Quality, Risk & Safety HSE Excel Risk Register Training manual, Lecture notes of Business

Download Quality, Risk & Safety HSE Excel Risk Register Training manual and more Lecture notes Business in PDF only on Docsity! 1 Quality, Risk & Safety HSE Excel Risk Register Training manual Version 1, September 2018 2 Contents Introduction, Scope and Function ................................................................................................... 3 Section 1: Preparing the Excel Risk Register ....................................................................................... 5 Section 1.1: Downloading and saving excel Risk Register from the HSE site ................................. 6 Section 1.2: Saving and enabling Excel Risk Register Macro .......................................................... 7 Section 1.3: Populate the “Basic Details” worksheet ..................................................................... 8 Section 1.4: Adding and removing a Risk Owner .......................................................................... 10 Section 1.5: Adding and removing a Risk Coordinator ................................................................. 11 Section 1.6: Adding and removing an Action Owner .................................................................... 13 Section 1.7: Unlocking the Excel Risk Register – S38 & S39 Agencies .......................................... 15 Section 1.8: Running a spell check ................................................................................................ 16 Section 1.9: Exercise ..................................................................................................................... 17 Section 2: Entering a risk onto the Excel Risk Register ..................................................................... 18 Section 2.1 Copying and pasting text from one source document into the Excel Risk Register. . 19 Section 2.2: Entering a risk onto the Risk Register ....................................................................... 19 Section 2.3: Adding existing controls ............................................................................................ 23 Section 2.4: Adding Initial risk rating – date risk was originally assessed .................................... 24 Section 2.5: Adding risk review date ............................................................................................. 26 Section 2.6: Adding an action, assigning an action owner and a due date .................................. 27 Section 2.7: Current Risk Rating – This is the point in time Risk Rating ....................................... 29 Section 2.8: Exercise ..................................................................................................................... 30 Section 3: Editing a risk on the Risk Register .................................................................................... 33 Section 3.1: Editing the Risk Owner, Risk Coordinator, Risk Criteria, and Primary Risk Category 34 Section 3.2: Editing risk description .............................................................................................. 35 Section 3.3: Updating risk status .................................................................................................. 35 Section 3.4: Deleting an existing control ...................................................................................... 36 Section 3.5: Deleting an Action ..................................................................................................... 37 Section 3.6: Changing a risk rating ................................................................................................ 38 Section 3.7: Exercise ..................................................................................................................... 39 Section 4: Generating Reports from the Excel Risk Register ............................................................ 40 Section 4.1: Running “sub-action list” reports for risk action owners .......................................... 41 Section 4.2: Running “sub-register” reports for Risk Coordinators ............................................. 43 Section 4.3: Receiving updated sub-action list(s) and sub-register(s) .......................................... 45 Section 4.4: Running Risk Register report ..................................................................................... 47 Section 4.5: Exercise ..................................................................................................................... 49 Section 5: Closing a risk ..................................................................................................................... 50 Section 5.1: Exercise ..................................................................................................................... 52 Section 6: Reviewing Dashboard....................................................................................................... 53 5 Section 1: Preparing the Excel Risk Register This section includes the following:  Section 1.1 Downloading and saving excel Risk Register from the HSE website  Section 1.2 Saving and enabling Excel Risk Register Macro  Section 1.3 Populate the “Basic Details” worksheet  Section 1.4 Adding and removing Risk Owner  Section 1.5 Adding and removing Risk Coordinators  Section 1.6 Adding and removing Action Owners  Section 1.7 Unlocking the Risk Register – S38 and S39 Agencies  Section 1.8 Running a spellcheck 6 Section 1.1: Downloading and saving excel Risk Register from the HSE site Top Tip Do not open directly from the HSE website as it opens in “Read only”. Chose the “Save as” option Step 1 •Go to www.hse.ie Step 2 •In the About US section click on Quality Assurance and Verification Division Step 3 •Click on the Risk Managment icon Step 4 •Click on the Risk Managment documentation icon Step 5 •Click on the Risk Managment Support Tools •Within this section there are two Excel Risk Registers • HSE Excel Risk Register (Version to be used by HSE Services) •S38 /S39 Excel Risk Register (Version to be used by S38/S39 Agencies ) Step 6 •Click on the HSE Excel Risk Register to downloaded the risk register •Click on Save as (give the register a name) and save into a folder. 7 Section 1.2: Saving and enabling Excel Risk Register Macro Click on the HSE Excel Risk Register at which point the ‘Save As window’ will open. Click on ‘Save As’ (yellow arrow) Enter the File name in the ‘File name’ field (red arrow), and then select “Microsoft Excel Macro-Enabled Worksheet” (yellow arrow) from the ‘Save as type’ field. Top Tip It is important to save document type as Microsoft Excel Macro-Enabled Worksheet as failure to do so will prevent the excel risk register template from performing all of the functionalities. Do not put a Share workbook password on the Excel Risk Register Workbook. This causes problems when closing risk. 10 Section 1.4: Adding and removing a Risk Owner 1. Adding a Risk Owner to the Risk Owner drop-down list The inputted name will now appear in the ‘Risk Owner’ drop-down list. 2. Removing a Risk Owner from the Risk Owner drop-down list •Select the 'Risk Register' worksheet by clicking it (red arrow). Step 1 •Above the ‘Risk Owner’ column heading, locate and click the ‘+’ button (red arrow) and this will open the ‘risk owner’ window. Step 2 •In the ‘New risk owner’ window, input the name of the Risk Owner in the field provided (red arrow) and then click 'ok' (yellow arrow). Step 3 •Select the 'Risk Register' worksheet by clicking it (red arrow). Step 1 11 Step 2 The deleted name will disappear from the ‘Risk Owner’ drop-down list. Section 1.5: Adding and removing a Risk Coordinator 1. Adding a Risk Coordinator to the Risk Coordinator drop-down list. •Above the ‘Risk Owner’ column heading, locate and click the' -’ button (red arrow) and this will open the 'risk owner’ window. Step 2 •In the ‘Owner’ window, select from the drop down list the name of the Risk Owner that you want to delete (red arrow) and then click 'ok' (yellow arrow). Step 3 •Select the “Risk Register” worksheet by clicking it (red arrow). Step 1 12 The inputted name will now appear on the ‘Risk coordinator’ drop-down list. 2. Removing a Risk Coordinator from the Risk Coordinator drop-down list •Above the ‘Risk Co-ordinator’ column heading, locate and click the ‘+’ button (red arrow) and this will open the ‘New risk co- ordinator’ window. Step 2 •In the ‘New risk cordinator’ window, input the name of the risk cordinator in the field provided (red arrow) and click ok (yellow arrow). Step 3 •Select the 'Risk Register' Worksheet by clicking it (red arrow) Step 1 •Above the ‘Risk Cordinator’ column heading, locate and click the ‘-’ button (red arrow) and this will open the ‘Cordinator’ window. Step 2 15 The deleted name will disappear from the ‘Action Owner’ drop-down list. Section 1.7: Unlocking the Excel Risk Register – S38 & S39 Agencies This function can only be performed on the S38 and S39 Agencies version – it is available in order to change the branding. •Click on the drop down list (red arrow) and select the name of the Action Owner that you want to delete and click ok (yellow arrow) Step 3 •Select the “Basic Details” worksheet by clicking it (red arrow). Step 1 •Locate and click the “Unlock” button (red arrow). Step 2 16 Section 1.8: Running a spell check •Now you can select the HSE logo, delete as required, and replace with a new logo. You can also select cells A6:A11 and change the colour to better reflect departmental branding. The colour of header cells in sheets “Summary”, “Risk Register”, “Risk Action Log” and “Closed Risks” can also be changed to reflect service branding. Step 3 •Once all changes have been made, go to “Basic Details” sheet. Locate and press the "lock" button. •It is important that you 'lock' the spreadsheet to prevent further 'customisations'. Step 4 •Select the 'Basic Details' worksheet by clicking it (red arrow) Step 1 17 The spell check function will perform and as spelling errors are identified you fix them as required. Section 1.9: Exercise  Download and save HSE Excel Risk Register from the website and save to desktop  Populate the “Basic Details Spreadsheet” with the following identification details o Division : Acute Hospital Division o HG/CHO/NAS/Function: Saolta Hospital Group o Hospital Site/Service: Letterkenny General Hospital o Month: 31-August-2018  Add Michelle Obama and Annie Lennox as Risk Owners  Remove Annie Lennox as a Risk Owner  Add David Bowie, Donald Duck and Jane Austin as Risk-Coordinators  Remove Donald Duck as a Risk Coordinator  Add David Bowie, Jane Austin, Kate Bush and Michelle Obama as Action Owners  Remove Kate Bush as an Action Owner. •Locate and click the “Spellcheck” button (red arrow). Step 2 20 •In the ‘New Risk’ window, select the risk owner from the drop- down menu in the ‘Risk Owner’ field (red arrow). Step 3 •Select the risk cordinator from the drop-down menu in the ‘Risk Cordinator’ field (red arrow). Step 4 TIP: If the Risk Owner name is not already in the drop down list click the cancel button (yellow arrow) and follow the instructions in Section 1.4 to add Risk Owner to drop down list. Once you add the risk owner move to Section 2.1 Enter a risk onto the Risk Register. TIP: If the Risk Coordinator name is not already in the drop down list click the cancel button (yellow arrow) and follow the instructions in Section 1.5 to add Risk Coordinator to drop down list. Once you add the risk Coordinator move to Section 2.1 Enter a risk onto the Risk Register. 21 •Select the risktype from the drop-down menu in the ‘Risk Type’ field (red arrow). Step 5 •Select the risk category from the drop-down menu in the ‘risk category’ field (red arrow). The options included in this drop-down list are aligned to the HSE impact table of the HSE Integrated Risk Management Policy Step 6 22 The risk data added in this New Risk window will now appear in the Risk Register worksheet and the date entered will auto-populate into column ‘G’ (red arrow), and the risk status will default to ‘Open’ in column ‘M’ (yellow arrow). The risk data entered in the ‘New Risk’ window will also prepopulate on the “Risk Action Log” worksheet (red arrow) and the “Summary” worksheet (yellow arrow). •Type or Ctrl V (paste) the risk description into the into the ‘Risk Description’ field (red arrow). Then click the ‘OK’ button (yellow arrow) Step 7 25 •Select and click the required rating (1,2,3,4 or 5) from the drop- down menu (red arrow). Step 3 •To input the impact rating from 1-5 select the appropriate cell in column ‘J’ and click the drop-down icon which appears (yellow arrow). Step 4 •Select and click the required rating (1,2,3,4 or 5) from the drop- down menu (red arrow). Step 5 26 Section 2.5: Adding risk review date The review date is the date that the risk is due for review/reassessment •The initial risk rating will then be calculated and inputted to the appropriate cell in column ‘K’. The colouring will also represent the severity of the risk rating; Green = Low; Amber = Medium; Red = High. Step 6 •The ‘Risk Review Date’ field is located on the “Risk Register” worksheet (red arrow), in column ‘L’ (yellow arrow). Step 1 •The risk review date is the date that the risk is due for review and is based on the managing and monitoring risk register procedure. To input the date, select the appropriate cell in column ‘L’ and input the date in the dd/mm/yyyy format. (red arrow) Step 2 Top Tip: The initial Risk Rating never changes as this is the date that the risk was originally assessed. 27 Section 2.6: Adding an action, assigning an action owner and a due date Step 1 •Select the “Risk Action Log” worksheet by clicking it (red arrow). Step 1 •If inputting the first action to the risk, continue to step 3. If inputting an additional action to the risk skip to step 7. Step 2 •Select the first available cell in column ‘F’ (red arrow) in the row related to the applicable risk (yellow arrow). •Double click the cell to activate the cell. NB •Type or copy and paste in the action required in that cell. Step 3 •To assign the action to an action owner select the associated cell in column ‘G’, and select the action owner from the drop- down menu (red arrow). Step 4 Top Tip: If the relevant action owner name is not included in the drop-down menu, add them to the drop-down menu (see section 1.6 above). Top Tip: If there are no actions required it is important to enter some text in this cell e.g. enter N/A or none in the cell. You cannot leave this cell blank. If this cell is left blank it distorts the running of the report and closing a risk function. 30 •To input the impact rating from 1-5 select the appropriate cell in column ‘M’ and click the drop-down icon which appears (yellow arrow). Step 4 •Select and click the required rating (1,2,3,4 or 5) from the drop- down menu (red arrow). Step 5 •The current risk rating will then be calculated and inputted to the appropriate cell in column ‘K’. The colouring will also represent the severity of the risk rating; Green = Low; Amber = Medium; Red = High Step 6 Top Tips: Any changes to a risk rating must be made on the Risk Action Log worksheet. The initial risk rating (on the risk register worksheet) and current risk rating must be populated even if they are the same rating. The Dashboards will not work if both are not populated. 31 Section 2.8: Exercise  Enter the below risk assessment form manually (by typing each field)  Enter the risk assessment form using the soft copy saved on your desktop. (Remember the information of copy and pasting and using Ctrl C & Ctrl V.) At the end of this exercise, you should have 2 risks on your risk register. Each risk should contain 5 existing controls, 5 actions, 1 risk owner and 3 action owners. Risk Assessment Form for Training 32 Division: Acute Hospital Division Source of Risk: Audit HG/CHO/NAS/Function: Saolta Hospital Group Primary Impact Category: Compliance Hospital Site/Service: Letterkenny General Hospital Risk Type: Operational Dept/Service Site: N/A Name Risk Owner: (BLOCKS) Michelle Obama (Hospital Manager) Date of Assessment: 31st August 2018 Signature of Risk Owner: N/A Unique ID No: Auto generates Risk Coordinator: David Bowie (Hospital QPS person) RISK DESCRIPTION EXISTING CONTROL MEASURES ADDITIONAL CONTROLS REQUIRED PERSON RESPONSIBLE FOR ACTION DUE DATE Risk of harm to service users and staff due to poor compliance with the HSE's Integrated Risk Management Policy and Incident Management Framework in the Hospital 1. Integrated Risk Management Policy, 2017 & supporting Guidance 2. HSE Incident Management Framework, 2018 3. Some staff received OD, IM & RM training 4. All incidents are input on NIMS 5. Monthly Incident reports (from NIMS) distributed to QPS Committee, Hospital Management team, Directorate/Function Manager to inform risk and target safety improvement programme within the hospital. 1. Define a process for the notification of SI's to the SAO in line with the IMF 2. Ensure that the Hospital Senior Accountable Officers name and details are communicated to all relevant stakeholders. 3. Develop the Hospital Registers that is in line with the IRM Policy 4. Develop and implement a process / procedure for managing and monitoring the Hospital Risk Register. 5. Set up a Hospital QPS Committee 1. David Bowie (QPS Lead) 2. David Bowie (QPS Lead) 3. Jane Austen (Hospital Business Manager), 4. Jane Austen (Hospital Business Manager), 5. Michelle Obama (Hospital Manager) 30-11-18 30-11-18 30-11-18 30-11-18 30-11-18 *One risk per formINITIAL RISK RATING Likelihood Impact Risk Rating 4 4 16 RISK STATUS Open Monitor Closed Open 35 Section 3.2: Editing risk description Section 3.3: Updating risk status •Select the “Risk Register” worksheet by clicking it (red arrow). Step 1 •To edit the risk description select the applicable cell in column ‘F’ (red arrow) and edit the cell contents. Step 2 • Select the “Risk Register” worksheet by clicking it (red arrow). Step 1 •To update the status of the risk to “Monitor” in column ‘M’ (red arrow), clicking the drop-down icon which appears (yellow arrow) and select 'Monitor' Step 2 36 Section 3.4: Deleting an existing control • Select the “Risk Register” worksheet by clicking it (red arrow). Step 1 •Locate and select the cell containing the existing control you wish to delete in column ‘H’. Step 2 •Locate and click the 'Delete' button (red arrow) Step 3 •This will delete the existing control selected. Step 4 •If the correct control was not selected in step 2, locate and click the ’undo' button (red arrow); this will reverse the action and start again at step 2. Step 5 Top Tip You can delete the text within the cell but you cannot delete the cell. It is important to place some text in the cell e.g. N/A as failure to have text in this cell will distort the document. 37 Section 3.5: Deleting an Action • Select the “Risk Action Log” worksheet by clicking it (red arrow). Step 1 • Locate and select the cell containing the action you wish to delete in column ‘F’ (red arrow). Step 2 •Locate and click the 'Delete' button (red arrow) Step 3 •This will delete the action selected. Step 4 40 Section 4: Generating Reports from the Excel Risk Register This section includes the following:  Running “sub-action list” reports for risk action owners  Running “sub-register” reports for risk coordinators  Receiving updated sub-register(s) and sub-action List(s)  Running a Risk Register Report Top Tips: Before running the Risk Register report, sub-registers or sub action list do the following checks: 1. Ensure reporting period is entered in the basic detail worksheet and that the date format is dd/mm/yyyy. 2. In the risk register worksheet ensure there are no blank cells in the existing control column 3. In the risk action log worksheet ensure there are no blank cells in the action column. 4. In the risk action log worksheet ensure that the current risk rating is complete Take a copy of the Excel Risk Register and run the reports from the copy. 41 Section 4.1: Running “sub-action list” reports for risk action owners The timing of the request for action updates will depend on the Risk Register managing and monitoring procedure that is in place. In preparing the risk report, information must be gathered from the risk action owners. To aid in doing this, sub-action lists can be created. Sub-action lists are separate excel files which contain only the risk actions that are owned by a certain person (action owners). If there are 10 action owners assigned to actions on the risk action log, there will be a need for 10 sub-action lists, one sub-action list per risk action owner. •To create the risk sub-action list(s), select the “Risk Action Log” worksheet by clicking on it (red arrow). Step 1 •Locate and click the "sub - Action List" button (red arrow). Pressing the 'sub -action list' button will generate an action report for each of the risk owners. Step 2 •The action reports when generated will have a file name of Book1, Book 2, Book 3 etc these need to be located, renamed and saved in a folder (red arrow) Step 3 42 Note: The sub-actions list (s) created do(es) not have the same functionality as the Risk Register, and there are no buttons or drop-downs included. Risk action owners will update the file as they would with any other excel file. When the Risk Action Owner(s) return the updated sub-action reports move to Section 4.3 for instruction on Receiving Updated Sub-action lists from the Risk Action Owners. •E-mail the sub-action list(s) to the relevant action owner(s), requesting that they provide an update on the actions that are assigned to them. Updates must be provided on the sub-action list template that is sent out to the action owners then returned to the Risk Register Administrator Step 4 45 Section 4.3: Receiving updated sub-action list(s) and sub-register(s) Once the risk action owner(s) and the risk coordinator(s) have updated their applicable sub-action list or sub-register, and have sent it back, the updates need to be mirrored to the master risk register. In order to highlight the changes made to the sub-action list and sub-register by the risk action owner(s) and the risk coordinator(s), you can use the ‘Track Changes’ functionality. Note: this functionality is not available if the excel file is read-only. Save the file and open in edit format. On the ‘Review’ tab (red arrow), in the ‘Changes’ group select ‘Highlight Changes…’ (yellow arrow) from the ‘Track Changes’ drop-down (blue arrow). This will open the ‘Highlight Changes’ window. In the ‘Highlight Changes’ window, ensure that ‘All’ (red arrow) is selected in the ‘When’ field. You can choose to have the changes highlight on the worksheet (yellow arrow), or have the changes listed on a new sheet (blue arrow). If ‘Highlight changes on screen’ is selected, continue to step 5. If ‘List changes on a new sheet’ are selected, skip to 6. Any cells that have been updated by the risk coordinator will now be highlighted with a coloured box around the cell (red arrow). Hover over the cell to expose the note (yellow arrow). This will help mirror updates from the sub-register(s) to the master register. Once all updates are mirrored, skip to step 7. A new sheet will have been created that lists all the updates that were made. This will help mirror 46 updates from the sub-register(s) to the master register. Once all updates from sub-register(s) are mirrored in the master register, select the “Summary” worksheet by clicking it (red arrow). Select the appropriate cell in column ‘I’, and determine if the current risk rating has changed since the last report. Click the appropriate button; No change (red arrow); increase (yellow arrow); decrease (blue arrow). The Risk Register is now ready to generate a report. Top Tips: An alternative and perhaps an easier option to Step 4.3 could be to ask the risk action owners and the risk coordinators to highlight the changes that they made in red text on the sub register and sub action list template that they received. On receipt of the sub register(s) and sub-action lists from the Risk action owners and risk coordinators copy and paste the updates and changes made into the Master Excel Risk Register – see Section 3 for instruction on how to edit a risk register. 47 Section 4.4: Running Risk Register report The timing for running Risk Register reports will depend on the Risk Register managing and monitoring procedure that is in place. •Select the “Basic Details” worksheet by clicking it (red arrow). Step 1 •Select cell "B11" and enter the report date in the following format dd/mm/yyyy (yellow arrow) and press return. The date will default as month/yy. This is the date that will appear on the risk register report. Step 2 •Locate and click the “Report” button (red arrow). Step 2 50 Section 5: Closing a risk Selecting “Closed” on the risk register worksheet does not archive the risk into the “Closed Risk” worksheet. The Risk will remain on the “Risk Register”, “Risk Action Log”, “Summary” and “dashboard” worksheets, and the status will be noted as “closed”. When a Report is generated, the closed risk will appear on the Report. A closed risk should only appear on a Report once. The risk should then be removed from subsequent reports by archiving the risk in the “Closed Risk” worksheet. Step 2 •Select the “Risk Register” worksheet by clicking on it (red arrow). Step 1 • Locate the risk that you want to close and select the appropriate cell in column ‘M’ (red arrow). Click the dropdown icon which appears (yellow arrow) and selecting “Closed” from the dropdown menu (blue arrow). Step 2 Top Tips: Before moving a risk from the “Dashboard”, “Summary”, ”Risk Register”, “Risk Action Log” worksheet to the “Closed Risk” worksheet carry out the following checks: 1. Ensure the risk is marked closed on the Risk Register worksheet (see Step 2 above). 2. In the risk register worksheet ensure there are no blank cells in the existing control column. If there are blank cells enter N/A in the cells 3. In the risk action log worksheet ensure there are no blank cells in the action column. If there are blank cells enter N/A in the cells. 4. In the risk action log worksheet ensure that the current risk rating is complete. 51 Selecting “OK” will remove the closed risk from the “Dashboard”, “Risk Register”, “Risk Action Log” and “Summary” worksheets and move it to the “Closed Risks” worksheet. Moving a risk to the “Closed Risk” Worksheet in Error. If you choose the wrong risk ID from the drop-down you can undo this error by clicking on the “Risk Register” worksheet (red arrow) and select the back arrow button (blue arrow). This will undo the action. This undo action will only work if you have not saved the document. •To remove a "closed" risk from the “Dashboard", "Risk Register”, “Risk Action Log” and “Summary” worksheets, to the "Closed risk" worksheet (after completing the checks as outlined in the tops tips section) on the “Risk Register” worksheet locate and click the ‘Closed Risk’ button (red arrow), which will open the ‘Closed Risk’ window. Step 3 •In the ‘Closed Risk’ window, select the alphanumeric ID of the closed risk from the dropdown (red arrow), and click the ‘OK’ button (yellow arrow). Make sure you select the right risk ID from the dropdown list. It is easy to choose the wrong risk ID from the list. Step 4 52 Section 5.1: Exercise Close Risk 1 on Risk Register Undo the Closing of Risk 1 on the Risk Register.