1. Risk Management in the National Health Service in England Stuart Emslie Head of Controls Assurance Department of Health, England ISO General Assembly 2001, Sydney

2. Context Population 56 million; 8.5 million hospital admissions per year; over 700 individual NHS organisations; £45 billion (A$120 billion) annual spend; over 1 million employees 850,000 medical errors per year resulting in up to 40,000 unintended patient deaths plus other harm

4. ‘UK: blunders by doctors kill 40,000 a year’ Sunday Times, 19 Dec 1999 Medical error is the third most frequent cause of death in Britain after cancer and heart disease…….kills four times more people than die from all other types of accidents.

5. Root causes of medical errors 65 orientation/training 50 patient assessment process 44 communication 43 physical environment 35 information not available 28 staff competency 25 equipment factors 25 staffing levels 18 storage/access issues Of the first 112 root cause analysis summaries the JCAHO reviewed, the root causes were (often >1 per case):

6. Context Population 56 million; hospital admissions 8.5 million per year; over 700 individual NHS organisations; £45 billion (A$120 billion) annual spend; over 1 million employees 850,000 medical errors per year resulting in up to 40,000 unintended patient deaths plus other harm In the majority of instances, the ‘root causes’ of medical error are systemic - i.e. there are inadequate or absent ‘systems of internal control’

7. Annual costs of ‘loss’ Adverse patient events (prolonged stay) > £2 billion Sickness absence > £2 billion? Crime (Fraud, theft, etc.) - £1-3 billion Hospital acquired infection - £1 billion Drug errors £300-500 million? Clinical negligence >£400 million (potential liabilities in excess of £2.8 billion) Malnutrition > £230 million Occ. health and safety > £150 million Avoidable mgt & legal costs >£100 million Maintenance of medical equipment - £18 million Overall £7-9 billion? (20 % of budget)

8. Context Population 56 million; hospital admissions 8.5 million per year; over 700 individual NHS organisations; £45 billion (A$120 billion) annual spend; over 1 million employees 850,000 medical errors per year resulting in up to 40,000 unintended patient deaths plus other harm In the majority of instances, the ‘root causes’ of medical error are systemic - i.e. there are inadequate or absent ‘systems of internal control’ Inadequacies or absences in ‘systems of internal control’ across the NHS cost £7-9 billion (up to 20% of spend)

9. Context Population 56 million; hospital admissions 8.5 million per year; over 700 individual NHS organisations; £45 billion (A$120 billion) annual spend; over 1 million employees 850,000 medical errors per year resulting in up to 40,000 unintended patient deaths plus other harm In the majority of instances, the ‘root causes’ of medical error are systemic - i.e. there are inadequate or absent ‘systems of internal control’ Inadequacies or absences in ‘systems of internal control’ across the NHS cost £7-9 billion (up to 20% of spend) Need better systems of internal control, including risk management

10. “The directors should, at least annually, conduct a review of the effectiveness of the [organisation’s] system of internal control and should report to the [stakeholders] that they have done so. The review should cover all controls, including financial, operational and compliance controls and risk management.” Combined Code of Practice on Good Governance D.2.1. London Stock Exchange Principles of Good Corporate Governance

11. Outcomes AccountabilityProcessesCapability Independent verification Monitor, review, learn & improve Objectives Communication Consultation Stakeholders

12. Establish Context Identify Risks Analyse Risks Treat Risks Monitor and Review Evaluate and Rank Risks ASSESS RISKS Communication and Consultation Risk management process AS/NZS 4360:1999 - Risk management

13. Controls Assurance “…a process designed to provide evidence that NHS bodies are doing their reasonable best to manage themselves so as to meet their objectives and protect patients, staff, the public and other stakeholders against risks of all kinds”

14. THE CONTROLS ASSURANCE PROJECT RISK MANAGEMENT HUMAN RESOURCES ESTATE MANAGEMENT BOARD THE PUBLIC FINANCE HEALTH & SAFETY EXTERNAL AUDIT INFECTION CONTROL Assurance AUDIT COMMITTEE OTHERS Self-Assessment INTERNAL AUDIT CNST

15. What do we want? Risk reduction through better management Minimise unintended human harm Minimise financial loss Improve patient safety and quality of care Improve health, safety & welfare of staff Meet objectives in an optimal way, ensuring best use of available resources Provide public assurances on the above Thank you………