1. 1 Grand River Hospital 2010 Enterprise Risk Assessment “Who’s Vote Wins?” Julie Nicholls, Director Risk Management

2. 2 Presentation objectives 1. Background Explain the model used at GRH Share learning's from previous ERM assessments 2. 2010 ERM process

3. 3 Grand River Hospital; Who are we? ♦ Large community hospital; 500 beds across 2 sites & 5 satellites. ♦ Regional cancer centre, dialysis provider & mental health services provider (doubling in 2010). ♦ 4000 births annually ♦ 65,000 ED visits annually ♦ 10,000 surgeries ♦ 3000 staff ♦ 300 physicians

4. 4 Risk Management at GRH ♦ Loss control! ♦ A process to identify, mitigate and prevent harm. ENTERPRISE risk management (ERM); A corporate process to develop a consolidated understanding of where GRH could be exposed to harm; financial harm, physical harm, inability to provide appropriate patient care…

5. 5 Background ♦ 2006/07 - Identified that there was no method of broadly understanding what risks may affect GRH, i.e., an enterprise risk management (ERM) process. ♦ Environmental scan resulted in the adoption of the Winnipeg Regional Health Authority ERM model. ♦ 2007 new CEO created a GRH model.

6. 6 Board Risk Management Policy

7. 7 LIKELIHOOD IMPACT Insignificant MinorModerateMajorExtreme Almost Certain 1. ER crowding 2. Form 1 in ER 3. Nursing recruitment Likely Possible Unlikely Rare Example of End Result: Heat Map from 2007

8. 8 2007 Process Positive: ♦ CEO & Board chair buy-in ♦ Awareness of ERM concept at management level Negative: ♦ Information too detailed/operational/granular ♦ Process was not built into our planning processes  The results did not influence ongoing & future decisions

9. 9 1. Background Explain the model used at GRH Share learning's from previous ERM assessments 2. 2010 ERM process Presentation objectives

10. 10 Changes in ERM 09/10 1. New program structures and leadership across the hospital. 2. Consolidation of risks into broader themes 3. Concept of an Internal Audit function introduced in 2010.

11. 11 Enterprise Risk Management Assessment (ERMA) Process Identify Risks Analyze and Quantify Risks Integrate Risks into Current Activities Prioritize Risks Mitigate Risks Monitor identified risks and review emerging risks

12. 12 ERMA Timelines DecJanFebMarAprMayJune Identify Risks (from external review sources) Identify Risks (from internal reviews) Analyze and quantify risks Prioritize risks Mitigate risks/Create action plans Board presentations and integration into operating plan

13. 13 ERMA Inputs 1. Winnipeg Assessment tool 2. Results from Patient Safety Walkabouts/Tracers 3. External review sources  HIROC RMSAM,  Accreditation Canada,  ISMP 4. QCIPA Rounds results 5. Incident reporting trends 6. Analysis of litigations & patient complaints 7. Best practice opportunities (AHRQ 11 practices, leapfrog group, JHACO)

14. 14 ERMA Inputs 8. Public Reporting Requirements (Funding opportunities) 9. Operational plans- GRH, LHIN, MOH. 10. Employee safety concerns- ie ministry of labour, WSIB trends 11. Employee & physician recruitment trends 12. Assessment tools through for High risk areas; Obstetrics Emergency Services Surgical Services Anaesthesia Psychiatric Services Radiology Services 13. Employee, Management & Board Feedback

15. 15 ERMA Goal To learn from management: “What are the critical issues that worry you or even keep you up at night?”  The important issues that you feel are not addressed OR not addressed adequately ClinicalOperations Over 60 identified risks.

16. 16 Enterprise Risk Management Assessment (ERMA) Process Identify Risks Analyze and Quantify Risks Integrate Risks into Current Activities Prioritize Risks Mitigate Risks Monitor identified risks and review emerging risks

17. 17 Analysis GRH Criteria: ♦ Mitigating strategies can be developed for the risk ♦ The risk is currently unmitigated or incompletely mitigated ♦ The risk has a serious impact outside of ‘expected’ business failures **Filtered out extremely low probability occurrences even if there was potential to be high impact** ♦ Narrowed the risks to 22 high level risks.

18. 18 Enterprise Risk Management Assessment (ERMA) Process Identify Risks Analyze and Quantify Risks Integrate Risks into Current Activities Prioritize Risks Mitigate Risks Monitor identified risks and review emerging risks

19. 19 Senior Leadership Survey Task 1: Add any risks you feel were left out to the list. Task 2: Rank likelihood & significance of the risks. 1____________________5_________________________9 low likelihood highly likely to occur in 3 years low significance highly significant impact Risk likelihood assesses the probability that the underlying risk event will occur, over a 3-year timeframe, assuming the current specific risk management activities are in place to manage the risk. The measurement of risk significance assumes that the underlying risk event has occurred and the intention is to assess the impact it would have on the Grand River’s ability to execute its strategies and achieve its objectives.

20. 20 Prioritization ♦ Surveyed executive team members  Individually ranked 22 risks for significance & probability of the risk occurring on a scale of one to nine. ♦ Averaged scores to assign ranking. ♦ Determined the standard deviation in responses. ♦ Those with a high deviation in responses were brought forward for group discussions with the executive team.

21. 21 Who’s vote wins? Average Sum Deviation Max-Min LikelihoodSignificance LikelihoodSignificance Min. Ave.Max.Min.Ave.Max. Total (L&S ) 5 7.1486 914.291.07 5 6.43856.79813.210.980.99 3 5.57757.29912.861.621.50 3 5.83757.00912.831.601.26 4 5.67857.00912.671.631.67 3 5.077.536.57911.642.091.81 3 5.57736.00811.571.401.63 2 4.33756.67911.001.971.51 1 4.00757.00911.002.551.41 4 5.17745.67810.831.331.37

22. 22 Prioritization ♦ Five hours of Senior Leadership discussions to;  Understand the perspectives of those who ranked the risk differently  Adjust and refine the risk definitions

23. 23 Prioritization ♦ Results: ‘heat map’ of eight highest risks ♦ High priority risk actions put forward for board approval in the hospital operating plan in June 2010. Life goes on… ♦ Two risks that were in the top 22 become more concerning due to information discoveries. ♦ Two are added and become the ‘top ten’.

24. 24 Underlined risks are the top 10 risks GRH Updated Risk Framework – 22 risks

25. 25 Enterprise Risk Management Assessment (ERMA) Process Identify Risks Analyze and Quantify Risks Integrate Risks into Current Activities Prioritize Risks Mitigate Risks Monitor identified risks and review emerging risks

26. 26 High Risk – 1: Capital & Operating Funding The risk that insufficient access to funds threatens the hospital capacity to achieve its mission, objectives and financial obligations. Mitigating strategy: Seek out opportunities to reduce operational costs and explore potential revenue streams including shared or integrated service delivery. Owner(s): CEO & CFO Action #1: Creation of a ‘business development’ position to increase revenue. Progress:Results: Action #2: Build capacity in finance and decision support to understand and report on HBAM model Progress:Results: Action #3: Investigate and develop partnership(s) and/or shared services aiming to reduce hospital operational expenses. Progress:Results: Action #4: Work with foundation to maximize donation revenues. Progress:Results: Business RiskResource RiskCompliance Risk

27. 27 Ongoing Process ♦ Current focus; broad education on the 2010 assessment. ♦ Develop understanding that this is an ongoing process ♦ Begin external analysis again!  HIROC’s Risk Management Self Assessment Module (RMSAM)  ISMP self-assessment

28. 28 Lessons learned 2010 ♦ Full ERMA takes 6 months ♦ Cross sectional core group results in better outcome ♦ Buy-in from senior leaders important ♦ Keep detailed notes on information, source and data on each identified risk for future reference ♦ Engrain results into overall hospital planning processes (ie capital approval processes, operating plans)