Enhancing Healthcare Risk Management Strategies: Implementing the HSE Enterprise Risk Management Policy and Procedure

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The “HSE Enterprise Risk Management Policy and Procedures 2023” document provides a comprehensive framework for managing risks within the Health Service Executive (HSE). It aligns with the ISO 31000:2018 guidelines, replacing the HSE Integrated Risk Management Policy 2017. The policy covers enterprise-wide risk management inclusive of all risks associated with management and service delivery processes. The purpose is to ensure proactive management of risk, assist staff in understanding their roles and responsibilities, and set out the systems and processes that are required to ensure that risks are managed consistently across the HSE. The scope extends across the HSE at both national and local levels, including Hospital Groups, Community Health Organisations, the National Ambulance Service, other national services, and the Health Regions once established.

In this blog, we provide an overview of the HSE Enterprise Risk Management process set out in the policy and procedure. We also outline how an electronic risk register is a valuable tool to support healthcare risk management strategies and the implementation of the HSE Enterprise Risk Management Policy and Procedures 2023.

Overview of the HSE Enterprise Risk Management Process

The HSE’s approach to risk management is aligned with ISO 31000:2018. The key components of the risk management process are:

  1. Scope, Context, and Criteria: The HSE Enterprise Risk Management process begins with establishing the Scope, Context, and Criteria. This foundational step ensures that the risk management activities align with the strategic objectives of the HSE. The process involves identifying the internal and external contexts which the HSE and its services must consider when they manage risk. Internally, this involves considering factors such as organisational objectives, governance structures, resources, organisational culture, data and information systems, and operational processes. Externally, factors such as regulatory requirements, societal expectations, external stakeholder relationships, contractual relationships, and market dynamics, should be considered. Moreover, this step underscores the necessity of risk-based decision-making, emphasising the importance of integrating risk considerations into strategic planning and day-to-day operations to foster informed decision-making and proactive management.
  2. Risk Assessment: Risk Assessment is integral to identifying, analysing, and evaluating risks that could potentially impact the organisation’s ability to achieve its objectives. This stage is crucial for the proactive identification of risks across all levels of the organisation. The process begins with Risk Identification, where potential threats and vulnerabilities are recorded. Following identification, Risk Analysis involves evaluating the likelihood and impact of each identified risk, enabling the organisation to prioritise risks based on their severity. Finally, Risk Evaluation allows the service to determine which risks need treatment and the treatment priorities. This systematic approach ensures that resources are allocated efficiently.
  3. Risk Treatment: Risk Treatment involves developing and implementing controls to manage identified risks effectively. There are four types of controls, both Preventative and Directive are proactive and, Detective and Corrective are reactive. Once suitable treatment strategies are selected, detailed plans are formulated, outlining specific actions, responsibilities, timelines, and resource allocations. These plans aim to reduce the likelihood of risk occurrence or diminish their impact should they materialise.
  4. Recording and Reporting of Risk: This stage ensures transparency, accountability, and continuous monitoring of risk management activities across the organisation. By maintaining a detailed and up-to-date risk register, the HSE service provides a comprehensive overview of all identified risks, including a detailed description, their risk assessment, treatment plans and controls, and status. It should also record performance in managing the risk over time through the decreasing or increasing of the ratings. This centralised documentation becomes an invaluable tool for tracking progress, facilitating audits, and supporting decision-making processes.
  5. Communication and Consultation: Effective communication and consultation are pivotal in the HSE’s Enterprise Risk Management Process. This stage emphasizes the importance of sharing risk-related information across teams, to ensure risks are better understood, systemic risks are identified, and effective plans are developed to manage risks. The HSE Enterprise Risk Management policy outlines three levels of communication, each of which increases the formality associated with the communication. These are Risk communication, Risk notification, and Risk escalation. Risk communication is the sharing of information and gaining a common understanding of the risk. Risk notification in the HSE, is recognising the risk is increasing or is not being managed effectively, and so requires notification to the next level of management. Risk escalation is required in certain circumstances that could include when a risk can no longer be managed at the level in which it is expected to materialise.
  6. Monitoring and Review of Risk: This crucial phase ensures that risks recorded in the risk register are subject to ongoing monitoring and that risk treatment measures are effective and adjusted as needed to respond to changing circumstances. The risk register should be regularly reviewed at Management Team meetings, and at a minimum on a quarterly basis.
  7. HSE Corporate Risk Register Reporting: This section outlines the structured approach to consolidating risk information across the organisation into a comprehensive Corporate Risk Register. The Register serves as a central repository, capturing principal risks, treatments, and actions planned or undertaken to mitigate these risks. It provides a holistic view of the organisation’s risk landscape, facilitating strategic oversight and informed decision-making.
  8. External Risk Engagement: The final integral component of the HSE Enterprise Risk Management Process is External Risk Engagement. This stage acknowledges the importance of interacting with external stakeholders to address strategic risks that extend beyond the HSE’s control. The service must establish mechanisms for communicating these risks with the relevant body, with a view to arriving at a shared understanding of the risk and of what is required to mitigate it.

Electronic Risk Register: Enhancing the implementation of the HSE Enterprise Risk Management Policy and Procedures

The adoption of an electronic risk register is a beneficial tool in streamlining the implementation of the HSE Enterprise Risk Management Policy and Procedure across HSE services. This digital tool revolutionises the way risks are recorded, assessed, and managed, offering a centralised, accessible, and dynamic platform for risk management activities.

Utilizing an electronic risk register such as HCI’s Risk Register, streamlines and improves the risk management process, aligning with the goals of the HSE Enterprise Risk Management Policy and Procedure, and ultimately enhancing patient care and service delivery within the HSE framework.


The implementation of the HSE Enterprise Risk Management Policy and Procedure represents a significant step forward in strengthening risk management practices within health and social care services. By embracing a structured, systematic approach, services can ensure that enhanced healthcare risk management strategies are integrated into all levels of the organisation, improving the safety, quality, and efficiency of healthcare delivery.

The adoption of a risk register such as HCI’s Risk Register, is a key component of this strategy, offering a dynamic and efficient tool for managing risks across the a service. By facilitating real-time data management, ensuring consistency and standardisation, enabling advanced reporting and analysis, promoting transparency and accountability, and supporting collaborative risk management efforts, the electronic risk register serves as a cornerstone for effective risk management implementation.

In conclusion, the diligent application of the HSE Enterprise Risk Management Policy and Procedure, supported by innovative tools like the electronic risk register, empowers health and social care services to navigate the complexities of healthcare delivery in today’s ever-changing environment. By proactively identifying, assessing, and managing risks, the services can continue to provide high-quality care while safeguarding the well-being of patients, service users and staff.

If you would like further information HCI’s Risk Register, contact HCI at +353 (0)1 629 2559 or email info@hci.care.

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For more information contact info@hci.care or Phone +353 (0)1 6292559.