risk management enhancement framework in ntwc on risk … · 2017. 7. 26. · risk management...
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Risk Management Enhancement Framework in NTWC on Risk Register Development and Performance Monitoring Process
Bonnie WONG Cluster Manager (Quality & Safety) Quality & Safety Division New Territories West Cluster Hospital Authority, Hong Kong
HA Convention 2017 16 May 2017
New Territories West Cluster (NTWC), Hong Kong Hospital Authority 1
Risk is everywhere in a hospital…
Delayed handling of investigation reports
Retention of materials
Wrong prescription of medication
Procedure performed in a wrong body part
Blood transfused to a wrong patient Loss of an important specimen
New Territories West Cluster (NTWC), Hong Kong Hospital Authority 2
To manage risks, it is all people’s responsibilities
Hospital Chief Executive
Senior Management
Middle Management
Frontline Colleagues
Information Resources
Actions Improvement
New Territories West Cluster (NTWC), Hong Kong Hospital Authority 3
New Territories West Cluster (NTWC), Hong Kong Hospital Authority 4
Risk registers (RRs) are developed for communication among different levels
New Territories West Cluster (NTWC), Hong Kong Hospital Authority 5
What information do staff base on in developing RR?
Gaps are identified…
Is the linkage of RR among cluster, hospital and department
levels strong enough?
Are we talking about the same risks but different names?
Reviewed and enhanced the:
• Risk management framework
• Risk register (RR) development process 2014
Aim to effectively identify, monitoring,
report and treat risks
New Territories West Cluster (NTWC), Hong Kong Hospital Authority 6
New Territories West Cluster (NTWC), Hong Kong Hospital Authority 7
Department Risk Register
Hospital Risk Register
Cluster Risk Register
Department Management Committee
Hospital Management Committee
Cluster Management Committee
HA (Corporate) Risk Register
Endorsed by
consolidate
consolidate
submit to
Clinical Non-clinical CQSC
CMSC & CNMC
Prioritise
Endorse
Consult
CQSC = Cluster Quality & Safety Committee CMSC = Cluster Medical Services Committee CNMC = Cluster Nursing Management Committee
Strengthened risk register (RR) development & endorsement processes 1
New Territories West Cluster (NTWC), Hong Kong Hospital Authority 8 8
Developed an NTWC Risk Taxonomy 2
50 risk categories & 244 sub-categories
• Referencing to EQuIP numbering system
• Review and update regularly
New Territories West Cluster (NTWC), Hong Kong Hospital Authority 9
Provided department incident reports 3 • Quarterly incident reports sent to departments since 2Q 2014 • Facilitate review by dept head, incidents • Categorised by risk category, severity index & incident location
New Territories West Cluster (NTWC), Hong Kong Hospital Authority 10 10
Developed an Electronic RR System (ERRS) 4
transform
Paper format (old)
Electronic format (new)
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Developed an Electronic RR System (ERRS) 4
Aims: • Provide a structured system to facilitate
reporting • Timely review / update by Dept Head
anytime • Adopt a structured list of common risk
categories
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Developed an Electronic RR System (ERRS) 4
Data can be easily exported to Excel for analysis
New Territories West Cluster (NTWC), Hong Kong Hospital Authority 13
Provided training to departments 5
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Developed Key Risk Indicators (KRIs) 6 • Enhance monitoring of risk performance (e.g. incident trends)
• Present in rate-based, e.g. per 1000 IP BDO
• 19 KRIs were developed
New Territories West Cluster (NTWC), Hong Kong Hospital Authority 15
Monitored risk by “Risk Control Sheets” 7 • Work with Risk Custodians in planning and updating progresses of
risk mitigation actions
• Timely update performance of each risk, i.e. KRIs
• Report to cluster / hospital management regularly
New Territories West Cluster (NTWC), Hong Kong Hospital Authority 16
NTWC was invited to support the development of Corporate Risk Management with KPMG
by HAHO Group Internal Audit in 4Q 2014
Summary
• Adopted both bottom-up & top-down approaches in the development of RRs
• Provided risk performance data for considering the priority of risks more objectively
• Piloted an Electronic Risk Register System to facilitate data input and aggregation
• Developed an NTWC Risk Taxonomy to standardise communication of risk terms among staff
• Developed Key Risk Indicators to monitor risk performance
• Used Risk Control Sheets to document progresses of risk mitigation actions and facilitate reporting to senior management
New Territories West Cluster (NTWC), Hong Kong Hospital Authority 17
Thank You!
New Territories West Cluster (NTWC), Hong Kong Hospital Authority 18