This involves having robust systems in place to understand, monitor and minimise risk to patients and staff to foster learning from mistakes and near misses if they occur.
This involves risk identification, risk analysis and evaluation, risk treatment and risk control, which involves sharing and learning from adverse risk incidents. There is also a process of regular ‘risk dissemination’ during the multidisciplinary team meeting to inform the team regarding important risk issues or incidents.
All existing pathways should have an existing transparent reporting culture and those will be already utilising departmental risk assessments for existing pathways. It is anticipated that those will be held on Datix and each Trust is likely to use a single framework for the assessment, rating, and management of risk. The Active Hospital project should be embedded in those processes, and this process is described in detail within the local Risk Management Policy and Procedure.
All staff will be following local training policy contained in a local Trust’s Mandatory Training Policy. This will be monitored and analysed by the local risk management team. All adverse incidents, including Serious Incidents Requiring Investigation (SIRIs) should be managed in line with each Trust’s agreed processes and existing structures.
Clinicians leading local implementation should be presented at the regular local governance meeting, and if applicable local Mortality and Morbidity (M&M) meetings (1), and should be taking the overall responsibility for highlighting potential risk and clinical adverse incidents that might be related to Active Hospital implementation. Learning lessons from adverse incidents and prevention of recurrence should be one of the priorities for the Active Hospital team.
All adverse incidents, including Serious Incidents Requiring Investigation (SIRIs) should be managed in line with each Trust’s agreed processes and existing structures. Quarterly reports of any SIRIs and learning outcomes related to PA interventions from each of the Active Hospital pathways will be reported by the local Physical Activity Champion and SEM team members to the Central Clinical Governance Committee for the Active Hospital Project.
The Central Clinical Governance Committee for Active Hospital Project will analyse action points related to physical activity interventions across different pathways and decide whether action is required in all areas of the project. By doing so, it will be able to performed risk anticipation and mitigation across the patient pathways.
Annual reports will be prepared to provide an integrated overview of all risk management activity in the project. The key risk management recommended activities will be disseminated across all pathways. This will contribute towards cultivation of an open and just culture in which risk management is identified as continuous improvement of care.
Risk Management Governance Matrix
You can use this matrix as a guide and checklist to help you with your Governance framework.