26-276 / Ward to Board Risk Register Capture and Assurance Framework process.

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
University College London NHS Hospitals Foundation Trust


Clinical risk management
Identification of risk and harm
GOP Description
Implementation level
Clinical settings
UCLH is a Large Acute NHS Foundation Trust located across 8 main hospital sites with 19 clinical divisions. There are 3 Clinical Boards with significant devolved authority, who oversee the day to day operations of divisions.

7000 staff provides a wide range of both acute and specialist services.

The objectives are as follows:
i.    To ensure risks are effectively captured, managed and mitigated in an open and fair culture.
ii.    To sustain a risk management process that instils accountability at Divisional and corporate level through the allocation of Board Risk leads.
Risks are captured through two inter-connected processes; the risk register and the Assurance Framework.

Risk register:
Local managers are required to undertake operational, financial and clinical risk identification.

It is the responsibility of the Board and Divisional Management Teams to undertake the strategic analysis of all identified risks.

The Chief Executive has overall responsibility for risk management at UCLH.

Designated ‘Risk Leads’ covering Divisions have specific roles as the focal point and local champion for risk management development. They work collaboratively with the Risk Management Team in the Governance department to ensure that local intelligence around risk is assessed and communicated appropriately throughout the organisation.

Risk registers are populated through Datix which enable the Governance department to have visibility of trust wide risks. These registers are then extracted (dependent on severity and current score) and populated into a quarterly risk report for discussion, scrutiny and debate at the Risk Co-ordination Board.

This also provides an opportunity for cross-divisional learning and trend analysis trust wide. Following this, key risks / issues / assurance can be provided to the Board.

There will be cases when risks identified at the tactical, operational or project level will be significant to UCLH. Such risk will be escalated to the appropriate level through the Trust’s line management processes. The Board sets the risk appetite of UCLH and the system for enabling risk control and contingency decisions.

Timeframe implementation
Divisions had previously managed and populated their own risk registers. The transfer to a centrally held software system (including training) took approximately six months (not including technical requirements). It is important to mention that a positive risk appetite / culture was already in place
Implementation tools available
The system adopted to achieve the aims of corporate risk visibility was Datix.

The risk register roll out project was delivered subsequent to the Datix incident reporting project completion. Thus there was little change management / engagement requirement needed.

A Datix administrator was key to the roll out of the project to ensure training was available as well as governance expertise.

Tools available included one to one training, e learning, induction training, and latterly drop in clinics

Implementation cost
Aside from the individual costs for inputting information within divisions and resource time required from the governance team for advice & monitoring. Costs can be related to the following:-

Datix administrator (band 5/6) covering all Datix management and training functions.

Cost of risk register Datix module (this cost is Trust specific).

Method used to measure the results
The new electronic risk register has been populated by all Clinical Boards and Divisions. Corporate functions are also represented.
There has been significant improvement in overall awareness and understanding of the key aspects and functions of risk registers
Analysis of the results
Interrogation of the register will show clear evidence that risks have been identified, reviewed and mitigated in a timely manner, previously the flow of risks could potentially remain stagnant due to the type of corporate monitoring that was in place.
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
The key barrier related to the acceptance of change in relation to populating an IT based system from a simple excel sheet.
Describe the strategies used to overcome the barriers (If needed)
Fortunately all employees had previously been exposed to a similar Datix system (incidents) which assisted in the mitigation of evasion behaviour.
Other information
Other information about the GOP that you would like to add (Link or attached document)
We have been recognised in our work by being identified as a good practice demonstration site for Datix, co-ordinating visits from as far afield as Saudi Arabia and neighbouring Trusts.