DHCR HSE Risk Management Policy

Department: HSE
Document Identifier: DHCR/PP/HSE/004/01
 Policy and Procedure – DHCR HSE Risk Management Policy

INTRODUCTION

This Risk Management (“RM”) policy has been prepared by DHCR HSE, and provides a clear policy on
Risk Management Procedures.

1- Purpose:
1.1 Engaging in pro-active risk management activity, in addition to the process of assessing risk, will
enable the early identification of many things that can go wrong as part of a systematic approach
to risk assessment.

The Risk Management Programme employs a number of systems to identify potential risks.
Research indicates that incidents are rarely due to individual failures but are usually associated
with systems failures.

The purpose of this policy is to provide guidance to effectively identify and manage risk in
conjunction with DHCR HSE procedures.

1.1 DHCC is committed to the continuous improvement of its risk management systems and
has a positive and supportive approach to the management of healthcare risks.
1.2 Implementation of systems where possible to prevent harm and conduct activities in
such a way as to ensure that all on campus are not exposed to unnecessary hazards through
the provision and maintenance of equipment and premises which are safe and without
unnecessary risks to health and safety.
1.3 Ensure that any premises under the control of the Business Partners /
Investors are maintained in a condition that is safe, and without unnecessary risks to
health and safety.
1.4 Business Partners / Investors are will incorporate in policies, procedures and guidelines
the practical guidance given in best practice methods, which are relevant to any work of
the organisation. In addition, where no “Best Practice Method” exists, the organisation will
compile and apply its own policies, procedures and guidelines, appropriate to specific
activities, in order to control the risks to patients, employees and others and provide for
the protection and avoidance of damage to the environment.

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1.5 Compliance with all Federal Law, Local Orders, Regulations and International best practice
relevant to the Hospitals activities.
1.6 Business Partners / Investors are will carry out and act appropriately on risk
assessments of current work practice methods, premises, plant, and equipment, to ensure
risks are efficiently managed.
1.7 Will actively promote and encourage the involvement of employees in the
organisations risk management practices and procedures.
1.8 Will provide such information, instruction, training and supervision as is necessary, to
ensure that risk management is an integral part of every employees work, and to ensure
that this policy is efficiently implemented.
1.9 Ensure that risk management matters are effectively addressed at all levels.
1.10 Provide information on risks and the appropriate protective and preventative
Measures.

2- Scope of application:
2.1 To demonstrate how to assess risk and establish a common approach for risk management
with the following objectives:
2.1.1 Ensure as far as is reasonable practicable there is a program for risk assessment
2.1.2 Identify the hazards and risks in respect of the work activity
2.1.3 Provide a program for performance and the development of risk elimination

3- Applicable To:
3.1 This policy applies to all, staff operating and applicable to all property (buildings owned or
occupied) and premises including residential accommodation, and businesses) within the DHCC
campus.
3.2 3.1.1 Every Business Partner and their staff including all contractors staff should
adhere strict adherence to this DHCR Risk Management Policy
3.1.2 All new staff shall be oriented on the Risk Management Policy as part of general
staff orientation program

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3.1.3 It should be understood that the onus on all operating / working in DHCC to
demonstrate compliance with the DHCC Regulatory Division Risk Management
Policy

4- Policy:
4.1 Policy
It is the objective of all Business Partners / Investors to effectively manage all risks who may be
affected by the organization’s activities through the implementation of a risk management
system that will pay due attention to efficient:
4.1.1 Identification of hazards
4.1.2 Assessment of risks associated with these hazards
4.1.3 Development and implementation of control measures to eliminate
these hazards or to reduce risks to acceptable levels
4.1.4 Evaluation to ensure that controls are effective, and monitoring of the
ongoing change situation
4.1.5 Minimization of harm caused by adverse incidents
4.1.6 Incident reporting and investigation
4.1.7 Claims management

PROCEDURE SEQUENCE
5.15.1What is a Risk Assessment
Each BP/Inv has a responsibility to ensure that there is a clear and appropriate
management structure that enables risk to be identified at High Level and at operating Management
Level and decisions to eliminate Harm are taken at an appropriate level.

The management of each BP/Inv will understand the risks associated with achieving its objectives
and will actively reassess and monitor them. Progress against action plans and the residual risks will
be an ongoing program.

Risks will be identified from risk assessments (reference to Appendix 6.1: Template Risk
Assessments).

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5.25.2 Aim of a Risk Assessment

Risk Management Process, the management of risk is a key component in the safety management
system within all organizations activities.

The risk management process is the systematic application of management policies, procedures and
practices that determine the approach for communicating, identifying, assessing, monitoring and
reviewing risks. This is a step-by-step approach that leads the user through from assessment of the
activities they undertake, identification of risks through to the incident reporting process. The aim of
risk assessment is to identify potential sources of harm and loss and put in place adequate controls
or preventive measures before they result in an accident or illness. The key stages of Hazard
Identification and Risk Assessment Survey are as follows:

5.35.3 When to carry out a Risk Assessment

In relation to all risks analyzed and assessed, dependent on the likelihood of occurrences, action
should be taken as soon as possible to eliminate, reduce or transfer risks.

Each risk should be allocated to a risk owner/s that is responsible for acting appropriate action to
minimize its impact/consequence.

Prior to commencing a Risk Assessment, an inventory of all work activities, processes, equipment and
machines used must be prepared for each work area or location being assessed. It is vital to include
infrequent maintenance tasks as well as more routine day-to-day work.

5.45.4 How to Analyze Risks

The management of risk is integral part of every process within each organization and is central to
having a robust system of internal control. The following actions 5.1.1 – 5.1.3 should be completed in
the Risk Assessment Template (reference to Appendix 6.1: Template Risk Assessments)

There are 3 x Steps to Analyzing the Risk

5.4.1 Identify the risk/Hazard
5.4.2 Analyze the Risk
5.4.3 Evaluate the Risks

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5.55.4.1 Identify the risk/Hazard

Identify the situation or source with a potential for harm in terms of death,
ill health, injury or damage to property.
Provide a description of the hazard providing detail on the persons at risk
and/or consequence of the risk/hazard being realized

For each activity, material, equipment and machine, the hazards must be identified. A hazard
checklist should be drawn up, taking into account the nature of work activities and locations where
work is carried out

Hazard Checklist (this is not an exhaustive list)

Chemical Biological Psychological Environmental,
Physical
Mechanical/
Biomechanical

 Excessive noise  Formaldehyde  Human  Stress  Tripping hazard

 Extreme  Xylene immunodeficiency  Rotating shift  Unguarded
Temperatures  Acetaldehyde virus (HIV) work equipment
 Inadequate  Phenols  Vancomycin  Prolonged  Air quality
Lighting  Hazardous drugs resistant working  Slippery floors
 Ionizing radiation such as cytotoxic enterococcus(VRE) hours  Confined space
 Lasers agents, ribavirin,  MRSA  Sexual  Forceful exertions
 Electricity pentamidine.  Hep. B virus harassment  Awkward
 Tools  Waste anesthetic  Hep. C virus  Workplace postures
 Pressurized gases  Mycobacterium violence  Localized contact
systems  Dust / Fumes  Fungi/Molds  Inadequate stresses
 Improper  Smoke  Blood samples staffing  Vibration
ventilation  Solvents  Body fluids  Heavy  Repetitive /
 Stairs/ladders  Pesticides  Insects workload prolong motion
 Slipping / Tripping  Paints  Plants  Lifting/ moving
 Pinch points  Flammables patients
 Fire  Alkalis/Acids  Cluttered or
 Working at obstructed work
heights. areas/
 Workplace passageways
violence

5.65.4.2 Analyze the Risk

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Risk analysis is about developing an understanding of the risks identified. In subjecting a risk to
analysis it is essential that account is taken of the existing must be recorded as, control measures.
These include all measures put in place to eliminate or reduce the risk and may include;

All controls to minimize the risk that are currently in place should be listed on the risk assessment
form. When listed, time should be taken to consider their adequacy (i.e. identify weaknesses in
existing procedures and opportunities for error), method of implementation and level of
effectiveness in minimizing the identified risk to the lowest reasonably practical level. It should
be noted that management should not assume that the controls which rely on people following
correct procedures will always work.

The risk associated with each hazard must then be assessed by determining who might be harmed
and how. The assessment should evaluate the potential for harm and its consequences.
Consideration should be given to the number of persons exposed to the hazard, the frequency and
duration of exposure to the hazard, potential failure modes and routes of exposure.
The consequences of harm could range from slight injury or illness to lacerations, fractures,
amputations, chronic pain, poisoning, cancer or fatal injuries.
Risk depends on many, often related, circumstances:
 Is anyone exposed to the hazard?
 Is the hazard likely to cause injury?
 How serious would the injury be?
 Is the hazard well controlled?
 Is the level of supervision adequate?
 How long are people exposed?
 What are the levels of exposure that should not be exceeded?

5.75.4.3 Evaluate the Risks

The purpose of risk evaluation is to make decisions based on the outcome of the risk analysis
regarding which risks require treatment and the priorities of that treatment. Depending on the risk
rating and the adequacy of the current controls in place an evaluation is made whether to;

5.4.3.1 Accept the risk

5.4.3.2 Treat the risk by;

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Avoiding
Transferring
Controlling

After assessing risks, it should be estimated that how likely it is that a hazard will cause harm and
how serious that harm is likely to be. This will help in prioritizing different risks as high, medium or
low and in deciding on the appropriate level of management effort and resources that will be
required to control each hazard. It will also help to decide how urgent any corrective measure needs
to be.
5.85.5 How are Risks are prioritized on the basis of their Risk Factor
Risk Factor = Likelihood x Severity

Rating of Likelihood:

Likelihood Definition Rating

 Improbable  May occur only in rare and exceptional 1
circumstances.
 Happen once in 10 years

 Unlikely  Is not likely to occur in normal circumstances 2

 More than once in 10 yrs. but not more than once
in 5 years.

 Possible
 Could occur at some time.
 More than once in 5 years but no more than once 3
a year.

 Will probably occurs in most circumstances. 4

 Likely  Multiple times a year but no more than once a
month.

 Almost Certain
 Almost certain to occur in most circumstances. 5
 Happen once or more in a month.

Rating of Severity:

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Severity Definition Rating

 Insignificant  Dealt with First Aid only. 1
 Non-serious equipment or facility damage.
 Medical help required (outpatient)
 Minor  Minor process loss or facility damage. 2
 Chemical release requiring only routine cleanup
without reporting.

 Moderate
 Significant reversible injury. Overnight
hospitalization (inpatient). 3
 Moderate process loss or facility damage
 Chemical release triggering external reporting
requirements.
 Major
 Extensive permanent injury/illness (eg. loss of
fingers/toes), extended hospitalization. 4

 Catastrophic
 Major process loss or facility damage 5
 Chemical release with temporary environmental or
public health impact.

 One or more fatalities.

 Permanent disabling injury (e.g. loss of entire limb,
blindness etc.)
 Entire process shutdown or extensive facility
damage.
 Chemical release with acute, lasting environmental
or public health impact

5.95.6 When to carry out a Risk Assessment

In relation to all risks analyzed and assessed, dependent on the likelihood of occurrences, action
should be taken as soon as possible to eliminate, reduce or transfer risks.

Each risk should be allocated to a risk owner/s that is responsible for acting appropriate action to
minimize its impact/consequence.

Prior to commencing a Risk Assessment, an inventory of all work activities, processes, equipment and
machines used must be prepared for each work area or location being assessed. It is vital to include
infrequent maintenance tasks as well as more routine day-to-day work.

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5.7 What is a Risk Matrix

5.10
The risk matrix below provides a visual picture of how to calculate the risk:
Low Medium High

The lowest risks are those in the GREEN boxes, which suggest the risk has been controlled to its lowest possible
level.

The risks located in the AMBER boxes suggest that controls are adequate, but ongoing monitoring is required.

Those risks located in the RED boxes are classified as key risks and should receive early management attention
and ongoing monitoring.

RISK MATRIX 5 X 5 RISK RATING MATRIX TOOL

Low Risk Green = 0 - 5
Moderate Risk Amber = 6 -10 Severity of the potential injury/damage
Major /Extreme Red = 11 - 24
Negligible Minor Moderate Major Extreme
Sentinel Event Purple = 25 (1) (2) (3) (4) (5) Risk Rating
Almost Certain
(5) 5 10 15 20 25 Sentinel
Likely (4) 4 8 12 16 24 High
Likelihood of the
hazard happening Possible (3) 3 6 9 12 15
Medium
Unlikely (2) 2 4 6 8 10
Rare/Remote
(1) 1 2 3 4 5 Low
Rating of Risk:
Risk Rating
Risk Factor
1 to 5 Low

6 to 15 Medium

16 to 24 High

25 Extreme

5.8 How to Apply a Risk Score

5.11
Risk ratings scores 1 - 5 – Low Risk
These risks in between 1 – 5, out of a score range 1 -25 are managed internally as low rated risks.

Risk rating scores of between 6 and 15 - Minor Risk

These risks in between 6 – 15, out of a score range 1 -25 are Minor Rating, managed internally, but
reported to DHCR HSE.

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Risk rating scores of 16 - 24 – Major / Extreme Risk

These risks in between 16 – 24, out of a score range 1 -25 are potential for Major / Extreme Risk
Rating, reported to DHCR HSE.

Risk rating scores of 25 – Sentinel Event

The risk with a score of 25, out of a score range 1 -25 are potential to lead to a Sentinel Event and
must be reported to DHCR HSE, immediately.
5.9 Is there an ‘Acceptable Risk’
5.12
Accepting the risk, a risk is called acceptable if it is not going to be treated, accepting a risk does not
imply that the risk is insignificant. Risks in a service may be accepted for a number of reasons:

The level of the risk is so low that specific treatment is not appropriate within available resources
The risk is such that no treatment option is available. E.g. dependent on external factors such as
government policy
The opportunity presented outweighs the treats to such a degree that the risk is justified.

Steps 1-3 (refer to 5.1.3 Evaluate the Risks) above conclude the Risk Assessment process, it is
however essential that in terms of managing assessed risks that the treatment (Action) plan is put in
place against those risks that have been evaluated as requiring treatment.
5.10 What each Risk Rating Colour Score means by way of Harm
5.13
Low Risk Minor Risk High Risk
(GREEN) (AMBER) (RED) (to Incl.
Sentinel event)

No obvious First aid/medical Extensive injury, major

harm or injury treatment required permanent harm or
fatality

5.11 What each Risk Rating Colour Score means by of Organisation Acceptability
5.14
Assessment Description

Low Acceptable as is it. No significant.

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Medium Acceptable with controls

High Unacceptable and significant.

Very high Extreme. Unacceptable and serious

5.12 How to Treat the Risk

5.15
There are three methods of treating the risk, these are;
5.12.1 Avoid the Risk
5.12.2 Transfer the Risk
5.12.3 Control the Risk

5.12.1 Avoid the risk

This is achieved by either deciding not to proceed with the activity that contains an unacceptable
risk, choosing an alternative activity, which meets the objectives and goals of the Hospital, or
choosing an alternative and less risky methodology or process within the activity

5.12.2 Transfer the risk

Risk transfer transmits the organization’s risk to an outside party. The most common method being
the purchase of insurance, the cost of which is dependent on the level of assurance provided to the
insurer in terms of the level of risk of a claim occurring.

5.12.3 Control the risk

This is the most commonly used treatment option as it is focused on reducing the likelihood and/or
the impact of the risk should it occur. Best practice is to remove or eliminate the risk; however, this is
not always possible. It is part of the Hospitals policy to provide appropriate training, instruction and
supervision for all tasks, while this assists in the control of unsafe acts, further controls are often
needed in order to reduce to acceptable levels the risk.

Best practice states that controls must be examined in the following order, in order to access its
effectiveness.

5.13 How to Decide on Measures to Control Risk

5.16

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Once the hazards have been identified and the associated risks assessed, action should be taken
reduce the risks so that the working conditions are improved. The most effective ways of reducing
risks are given below in order of preference

5.13.1 Elimination
5.13.2 Substitution
5.13.3 Isolation
5.13.4 Engineering
5.13.5 Administrative
5.13.6 Standard operating procedures
5.13.7 Personal Protective Equipment

5.13.1 Elimination of hazard is on the top of hierarchy of control measures. The ideal
Elimination solution is to get rid of the hazard completely. This is the most effective control
measure and should always be considered first i.e. remove/avoid the risk from the
activity, process, area etc.
5.13.2 Substituting with an alternate, that is capable of performing the same task but is
Substitution safer to use, can effectively reduce the risk. For example, substituting
glutaraldehyde disinfectant with a less toxic ortho-Phthalaldehyde disinfectant.
Therefore, replacement of dangerous articles, substances or systems of work by
less dangerous articles, substances or systems of work.
5.13.3 Isolation - Restrict access to areas, processes that represent a significant risk of
Isolation injury to authorized persons.

5.13.4 Engineering controls include using machine guards, enclosure of hazards, local
Engineer exhaust ventilation, mechanical handling methods or protective physical barriers.
However, where hazards cannot be reduced it may be necessary to
develop/purchase appropriate equipment in order to minimize the risk.

5.13.5 Administrative - Administrative controls can be used to reduce or eliminate

Administrative exposure to a hazard by adherence to procedures or instructions. These may
include training, supervision, permit-to-work system and job rotation. Training is
an effective way of making a workplace safe and effective. Training of employees
should cover the correct and safe way of performing a particular task, proper use

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of machines, equipment and tools, and understanding of the hazards related to

the work.
5.13.6 Standard operating procedures aid in giving collective advice on the safest
Standard possible way a task is to be performed, after all other controls have been
operating investigated.
procedures
5.13.7 The personal protective equipment (PPE) should be considered as a last resort. It
Personal should be kept in mind that they do not eliminate the hazard, thus their failure
Protective means immediate exposure to the hazard, it should be ensured that the collective
Equipment protective measures highlighted above are exhausted prior to the use of
individual protective measures, such as PPE.

5.14 What is an Appropriate Action Plan / Treatment Plan

5.17
Implement Appropriate Control Measures: The control measure shall adequately control the risks,
without generating new risks and shall allow staff to do their work without undue discomfort or
distress. Develop work procedures in relation to the new control. Inform all relevant persons about
the control measures being implemented and in particular, the reasons for the changes.

5.14.1 Treatment Plan

In order to ensure that the treatment plans are implemented the following should be documented
and subjected to on-going monitoring and review, as part of the normal activities in which the risks
are to be treated.

The treatment plan should include;

5.14.1 Proposed actions (Avoid, transfer, Control)
5.14.2 Resource Requirements (Local or escalation required)
5.14.3 Responsible person
5.14.4 Timeframe (Review Dates and/or action completion dates
5.15 Competency of Risk Assessment Team
5.18
People responsible for carrying out hazard identification and risk assessment must have the
necessary skills. The team should include a person who has direct relation with the area to be
assessed. This could be the area supervisor or any other employee from that area.

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5.16 What is a Risk Register

5.19
Each Business Partner / Investor (“BP/Inv”) must have a risk register which clearly outlines those
risks that threaten the organizations ability in achieving its stated aims and objectives. (reference to
Appendix 6.2: Template Risk Register).

Components of an Organizations Risk Register

Risk Number Risk Management unique reference number
Risk Source State where the risk originates .i.e. A high risk identified from a
Business Continuity Plan or a Serious Incident
Date Added When was the Risk Added to the Register?
Risk Category/
Description Contains a high level statement of the risk and more detail
about how that risk might present itself and impact on organization
Likelihood How likely is it that the risk will occur? Use risk Matrix
Consequence What would be the consequence(s) should it occur? Use risk matrix
Risk Grade Use the risk matrix top grade the risk with current controls in place.
Management
Action Identify additional actions necessary to improve the management of
the risk, give a reference to a separate action plan/relevant part of
a business plan in which it appears if apparent.
Risk Owner Who owns the risk? Identify a named person, who will be responsible
for taking action to effectively manage the risk
Review Date When will you review the assessment of the risk and any actions identified?
Results of Review What was the outcome of the review?
Date Last Reviewed When was the risk last reviewed?
Risk Status Is the risk still active or is it no longer a live risk for
the organization
5.17 Monitor & Review
5.20
Ensure the following is continuously updated:
5.17.1 Chosen control measure has been implemented, as planned
5.17.2 Control measures are working and are adequate
5.17.3 Did the implementation of control create other hazards
5.17.4 Has anything changed over time since the process was implemented

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5.17.5 Is the control of risk, still adequate

5.17.6 Was the risk management process conducted effectively?

5- Appendix
5.1 Risk Assessment Template
5.2 Risk Assessment Register

6- Communication: (Check all that apply)

 Announcement

☐ Awareness

 Training

Other specify

7- Definitions:
Accident: An accident is an unplanned event resulting in death, or resulting in an
injury such as a severe sprain or strain (for example, manual handling
injuries), a laceration, a broken bone, concussion or unconsciousness
Adverse Event: An adverse event is defined as an unexpected, undesirable, or potentially
dangerous occurrence
Dangerous (Below is not an exhaustive list)
Occurrence: dangerous occurrence’ means an occurrence arising from work activities in
a place of work that causes or results in –
(a) the collapse, failure, explosion, bursting, electrical short circuit
discharge or overload, or malfunction of any work equipment,
(b) the collapse or partial collapse of any structure under construction or in
use as a place of work,
(c) the uncontrolled or accidental release, the escape of any chemical, fume,
gas or the ignition of any substance,
(d) a fire involving any substance, or

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(e) any unintentional ignition or explosion of explosives, as may be

prescribed.
Event: Anything that constitutes an Incident, Unsafe Act, Near Miss and
Dangerous Occurrences
First Aid: Incident that resulted in injury and treated by a first aider on site or no
treatment required and the injured is generally able to return to the normal
duties afterwards
Hazard: Hazard is the potential of an activity, arrangement, circumstance or
substance to cause harm or loss to either by injury/illness to human,
damage to property or environment, and or loss to process.
For example, working at height is a hazardous activity, a machine without
proper guards are a hazardous arrangement, insufficient light or too
much noise is hazardous circumstances and flammable liquids or
toxic chemicals are hazardous substances.
Incident: Any event that could have or did lead to unexpected or unintended harm,
loss or damage to a patient, staff, visitor, third party, hospital property or
premises
Lost Time Injury: A Lost Time Injury occurs when an employee cannot return to work for
more than 3 days due to an injury or illness.
Near Miss: An incident, which could have but did not result in harm, loss or damage to
a patient, staff, visitor, third party, hospital property or premises.
Property Damage: Property Damage incidents do not affect the SHE performance statistics
but do provide a means of early identification of potential problem areas
Risk: Risk is defined as the chance of something happening that will have an
impact on the achievement of organisational stated objectives and the
likelihood that a specified undesired event will occur due to the realization
of a hazard by, or during, work activities. A risk always has two elements;
the likelihood that a hazardous event may occur and the consequences of
the hazardous event.
Risk Assessment: A Risk Assessment is the process of identification of hazards and the
qualifying of the risk of harm that such hazards might cause.

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Risk Rating: The risk rating is determined by a combination of the likelihood and
impact the risk
Risk Register: is a log of risks that threaten an organization’s success in achieving its
declared aims and objectives. It is a dynamic living document, which is
populated through the organization’s risk assessment and evaluation
process. This enables risk to be assessed and rated. It provides a structure
for collating information about risks that helps both in the analysis of risks
and in decisions about whether or how those risks should be treated.
Sentinel Event: A sentinel event is defined as, but not limited to: An unexpected occurrence
involving: unanticipated death; or Major permanent loss of function or
major injury; or serious psychological injury

8- References :
8.1 DHA Health Care Standards – April 2012
8.2 Joint Commission International Accreditation Standards for Hospitals, 6th ed, 2016

8.3 Local Order 11 of 2013 Concerning Public Health & Community Safety in the Emirate of Dubai

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Revision History

S No: Summary Amend Type* Page Issue No. Issue Date

1.
2.
3.
4.
5.
6.
* Amend Type: New- Add – Modify – Cancel

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