RISK MANAGEMENT STRATEGY
2016 - 2018
Version
2
Name of responsible (ratifying)
committee
Risk Assurance Committee
Date ratified
19 May 2016
Document Manager (job title)
Head of Risk Management
Date issued
26 May 2016
Review date
01 March 2018
Electronic location
Corporate Strategies
Related Procedural Documents
Risk Assessment Policy, Risk Management Policy,
In the case of hard copies of this policy the content can only be assured to be accurate on the date
of issue marked on the document.
For assurance that the most up to date policy is being used, staff should refer to the version held on
the intranet
VERSION
DATE
RATIFIED
1
2 June 2015
Strategy rewritten
2
19 May 2016
Strategy updated with clear process
for risk escalation
Updated Risk Management team
objectives to support delivery of the
Strategy
Updated organisational committee
structure
BRIEF SUMMARY OF CHANGES
AUTHOR
Acting Head of Quality, Head Of Risk
Management
Acting Head Of Risk Management
In the case of hard copies of this strategy, the content can only be assured to be accurate on the date of issue
marked on the document
For assurance that the most up to date strategy is being used, staff should refer to the version held on the
intranet
PHT Risk Management Strategy 2016-2018
Version: 2
Date of Issue: 26.05.2016
Review Date: 01 March 2018 (unless requirements change)
Page 1 of 15
Table of contents
1.
INTRODUCTION ..................................................................................................................... 3
2.
STATEMENT OF INTENT ....................................................................................................... 3
3.
WHOSE RESPONSIBILITY IS RISK MANAGEMENT? ........................................................... 3
4.
AIMS AND OBJECTIVES ........................................................................................................ 4
5.
EMBED RISK MANAGEMENT AT ALL LEVELS OF THE ORGANISATION ........................... 4
6.
CREATE A CULTURE WHICH SUPPORTS RISK MANAGEMENT ........................................ 6
7.
PROVIDE THE TRAINING TO SUPPORT RISK MANAGEMENT ........................................... 8
8.
EMBED THE TRUST’S RISK APPETITE IN DECISION MAKING ........................................... 9
9.
MEASURE THE IMPACT OF IMPLEMENTATION ................................................................ 10
10. ORGANISATIONAL RISK MANAGEMENT STRUCTURE ..................................................... 10
11. EQUALITY IMPACT STATEMENT ........................................................................................ 11
12. MONITORING COMPLIANCE WITH THE RISK MANAGEMENT STRATEGY ...................... 11
13. ASSOCIATED DOCUMENTATION ....................................................................................... 11
14. REVIEW ................................................................................................................................ 12
Appendix A: Organisational Committee Structure ......................................................................... 13
Appendix B: Duty of Key Individuals in the Risk Management Framework .................................... 14
Appendix C: Assurance Framework / Risk Register protocol flowchart ......................................... 15
PHT Risk Management Strategy 2016-2018
Version: 2
Date of Issue: 20.05.2016
Review Date: 01 March 2018 (unless requirements change)
Page 2 of 15
1.
INTRODUCTION
An understanding of the risks that face NHS Trusts is crucial to the delivery of healthcare
services moving forward. The business of healthcare is by its nature, a high-risk activity and
the process of risk management is an essential control mechanism. Effective risk
management processes are central to providing Portsmouth Hospitals Trust (the Trust) Board
with assurance on the framework for clinical quality and corporate governance.
The Trust Board recognises that complete risk control and/or avoidance is impossible, but the
risks can be minimised by making sound judgments from a range of fully identified options.
The Trust’s aim, therefore, is to promote a risk awareness culture in which all risks are
identified, assessed, understood and proactively managed. This will promote a way of
working that ensures risk management is embedded in the culture of the organisation and
becomes an integral part of the Trust’s objectives, plans, practices and management
systems.
2.
STATEMENT OF INTENT
The Trust Board is committed to leading the organisation forward to deliver a high quality,
sustainable service achieving excellent results. Thereby ensuring the organisation delivers
the best patient-centred care possible, in the hospital of choice whilst making the very best
use of public funds.
The Board recognises that to achieve these goals, there is a need for robust systems and
processes to support continuous improvement, enabling staff to integrate risk management
into their daily activities wherever possible and support better decision making through a
good understanding of risks and their likely impact.
This can only be achieved through an ‘open and just’ culture where risk management is
everyone’s business and where risks, accidents, mistakes and ‘near misses’ are identified
promptly and acted upon in a positive and constructive way. Staff are, therefore, encouraged
and supported to share best practice in a way that creates a culture of learning and a drive to
reduce future risk: a cornerstone of building safer, effective, and efficient care for the future.
This Risk Management Strategy is underpinned by a suite of policies guiding staff on the day
to day delivery of effective risk management processes. These linked policies are listed in
section 9.
An Annual Risk Management Plan will be developed by the Head of Risk Management, and
will be agreed and monitored by the Risk Assurance Committee. The Annual Plan will include
objectives to address key risk issues in order to ensure continuity and progression in the
Trust’s strategic direction for risk management.
3.
WHOSE RESPONSIBILITY IS RISK MANAGEMENT?
The success of the risk management programme is dependent on the defined and
demonstrated support and leadership offered by the Trust Board as a whole.
However, the day-to-day management of risk is the responsibility of everyone in our
organisation at every level, and the identification and management of risks requires the active
engagement and involvement of staff at all levels. Our staff are best placed to understand
the risks relevant to their areas of work and must be enabled to manage these risks, within a
structured risk management framework.
PHT Risk Management Strategy 2016-2018
Version: 2
Date of Issue: 20.05.2016
Review Date: 01 March 2018 (unless requirements change)
Page 3 of 15
4.
AIMS AND OBJECTIVES
The aim of this strategy is to strengthen the existing risk management framework, embedding
risk management at a local level and ensuring appropriate escalation of the risks through the
organisation to the Board. In addition, greater local level ownership of risk, enhanced clarity
regarding roles and responsibilities for risk management and strengthened governance
arrangements to support the current framework. The strategy is supported with an
implementation plan, with objectives to support the achievement of the aims as outlined
below. Both the strategy and implementation plan will be monitored by the Risk Assurance
Committee.
The key objectives of the Risk Management Strategy are to:

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5.
Embed risk management at all levels of the organisation.
Create a culture which supports risk management.
Provide the tools to support risk management.
Provide the training to support risk management.
Embed the Trust’s risk appetite in decision making.
Measure the impact of implementation.
EMBED RISK MANAGEMENT AT ALL LEVELS OF THE ORGANISATION
One of the key aims of this strategy is to ensure greater local ownership of risks. To achieve
this, we will continue to strengthen risk registers at Clinical Service Centre (CSC) and
specialty level supported by clear criteria and timeframes for escalation of risks. Increasing
transparency of the CSC risk registers will support this and will be achieved by utilising the
risk register module within the updated DatixWeb incident reporting system. This will allow
for ease of transference of risk and link to incidents related to specific identified risks.
To support this greater local ownership of risks, the roles and responsibilities for the risk
identification, assessment, management and monitoring will be clarified and to ensure clear
escalation of risks between the different levels of the organisation, from ‘ward to board’. The
following procedure will continue to be embedded to ensure appropriate escalation of risk.
5.1 Interface Between Trust Risk Register and Board Assurance Framework (BAF)
All red risks (15+) on the Trust Risk Register must be linked to the BAF. The BAF enhances
the information in the Trust Risk Register by detailing through assurance how well the highest
risks to the delivery of strategic objectives are being controlled and mitigated to satisfy both
internal and external requirements. In turn it will inform the Board where the delivery of
principal objectives are at risk due to a gap in control and/or assurance.
The Trust Risk Register and the BAF work together to provide a flow of information regarding
achievement of and threats to strategic objectives. The highest scoring operational risks on
the Trust Risk Register will be associated with and help to inform the strategic risks on the
BAF either individually or collectively (where risks from the Trust risk register are grouped into
an overarching strategic risk on the BAF), this is evidenced through cross referencing
between the 2 documents.
In turn each BAF risk is clearly cross referenced to the Trusts strategic objectives and Trust
Risk Register referenced to the BAF, thus allowing a clear mapping of objectives, risks,
controls, and assurance across all 3 documents.
The Director of Corporate Affairs coordinates this process with the risk owners for the BAF
and the Risk Management team for the Trust Risk Register on behalf of the Risk Assurance
Committee and Trust Board.
PHT Risk Management Strategy 2016-2018
Version: 2
Date of Issue: 20.05.2016
Review Date: 01 March 2018 (unless requirements change)
Page 4 of 15
5.2 Management of Risk Registers and Escalation of Risk
All specialties are required to maintain a risk register of identified risks; these can be
proactive or reactive risks pertinent to the service or area. Speciality risk registers are
reviewed regularly by the CSC governance committee where high level risks can be agreed
for inclusion on the CSC risk register.
The purpose of the Risk Assurance Committee (RAC) is to promote effective risk
management to establish and maintain a Trust Risk Register and review the BAF to ensure
all risks are captured and are referenced between the two documents. This enables the
Board to monitor the arrangements in place to achieve a satisfactory level of internal
control, safety and quality.
In accordance with the terms of reference; the Risk Assurance Committee will review CSC
risk registers on a 6 monthly basis and consider all risks identified at a score of 15 or above
(unacceptable risks) for inclusion on the Trust Risk Register, if not already identified on the
document. The committee can recommend inclusion on the BAF should the risk be deemed
sufficiently high level to affect delivery of the Trust Strategic Aims.
Similarly if a risk has been mitigated to a level where it is deemed appropriate for the CSC
to continue management at that level, the Risk Assurance Committee will recommend
removal of that risk from the Trust Risk Register.
Any risk that has been identified by a CSC outside of their scheduled reporting timescale
can be brought to the attention of the Risk Assurance Committee as a separate agenda
item for consideration for inclusion on the Trust Risk Register.
The Risk Assurance Committee ensures that all risks on the Trust Risk Register and Board
Assurance Framework (BAF) have an identified operational lead responsible for updating
the risk information as appropriate, and a responsible committee identified to ensure that
the risk is monitored in the appropriate forum.
Trust Risk
Register
CSC Risk Registers
Specialty Risk Registers
Reviewed monthly by RAC
Full register reviewed quarterly by TB
Reviewed monthly by CSC
Governance Committees
Reviewed 6 monthly by RAC
Reviewed regularly by
Specialty Governance
Committees
Appendix B identifies the responsibilities of key individuals in the risk management
framework.
PHT Risk Management Strategy 2016-2018
Version: 2
Date of Issue: 20.05.2016
Review Date: 01 March 2018 (unless requirements change)
Page 5 of 15
In order to ensure that the framework is effective, we will continue to monitor the
strengthened role and membership of the Risk Assurance Committee (RAC) so that it
challenges the management of risk at Clinical Service Centre (CSC) and corporate function
level, aggregates risks across those areas and escalates Trust Board accordingly. RAC will
monitor compliance with the Risk Management Strategy and associated policies by reviewing
risks at CSC and corporate function level, but also scrutinising the arrangements for risk
management at the lower level and holding CSCs to account for the effectiveness of their
specialty arrangements.
Embed risk management at all levels of the organisation
Action
Lead
CSC Risk Registers available on the risk management
intranet page – ensure these are current and up to date
through spot audits until process embedded.
Acting Head
of Risk
Management
Completed
December
2016
Transference of the Corporate Risk Register and BAF
to Datix to allow for a system for aggregation and
escalation between specialty and CSC risk registers.
Acting Head
of Risk
Management
Acting Head
of Risk
Management
Implement the complete Datix functionality upgrade,
deliver the project plan and engage CSCs with process
changes to continue to enhance reporting of risk.
Risk
Analyst/Datix
Manager
July 2016
Support CSC Governance Leads to embed the new
processes for review of reported Safety Learning
Events
Risk
June 2016
Analyst/Datix
Manager/Risk
Management
Team
Acting Head
May 2016
of Risk
Management
Ensure all CSC risk registers are migrated to the new
Datix risk register module.
Revise the Risk Management Strategy in line with
internal audit recommendations.
Align central risk management team responsibilities to
further support CSCs.
6.
Acting Head
of Risk
Management
Deadline
September
2016
December
2016
CREATE A CULTURE WHICH SUPPORTS RISK MANAGEMENT
A key component of an effective and mature risk management framework is having a culture
of knowledge and understanding of risk management and leadership. This means that roles
and responsibilities need to be clearly defined so that risk management is ‘owned’ by
appropriate members of staff and that staff are encouraged to be more risk aware by
promoting openness and supporting them to manage risks locally where possible. It also
means visible and effective leadership from the Board in ensuring effective systems and
processes for the management and escalation of risks.
The Trust has board level leadership for risk management and a clear committee structure
that supports the aggregation and escalation of risk through the Risk Assurance Committee,
now a Trust Board sub committee. We have already identified and strengthened the
leadership within that framework by adding Non-Executive level input and challenge into
PHT Risk Management Strategy 2016-2018
Version: 2
Date of Issue: 20.05.2016
Review Date: 01 March 2018 (unless requirements change)
Page 6 of 15
RAC, in addition to the existing clinical representation and Executive leadership. We will
strengthen the role of RAC in providing the Board assurance as to the effectiveness of the
framework of controls and assurances, by continuing to develop the ‘deep dive’ methodology
to understand risks on the Corporate Risk Register and Board Assurance Framework (BAF).
A flowchart outlining the protocol for management of risk can be found in appendix C.
As well as structure, a mature risk management framework requires risk management to be
at the heart of board level discussion. To enhance the maturity of existing conversations at
board level, one of the aims of this strategy is to create a clear link between assurance, risk
management, corporate governance and regulation. Using the agreed risk appetite matrix,
the Board can set out a framework within which all risk should be considered, linking
objectives, business planning and risk appetite. This will also help to develop an approach
that engenders risk forecasting.
Management of risk at CSC and specialty level has been further supported with the
introduction of CSC Governance Leads. We aim to further develop these roles to support the
delivery of this strategy. We will also create local ownership of risk management through
involvement of staff in designing the tools to manage risk, training programmes and
implementation of the upgraded Datix Safety Learning Event (incident) reporting function.
Create a culture which supports risk management
Action
Lead
Gain Board leadership and support for this strategy
and work plan, through presentation at RAC and Board
approval.
Associate
Director of
Quality &
Governance
Strengthen process to review risks on the Corporate
Director of
Risk Register and BAF; to include more robust scrutiny Corporate
of effectiveness of actions to mitigate risks. This will
Affairs/Acting
enhance the process of assurance.
Head Of Risk
Management
Implement an enhanced robust system for completion
Acting Head
of SIRI investigation process and submission to
of Risk
Commissioners for review. Ensuring escalation of
Management
issues is undertaken within timescales to support
delivery of the 60 day requirement.
Deadline
May 2016
July 2016
June 2016
Promote reporting
Action
Lead
Implementation of Datix web upgrade modules to
maximise this as a resource within the Trust:
Further development of reporting functionality to
identify trends/themes
Revise process for reporting on to NRLS to ensure
timely uploading of all reported Safety Learning Events
to improve the Trust’s national reporting position.
Risk
Analyst/Datix
Manager
Implement agreed changes.
Deadline
September
2016
Acting Head
April 2016 of Risk
complete
Management/
Datix Project
Team
May 2016
PHT Risk Management Strategy 2016-2018
Version: 2
Date of Issue: 20.05.2016
Review Date: 01 March 2018 (unless requirements change)
Page 7 of 15
7.
PROVIDE THE TRAINING TO SUPPORT RISK MANAGEMENT
In order to develop a culture for risk management and to ensure successful implementation of
this strategy, there needs to be a targeted training programme for staff to supplement existing
training provision.
Risk management training and awareness already occurs in a number of different methods.
The Board currently have a session on risk management once a year as part of the board
development programme and risk, governance and quality features in a number of leadership
development programmes as well as ad hoc training provided. However we recognise that in
order to successfully implement this strategy we will need to develop a more structured risk
management training programme to increase staff knowledge and understanding of risk
management for specific staff groups.
As well as including training in the trust’s risk management processes, we will use the
organisation-wide programme to help to embed a consistent language of risk management,
including concepts such as controls, mitigations, assurances and residual risk. This will
enhance the quality of conversation and consistency of approach. We will therefore review
the existing training programme and training materials to ensure appropriate knowledge and
skills in risk management at different levels of the organisation.
Provide the training to support risk management
Action
Risk Management team to obtain appropriate Risk
Management and training qualifications.
Once team are suitably trained - review existing inhouse training provision in relation to risk
management to identify gaps, design programme to
deliver appropriate sessions.
Provide RCA training in 2016/17 which can be
cascaded throughout CSCs in order to develop a pool
of staff skilled in RCA methodologies
Review current availability of training opportunities
both internal and external.
Ensure the Board receive a risk management session
as part of the Board development programme
Continued delivery of CSC specific training to enhance
the use of Datix reporting functionality.
PHT Risk Management Strategy 2016-2018
Version: 2
Date of Issue: 20.05.2016
Review Date: 01 March 2018 (unless requirements change)
Lead
Acting Head
of Risk
Management/
Risk
Management
team
Acting Head
of Risk
Management
Deadline
December
2016
July 2016
December
2016
Acting Head
September
of Risk
2016
Management/
Associate
Director of
Quality &
Governance
Acting Head
Completed
of Risk
Management
Acting Head
of Quality /
Head of Risk
Management
Risk
Analyst/Datix
Manager
July 2016
September
2016
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8.
EMBED THE TRUST’S RISK APPETITE IN DECISION MAKING
8.1 Acceptable Risk
The Trust acknowledges that some of its activities may, unless properly controlled, create
organisational risks, and/or risks to staff, patients and others. The Trust will therefore make
all efforts to eliminate risk or ensure that risks are contained and controlled so that they are
as low as reasonably practical.
However it is not always possible to reduce or mitigagte an identified risk completely and it
may be necessary to make judgments about achieving the correct balance between benefit
and risk. A balance needs to be struck between the costs of managing a risk and the benefits
to be gained.
A decision must therefore be made regarding the level which a risk would be deemed
acceptable to tolerate. A risk is considered acceptable when there are adequate control
measures in place and the risk has been managed as far as is considered to be reasonably
practicable. Tolerated risks should be brought to the attention of RAC through CSC risk
registers or the Trust Risk Register on a bi-annual basis.
Where a risk has been reduced to the point where the cost of further controls to reduce the
risk outweigh the benefit they may provide, it may not be considered reasonably practicable
to implement those controls. However where risk controls are available it is the duty of the
organisation to demonstrate that the cost of implementation outweighs the benefit, or, that
alternative effective control measures have been implemented. Risks requiring a cost benefit
analysis must be discussed at RAC for wider debate and decision on ‘acceptability’
8.2 Risk Appetite.
Risk appetite can be defined as the amount of risk, on a broad level, that an organisation is
willing to accept in the pursuit of its strategic objectives.
Risk appetite is a core consideration in any corporate risk management approach. No
organisation, whether in the private, public or third sector can achieve its objectives without
taking a risk. The question for the decision-makers is how much risk do they need to or are
prepared to take?
The UK Corporate Governance Code states that “the board is responsible for determining the
nature and extent of the significant risks it is willing to take in achieving its strategic
decisions”. As well as meeting the requirements imposed by corporate governance
standards, organisations are increasingly being asked to express clearly the extent of their
willingness to take risk to meet their strategic objectives.
Risk appetite, correctly defined, approached and implemented, should be a fundamental
business concept that makes a difference to how organisations are run. The strategy will be
to develop an approach to risk appetite that is practical and pragmatic, and that makes a
difference to the quality of decision-making, so that decision-makers understand the risks in
any proposal and the degree of risk to which they are permitted to expose the organisation
while encouraging enterprise and innovation.
PHT Risk Management Strategy 2016-2018
Version: 2
Date of Issue: 20.05.2016
Review Date: 01 March 2018 (unless requirements change)
Page 9 of 15
Embed the Trust’s risk appetite in decision making
Action
Raise board awareness of risk appetite and its use
through a board development session regarding risk
appetite.
Include risk appetite and risk assessment in the annual
business planning process, at clinical service centre
and corporate level.
9.
Lead
Director of
Nursing /
Director of
Corporate
Affairs
Director of
Nursing /
Director of
Corporate
Affairs
Deadline
Feb 2016 completed
July 2016
MEASURE THE IMPACT OF IMPLEMENTATION
There is a need to measure the impact of the strategy, to measure its effectiveness in
developing the maturity of the Trust’s risk management framework. We will therefore review
the strategy and implementation plan on an annual basis.
In order to measure the impact of implementation of this strategy, we will complete an annual
risk maturity assessment to evaluate performance and progress in developing and
maintaining effective risk management capability and assessing the impact on delivering
effective risk handling and required/planned outcomes. To undertake this, the framework
below will be utilised:
Capabilities
1. Leadership: do senior management and Clinical leaders support and promote risk
management?
2. Are people equipped and supported to manage risk well?
3. Is there a clear risk strategy and supporting risk policies?
4. Are there effective arrangements for managing risks with partners?
5. Do the organisation’s processes incorporate effective risk management?
Risk Handling
6. Are risks handled well?
Outcomes
7. Does risk management contribute to achieving outcomes?
By completing this on an annual basis, we will assess the key aims of this strategy:
10.
ORGANISATIONAL RISK MANAGEMENT STRUCTURE
An organisational structure to help manage delegated responsibility for implementing risk
management systems with in the Trust is illustrated and explained in Appendices A and B.
The Risk Management structure is based on committees and groups which have key roles in
the management of risk and delivery of this strategy. This is kept under regular review with
terms of reference reviewed annually.
This provides the assurance required by the Board that all areas of risk are being adequately
managed. Appendix A demonstrates the organisational committee structure and lines of
reporting.
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Date of Issue: 20.05.2016
Review Date: 01 March 2018 (unless requirements change)
Page 10 of 15
All members of staff have an individual responsibility for the management of risk and all
levels of management must understand and implement the Trust’s Risk Management
Strategy and supporting processes.
The Risk Management Team supports and co-ordinates risk management activity.
11. EQUALITY IMPACT STATEMENT
The Trust is committed to ensuring that, as far as is reasonably practicable, the way we
provide services to the public and the way we treat our staff reflects their individual needs
and does not discriminate against individuals or groups on any grounds.
This Strategy has been assessed accordingly.
12. MONITORING COMPLIANCE WITH THE RISK MANAGEMENT STRATEGY
Element to be
monitored
Lead
Tool
Risk Management
structure and
committee
functions are
operating as per
this Strategy
Acting Head of
Quality / Head
of Risk
management

CSC local
management of
risk (risk registers)
is operating as set
out in this strategy
Acting Head of
Quality / Head
of Risk
management

Internal
Audit
Frequency
Annually
Reporting
arrangements
Reported to:
 Trust Board
 Audit Committee
 Risk Assurance
Committee
Internal
Audit
Annual
Reported to:
 Trust Board
 Audit Committee
Leads for
Acting on
Recommenda
tions
Acting Head of
Quality / Head
of Risk
management
CSC
Management
Teams
 Risk Assurance
Committee
13. ASSOCIATED DOCUMENTATION
The following internal and external documents support the implementation of the Risk
Management Strategy
Internal – these can be found on the Trust’s Intranet site.
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Duty of Candour and Being Open Policy
Claims Management Policy
Transformation Programme Development (Including Quality Impact Assessment)
Health and Safety Policy
Major Incident Response Policy
Maternity Risk Management Strategy
Adverse Event and Near Misses Management Policy
Serious Incident Requiring Investigation Management Policy
Complaints Concerns Comments and Plaudits Management Policy
Risk Assessment Policy
Whistleblowing Policy
PHT Risk Management Strategy 2016-2018
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Date of Issue: 20.05.2016
Review Date: 01 March 2018 (unless requirements change)
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If, for any reason, a member of staff does not have access to the Trust Intranet a hard copy
can be made available by their line manager or the Risk Management Department
External:
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
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An Organisation with a Memory: Department of Health 2000 www.dh.gov.uk
Building a Safer NHS: Department of Health (2002) www.dh.gov.uk
Building a Memory: preventing harm, reducing risks and improving patient safety:
National Patient Safety Agency (2005) www.npsa.nhs.uk
Being Open: National Patient Safety Agency (2005) www.npsa.nhs.uk
National Standards, Local Action, Health and Social Care Standards and Planning
Framework: Department of Health (2004) www.dh.gov.uk
Assurance: The Board Agenda: Department of Health. (2002) www.dh.gov.uk
The Handbook to the NHS Constitution www.dh.gov.uk
Acute Hospitals: Provider Handbook www.cqc.org.uk
The NHS Outcomes Framework 2013/14 – DoH www.dh.gov.uk
Equity and Excellence: Liberating the NHS – DoH 2010 www.dh.gov.uk
Assurance: The Board Agenda – DoH 2002
Management of Risk: A Strategic Overview – HM Treasury 2000
14. REVIEW
This Strategy will be reviewed in 2018, unless requirements change.
PHT Risk Management Strategy 2016-2018
Version: 2
Date of Issue: 20.05.2016
Review Date: 01 March 2018 (unless requirements change)
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Appendix A: Organisational Committee Structure
PHT Risk Management Strategy 2016-2018
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Date of Issue: 20.05.2016
Review Date: 01 March 2018 (unless requirements change)
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Appendix B: Duty of Key Individuals in the Risk Management Framework
Chief Executive: is the Accountable Officer for the Trust and has overall responsibility for the
management of risk. The Chief Executive has delegated this responsibility to an Executive Lead for
Risk (Director of Nursing). The Executive Lead for Risk is responsible for reporting to the Trust
Board on the development and progress of Risk Management, and for ensuring that the Risk
Management Strategy is implemented and evaluated effectively.
Executive and Non Executive Directors:
The Executive and Non Executive Directors have a collective responsibility as a Trust Board to
ensure that the Risk Management processes are providing them with adequate and appropriate
information and assurances relating to risks against the Trust’s objectives.
Non-Executive Directors: have a responsibility to scrutinise and, where necessary, challenge the
robustness of systems and processes in place for the management of risk.
Director of Nursing: is the Executive lead for governance, risk and patient safety. In partnership
with the Medical Director, the post holder ensures organisational arrangements are in place, which
satisfy the legal requirements of the Trust with regard to the quality and safety arrangements or
patients and staff; including delivery of processes to enable effective risk management and clinical
standards.
Chief Operating Officer: has executive responsibilities, which include effective and safe delivery
of clinical services through effective operational governance arrangements across the organisation.
Director of Finance: has executive responsibility for the financial governance arrangements
throughout the organisation, including overseeing financial performance management at corporate
and CSC level
Director of Corporate Affairs: is responsible for the work of the Board and its Committees and for
ensuring integration of their activities with respect particularly to their governance and regulatory
responsibilities. Management of the Board Assurance Framework.
Associate Director of Governance and Quality: supports the Director of Nursing and the Medical
Director with regard to their safety and risk management responsibilities. This includes overseeing
the risk management function, encompassing the Trust Risk Register, Statement on Internal
Control and compliance with the requirements of the CQC standards.
Risk Management Team: has responsibility for the operational delivery and implementation of the
Risk Management Strategy and associated policies/processes.
CSC Senior Management Teams: the teams comprise a General Manager, Chief of Service and
Head of Nursing and have delegated authority and responsibility for: directing governance activity;
managing risk and developing monitoring systems for providing assurance that activity is being
carried out appropriately. The Teams are also responsible for escalating any issues up through the
governance structure.
Managers: have delegated responsibility and authority with regard to the management of quality,
risk and performance within their specific spheres of activity included in their job descriptions.
Managers are also responsible for escalating issues up through their designated governance
structures.
All Staff: are responsible for their own and others health and safety within their immediate
workplace and for participating in the wider governance, quality and risk management activities, as
appropriate and have this included in their job descriptions. Staff are also responsible for escalating
issues up through their designated line management structures.
PHT Risk Management Strategy 2016-2018
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Date of Issue: 20.05.2016
Review Date: 01 March 2018 (unless requirements change)
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Appendix C: Assurance Framework / Risk Register protocol flowchart
PHT Risk Management Strategy 2016-2018
Version: 2
Date of Issue: 20.05.2016
Review Date: 01 March 2018 (unless requirements change)
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