Get documents about "Medical Operational Data System Training
Description
Medical Operational Data System Training document sample
Document Sample
fb34f9d6-54de-4e33-83a5-1d88bd86d7cf.xls
RISK RISK DESCRIPTION COMMENT ON RISK PREVIOUS RISK RISK CATEGORY CONTROLS CONSEQUENCE LIKELIHOOD CURRENT RISK CONTROL CHANGE IN RISK OWNER RISK STRATEGY RISK TREATMENT DUE
NO. RISK IDENTIFIED SEVERITY SCORE SCORE SCORE SEVERITY EFFECTIVENESS RISK TREATMENT/S DATE (MM/DD/YYY)
(MM/DD/YYYY) SCORE SCORE
(RESIDUAL)
1 Declines in service delivery standards due July 25, 2007 20 OPERATIONAL - HR Bursary Programme/ 5 4 20 4 UNCHANGED HR Manager/ Transfer To be confirmed December 31, 2007
to a shortage of adequately skilled nursing & Training Training interventions/ Director
staff Quality reviews/ incident
reporting and analysis
7 Inability to attract and retain skilled staff July 25, 2007 12 OPERATIONAL - HR Staff development 4 5 20 3 GETTING HR Manager/ Reduce To be confirmed December 31, 2007
impacting on service delivery standards & Training schemes/ Funding WORSE Director
obtained to 'top-up' base
pay levels for critical
positions/ Use of
recruitment agencies
6 Death of patients due to medication errors July 25, 2007 12 CORE SERVICES - Recruitment and training 4 4 16 2 GETTING Director: Clinical Reduce To be confirmed December 1, 2007
Clinical programmes/ Incident and WORSE Services
Effectiveness near miss reporting in
RiskMan/ Incident
investigation process/
Prescription of high-risk
drugs managed by
experienced senior
medical staff.
19 Harm suffered by customers/ patients due July 25, 2007 4 OPERATIONAL - Maintenance programme/ 4 4 16 2 GETTING UNALLOCATED Reduce To be confirmed September 30, 2007
to malfunction of key medical equipment Facilities Capital replacement WORSE
(e.g. ventilators, heart monitor) Management programme/ Staff training
in equipment usage
25 Current IT systems lack adequate July 25, 2007 12 IT & SYSTEMS - No controls in place 3 5 15 4 GETTING Financial Manager Avoid To be confirmed January 15, 2008
Management Information and Reporting System Functionality WORSE
capabilities, resulting in poor decision
making and funds allocation.
5 Death of patients due to delays in July 25, 2007 16 OPERATIONAL Internal Audit review and 5 3 15 2 IMPROVING Operations Reduce To be confirmed September 20, 2007
admissions process redesign of Admissions Manager/ Director
process (2006)/ New
Patient Records IT system
23 Life threatening patient care errors and July 25, 2007 9 CORE SERVICES - Limit to shift length/ 5 3 15 2 GETTING Director: Clinical Reduce To be confirmed August 15, 2007
omissions resulting from overworked/ Clinical Risk Enforced breaks during WORSE Services
tired clinical staff. shifts/ Annual leave
27 Loss of accreditation due to consistent July 25, 2007 15 CORE SERVICES Staff recruitment and 5 3 15 2 UNCHANGED UNALLOCATED Reduce To be confirmed August 30, 2007
pattern of patient harm, caused by (CLINICAL) training/ Limit to shift
incorrect diagnoses and treatment plans. length/ Approved
treatment regimes for
common medical
conditions/ Enforced
breaks during shifts/
Annual leave/ Junior
medical staff not permitted
to prescribe/ dispense
high risk medicines,
managed high risk
patients
28 Lack of cash handling procedures and July 25, 2007 20 FINANCIAL - Billing Patient Admissions IT 3 5 15 2 IMPROVING Chief Financial Reduce To be confirmed December 1, 2007
controls resulting in misappropriation/ & Debtors system incorporates a Officer
theft of funds. billing module/ Daily
reconcilliation of tills in
pharmacy, admission
desks and canteen/
Internal Audit reviews/
Cash takings banked
daily, recorded on Finance
system
24 Inability to meet demand for home-based July 25, 2007 12 OPERATIONAL - No controls in place/ 3 4 12 4 UNCHANGED Financial Manager Reduce To be confirmed August 15, 2007
care due to shortages of fleet vehicles. Asset & Fleet Volunteer driver
Management programme under
investigation/ Carers
transported by relatives
10 Unplanned failure/s to core IT systems July 25, 2007 6 IT & SYSTEMS BCP Plan in development/ 4 3 12 3 GETTING IT Manager/ CIO Reduce To be confirmed February 28, 2008
Off-site back-up of patient WORSE
data/ Use of paper-based
records
21 Competition from other institutions July 25, 2007 3 STRATEGIC Medium term strategic 4 3 12 2 GETTING CEO Reduce To be confirmed February 28, 2008
(public and private) in terms of use of new planning process/ WORSE
medical technology, which may result in a Ongointg research into
decline in organisation’s standing, and healthcare trends/
hence patient and revenue growth. Membership of indusrty
discussion forums
30 Failure to meet financial reporting July 25, 2007 6 FINANCIAL - Annual budgeting and 3 4 12 1 GETTING Chief Financial Reduce To be confirmed September 1, 2007
deadlines resulting in non-compliance Reporting reporting cycles defined/ WORSE Officer
with government/ Auditor General Monthly and annual
requirements. reporting processes/
Compliance and risk
management reviews
12 Injuries, losses and interruptions caused July 25, 2007 5 STRATEGIC - State Disaster 5 2 10 3 GETTING Risk Committee Reduce To be confirmed February 28, 2008
by a natural disaster (floods, fires etc) Business Continuity Management Processes/ WORSE
BCP in development/
Emergency Response dry-
runs
26 Loss of customer records due to IT July 25, 2007 8 IT & SYSTEMS BCP Plan in development/ 5 2 10 3 GETTING IT Manager/ CIO Reduce To be confirmed February 28, 2008
system failure/ corruption of system data. Off-site back-up of patient WORSE
data/ Use of paper-based
records
Page 1 of 9
fb34f9d6-54de-4e33-83a5-1d88bd86d7cf.xls
RISK RISK DESCRIPTION COMMENT ON RISK PREVIOUS RISK RISK CATEGORY CONTROLS CONSEQUENCE LIKELIHOOD CURRENT RISK CONTROL CHANGE IN RISK OWNER RISK STRATEGY RISK TREATMENT DUE
NO. RISK IDENTIFIED SEVERITY SCORE SCORE SCORE SEVERITY EFFECTIVENESS RISK TREATMENT/S DATE (MM/DD/YYY)
(MM/DD/YYYY) SCORE SCORE
(RESIDUAL)
8 Failure to deploy and manage resources July 25, 2007 20 STRATEGIC - Annual business planning 5 2 10 2 IMPROVING CEO Reduce To be confirmed December 1, 2007
effectively to meet required service level Strategic Planning and budgeting process/
standards Zero based budgeting/
Expenditure review
committee/ Internal Audit
15 Loss of patient records due to IT system July 25, 2007 12 IT & SYSTEMS BCP Plan in development/ 5 2 10 2 IMPROVING IT Manager/ CIO Reduce To be confirmed February 28, 2008
failures Off-site back-up of patient
data/ Use of paper-based
records
4 Legal claims resulting from breaches of July 25, 2007 20 STRATEGIC - Secure storage and 3 3 9 3 IMPROVING Legal and Reduce To be confirmed September 1, 2007
patient confidentiality requirements Compliance & Legal limited access rights to Compliance
patient records/ Patient Officer
consent forms/ Staff ethics
training
22 Corporate failure of Hospital Food July 25, 2007 9 OPERATIONAL - Service Level Agreement 3 3 9 3 UNCHANGED Operations Reduce To be confirmed August 20, 2007
Company, impacting on XYZ Hospital’s Purchasing and with supplier/ Alternative Manager/ Director
ability to meet in-patient nutritional (meal) Supplies suppliers investigated
requirements.
11 Research misconduct by scientist can lead July 25, 2007 10 CORE SERVICES - Clinical Ethics committee/ 3 3 9 2 IMPROVING Director: Clinical Reduce To be confirmed November 1, 2007
to patient harm, damage to institution’s Clinical Risk Research review Board/ Services
reputation and loss of funding Independent researchers
not granted access to
research facilities/
Contract prohibiting
researchers from
communicating with press
18 Severe injury/ death of staff due to July 25, 2007 16 OPERATIONAL - Facilities Management 3 3 9 2 IMPROVING Facilities Manager Reduce To be confirmed September 30, 2007
workplace accidents caused by lack of Facilities involvement with
maintenance to public areas (lifts, Management Worksafe programmes/
stairwells, corridors etc.) Maintenance budget/
OH&S training/ Signage of
potential dangers/ Access
14 Loss of public confidence in the July 25, 2007 20 STRATEGIC - Communications Officer/ 4 2 8 3 IMPROVING CEO Reduce To be confirmed August 20, 2007
organization due to negative publicity Stakeholder Public Communications
Relations Programme/ Researchers
and staff not permitted to
speak directly to press
16 Organisation’s funding allocation from July 25, 2007 16 STRATEGIC Annual budgeting and 4 2 8 3 IMPROVING CEO Reduce To be confirmed December 31, 2007
State is not sufficient to provide for business planning
increasing costs associated with provision process/ Submissions of
of current services, resulting in possible strategic plans to
decline in patient care levels, removal of healthcare agencies/
non-core services and/or decline in patient Donations and
numbers. Sponsorship initiatives
20 Organisational services not changing/ July 25, 2007 5 STRATEGIC - Medium term strategic 4 2 8 3 GETTING CEO Reduce To be confirmed February 28, 2008
adjusting to meet changing public and Strategic Planning planning process WORSE
customer needs, resulting in a loss of
patients and funding.
2 Personnel job descriptions do not reflect July 25, 2007 15 OPERATIONAL - HR Alignment of job 4 2 8 2 IMPROVING HR Manager/ Reduce To be confirmed December 31, 2007
organisational needs, resulting in & Training descriptions to balanced Director
unqualified employees performing critical scorecard for
tasks. organisation/ Annual
review of reporting
structures
9 Inability to implement legislative changes July 25, 2007 8 OPERATIONAL - Regulatory compliance 4 2 8 2 UNCHANGED Legal and Reduce To be confirmed February 28, 2008
in a timely manner Health & Safety workgroup/ Health Legal Compliance
updates/ Project Officer
Management Office
17 Duplication of effort/ critical tasks not July 25, 2007 15 STRATEGIC - Alignment of job 2 4 8 2 IMPROVING HR Manager/ Reduce To be confirmed November 15, 2007
completed due to overlap in staff Governance descriptions to balanced Director
responsibilities, lack of role clarity. scorecard for
organisation/ Annual
review of reporting
structures
29 Budget over-runs due to poor control of July 25, 2007 10 FINANCIAL Annual budgeting process/ 2 4 8 2 IMPROVING Chief Financial Reduce To be confirmed August 25, 2007
expenditure relating to the hospital Monthly budget variance Officer
expansion programme. reports/ Management
approval of all extrodinary
expenditures/ Internal
Audit reviews/ Financial
system reporting
13 Failure to raise adequate philanthropic July 25, 2007 3 FINANCIAL No controls in place 2 2 4 4 GETTING CEO Reduce To be confirmed March 20, 2008
funds to support ongoing outpatient care WORSE
programme.
3 Ineffective marketing of aged care July 25, 2007 10 STRATEGIC - Public Communication 3 1 3 3 IMPROVING PR and Marketing Reduce To be confirmed October 16, 2007
services and facilities leading to under Stakeholder Programme/ Aged Care Manager
utilised resources Relations Outreach Initiatives
Page 2 of 9
RISK CATEGORY
CORE SERVICES (CLINICAL)
CORE SERVICES - Clinical Effectiveness
CORE SERVICES - Clinical Risk
CORE SERVICES - Education & Training
CORE SERVICES - Emergency Services
CORE SERVICES- Consumer Participation
FINANCIAL
FINANCIAL - Billing & Debtors
FINANCIAL - Budgeting
FINANCIAL - Creditors and Payments
FINANCIAL - Reporting
IT & SYSTEMS
IT & SYSTEMS - Data Completeness
IT & SYSTEMS - Data Quality
IT & SYSTEMS - IT Security
IT & SYSTEMS - System Functionality
OPERATIONAL
OPERATIONAL - Asset & Fleet
Management
OPERATIONAL - Customer Services
OPERATIONAL - Facilities Management
OPERATIONAL - Health & Safety
OPERATIONAL - HR & Training
OPERATIONAL - Purchasing and Supplies
STRATEGIC
STRATEGIC - Business Continuity
STRATEGIC - Compliance & Legal
STRATEGIC - Governance
STRATEGIC - Stakeholder Relations
STRATEGIC - Strategic Planning
CONSEQUENCE
SCORE DESCRIPTION FINANCIAL
(Additional costs
and/or loss of
income)
1 INSIGNIFICANT < $10,000
2 MINOR $10,000 to $49,999
3 MODERATE $50,000 to
$249,999
4 MAJOR $250,000 to
$999.999
5 CATASTROPHIC >$1,000,000
CONTROL EFEFCTIVENESS
SCORE DESCRIPTION PERCENT
EFFECTIVE
1 VERY EFFECTIVE CONTROL
DESIGN, WELL
IMPLEMENTED, PREVENT &
DETECT RISKS/ BREACHES
2 SOME CONTROLS IN PLACE,
PARTIALLY EFFECTIVE
3 FEW CONTROLS IN PLACE,
POORLY FUNCTIONING
4 NO CONTROLS IN PLACE, OR 10-20%
CURRENT CONTROLS HAVE
NO EFFECT
RISK
STRATEGY
Avoid
Transfer
Reduce
Accept
CONSEQUENCE
REPUTATIONAL LEGAL OPERATIONAL/ PROCESS
Little or no impact Little or no impact Little or no impact
Sporadic localised unfavourable Minor delays in meeting legal Some inefficiencies and/or delays
publicity; No impact on staff morale requirements/ fulfilling SLAs in delivery of support services and
etc. non-critical functions. No impact
on client service standards.
Localised negative publicity; Some breach of material terms Inability to provide key support
Limited impact on staff morale; of key contracts/ SLAs. Threat services according to minimal
Managed by appropriate response of legal action against expected service levels (billing,
by Institution's PR/ Marketing institution, but able to be security; payroll, canteen; staff
function resolved through negotiation/ training). No notable impact on
remedial action by institution. client service standards.
Significant/ continued negative Noticeable increase in claims Delays and inefficiencies in core
publicity in local/ regional press; and legal liability; Most processes and systems impacting
Low staff morale; Requires exposures covered by existing significantly on customer service
intervention of Institution's insurance cover levels. Increased risk of serious
Executive/ CEO to answer public client injury, disability etc.
concerns
Significant/ continued negative Significant increase in volume Critical processes/ systems not
publicity in national press; Low staff and value of legal exposures available for extended period.
morale resulting in loss of key staff; and claims; Critical services Inability to perform core client-
Permanent loss of patient trust; impacted by cancellation of facing functions. Prolonged
Withdrawal of funding/ key grants supplier contracts; Exposures inability to provide basic services.
etc.; Possible intervention of not covered by current Possibility of client death due to
Minister insurance cover interruptions to basic services.
LIKELIHOOD
SCORE DESCRIPTION EXAMPLE
1 RARE Highly unlikely to occur in next 5
years. No history of adverse event
in organisation.
2 UNLIKELY Event not likely to occur in next 12
months, but there is a slight
possibility of occurrence.
3 POSSIBLE 50% chance of occurrence in next
12 months.
4 LIKELY There is a strong likelihood that the
event will occur at least once in the
next 6-12 months. History of
event/s in institution or similar
organisations.
5 ALMOST The adverse event will definitely
CERTAIN occur, probably multiple times in a
year.
POSITION
Board of Directors
CEO
Chief Financial Officer
Facilities Manager
Director: Clinical Services
Financial Manager
Head of Nursing
HR Manager/ Director
Internal Audit Manager
IT Manager/ CIO
Legal and Compliance Officer
Operations Manager/ Director
PR and Marketing Manager
Risk Committee
Risk Manager
UNALLOCATED
Related docs
