Page 142 - Hospital Authority Convention 2017

Service Enhancement Presentations
HOSPITAL AUTHORITY CONVENTION 2017

F4.3 Clinical Safety and Quality Service II 16:15_Room 421

Risk Management Enhancement Framework in New Territories West Cluster on Risk Register Development and
Performance Monitoring Process
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Wong B , Kwok YTA , Chui HWA , Lau W , Tang KS 1
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1 Quality and Safety Division, New Territories West Cluster, Information Technology Department, Hospital Authority Head Office,
Hong Kong
Introduction
Risk register is one of the important tools to manage the risk of an organisation. Each year, risk registers (RRs) have to be
formulated at the cluster, hospital and departmental levels to facilitate risk monitoring and implement risk mitigation actions.
Cluster management was aware that there should be strong linkage among different levels and a more objective method to
develop the RRs should be adopted. In view of this, the New Territories West Cluster Quality and Safety Division had been
working with the Hospital Authority (HA) Head Office in revamping the risk management framework and RR development
process since 2014.

Objectives
(1) To strengthen the framework in risk identification, monitoring, reporting and RRs development process; (2) to provide
a common risk language for better communication; (3) to develop an Electronic Risk Register System (eRRS) to enhance
reporting of RRs; and (4) to timely update risk performance by using a standardised Risk Control Sheet.
Tuesday, 16 May Methodology

Both bottom-up and top-down approaches were adopted in the development of RRs. Firstly, departments formulated their
departmental RRs (e.g. top three to five risks) which the development process was facilitated by workshops. Departmental
incident trends were provided to facilitate their consideration and a new NTWC risk taxonomy was used to standardise the
common risk terms with reference to the numbering system of the Hospital Accreditation criteria. Further, an Electronic Risk
Register System (eRRS), which was jointly developed with Information Technology Department of Hospital Authority Head
Office to facilitate frontline departments’ submission. The eRRS could facilitate aggregation of department RRs for hospital
management to formulate the hospital’s RRs. The cluster RRs would then be formulated with reference to the hospital RRs
and cluster-wide data. All cluster/hospital RRs would be endorsed by the Cluster/Hospital Management Committee. After
that, risk custodians were identified for planning risk mitigation actions and monitoring the risk performance. All actions would
be documented in Risk Control Sheets and the risk performance would be reported to the senior management regularly.

Results
Workshops were held for departments to familiarise with the RR development process. Quarterly incident trends were
provided to departments for their consideration of risk registers with positive feedback. Department managers welcomed
the eRRS which facilitated RR reporting. Also, cluster/hospital management were regularly and timely updated on risk
performance and Risk Control Sheets. It can be concluded that the new initiatives have enhanced the implementation of risk
management with the new framework and tools.

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