Updated Policy: QM-180 Integrated Risk Management

Shared on behalf of Quality and Risk Management

Please be advised that the Hospital’s Integrated Risk Management policy (QM-180) has been revised. 

Actions Required

  • All – Review the updated policy to familiarize yourself with key policy changes and as a refresher on procedural steps. The approved updated policy is attached for reference and is now available on the iNtranet .
  • Managers – Review this memo and the attached poster with your staff during Safety/Quality Huddles and post in your department.

Policy Changes

  • Policy Statement:

The Hospital is committed to high standards of care and patient safety. Risk management is embedded within day-to-day business, in addition to informing strategic and operational planning. Integrated Risk Management (IRM) at the Hospital is a coordinated, organization-wide approach to identifying, assessing, mitigating and monitoring risks that could impact patient safety, clinical outcomes, staff well-being, finances, reputation and compliance.   

  • Scope Change:

Contract employees added. 

  • Definitions:

Definitions have been refreshed.

  • Roles and Responsibilities Updated:

5.6 All Workers (staff, professional staff, learners, volunteers and contract employees) will:

  • identify actual or potential risks and report them to their manager/leader;
  • safely conduct work and make daily decisions using the Risk Assessment Tool (Appendix B) and Risk Impact/Likelihood Matrix (Appendix C);
  • conduct Occupational Health and Safety (OHS) risk assessments in accordance with policy OHS-os-251 Risk Assessments; and,
  • report Patient Safety Incidents via the Incident Learning System (ILS) as per policy QM-60 Incident Learning System: Reporting, Investigation, and Trending of Incidents and Near Misses (excluding volunteers and security staff who will bring the information to their manager).
  • Procedure Updated:

6.1 All Department/Program Leaders will:

  • incorporate discussions on quality and IRM in team meetings and Director/VP meetings on a regular basis 
  • Appendix B Updated:Risk Assessment Tool updated to the most recent version provided by HIROC (see updated policy/attached poster).
  • Appendix C New:Added TBRHSC Risk Impact/Likelihood Matrix (see updated policy/attached poster).

Process Reminders

  • Please see the attached poster.  

 If you have any questions, please email: TBRHSC.QualityandRiskManagement@tbh.net For more resources related to risk management (including Risk Register and Risk Assessment Checklist), please visit the Risk Management tab on the iNtranet: