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Risk register: an integrated governance approach
  1. Chris Haywood and
  2. Alison Coackley
  1. Willowbrook Hospice, St Helens, UK


Introduction While risk management is an integral component of high quality care it can be difficult to demonstrate effectiveness. A key aim of the Hospice Business Plan was to devise and develop a Risk Register that could incorporate Fundraising and Clinical activities as part of an Integrated Governance Framework.


  • To produce a Risk Register to identify areas and work practices most at risk

  • To implement a Risk Register to minimise risks that could affect the running of the Hospice

  • To use a Risk Register to monitor effectiveness of actions/initiatives.



  • Literature review

  • Risk Matrix

  • Risk scoring process

  • Audit cycle.


Example Risk Date Governance

Area Description of

Risk concern

(x,y,z) Potential Impact including current controls Risk Score

(Pre) Risk control processes to reduce or transfer risk

Date for completion Risk Score

(Post) Likelihood rating Impact rating RISK.

Clinical effectiveness Administration of bisphosphonate infusions without adequate checks causing harm

Patient condition compromised

Develop hospice policy on bisphosphonate infusions with flow chart

Training and education for nursing and medical staff

Distribution of new regional audit guidelines

Audit to check on process


  • Organisational risks were identified and scored using likelihood and impact ratings

  • Risks were categorised into seven key themes

  • Potential impact including current controls were described

  • Risk control processes to reduce/transfer risk were shown for each individual risk

  • Following intervention 86% of high risks were significantly reduced within a 7 month period.


  • Use of a Risk Register clearly demonstrates effectiveness

  • Heightened awareness; risk is everyone's business

  • Audit has shown improvements in identifying risks

  • Strengthened communication across fundraising and clinical services.


  • Understanding of Risk Register to be part of induction training

  • Use of Register needs to be an ongoing process and should be regularly monitored and updated.

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