failure to deliver the immunization programme due to changes with the new GP contact was discussed in detailed at the meeting in November 2017. It was agreed that it would remain on the Public Health risk register as plans to mitigate the risk were in place. If plans changes this would be escalated back to the Risk Management Steering Group.

Finally two risks were taken off the Strategic Risk Register as assurance was given that these were being managed appropriately. These were:-

• The exploitation of vulnerable clients • Cervical Screening

4. Contribution to Board Objectives

The contents of the Board Risk Management Policy and the risks contained within the Strategic Risk Register have a direct link to NHS Highland Quality Objectives.

3

5. Governance Implications

• Staff Governance

The policy applies to all employee of NHS Highland and will require active input from Directors and Managers at all levels to ensure that risk management is a fundamental part of our approach to quality. The Executive Directors are responsible for ensuring that the risk is managed and actions are taken to manage the risk.

• Patient and Public Involvement

Without a comprehensive risk management policy patient and public safety could be compromised

• Clinical Governance

All clinical activities at NHS Highland involve risk. It is important that we proactively manage risk to an acceptable level by embedding processes focused on assessment and prevention, rather than reaction and remedy.

• Financial Impact

All financial decision making in NHS Highland involves risk. It is important that we proactively manage risk to an acceptable level by embedding processes focused on assessment and prevention, rather than reaction and remedy. A robust risk management policy should have a positive financial impact by ensuring that risks are mitigated.

6. Risk Assessment

This document sets arrangements for risk management and assessment within NHS Highland.

Mirian Morrison Clinical Governance Development Manager

March 2018

Issues Log 2017-18Issue Log Date ID Issue owner Issue description Mitigation/action Monitoring

1 15-Nov-17 448 Director of Finance

There is a risk of not delivering the savings plan in full, because of a failure to redesign at suffient pace, resulting in a failure to meet financial targets

brokerage through SG; preparing a threee year financial plan to balance the budget; weekly monitoring of information on wall walk; financial committee of Board set up and monitoirng monthly; regulsr meetings with SG; Peer support through NHS Grampian At every RMSG

2 21-Feb-18 Board Medical DirectorRadiology Staff Raigmore Hospital

Work being undertakne at local, regional and national leave to look at ways to address radioloogy waiting times. Recuitment initiatives ongoing At every RMSG