University of Tasmania Division/Faculty/School/Project Risk Assessment Guide Risk assessment date 2 University of Tasmania Risk Assessment Guide Division/Faculty/School/Project Risk Assessment Month Year Contents 1 Introduction .................................................................................................................. 3 2 The risk assessment process ...................................................................................... 5 Appendix A - Risk Terminology..................................................................................... 10 Appendix B – Division/Faculty/School/Project objectives ............................................. 11 Appendix C – Division/Faculty/School/Project structure and activities .......................... 12 Appendix D - Risk assessment parameters .................................................................. 13 University of Tasmania Risk Assessment Guide Division/Faculty/School/Project Risk Assessment Month Year 3 1 Introduction Guidance (for deletion): This guide has been developed to assist the Division/Faculty/School/Project undertake a structured risk assessment in accordance with the University of Tasmania’s Risk Management Policy and risk measurement framework. The document is guidance in nature only and its use in not mandatory. The document may be tailored as required and can also be used as a basis for developing a formal Participant’s Guide to be issued to all those involved in a risk assessment process. The document, once completed, will evidence that a formal risk assessment has been undertaken. The preparation of a formal document may not be necessary depending on the scale of the risk assessment project. The matters highlighted in blue within text boxes provide instructions to participants to aid in preparing for each stage of the risk assessment process. The matters includes in the grey text boxes are guidance in nature and should be deleted once considered. Text in red should be tailored as appropriate. It is envisaged that for each risk assessment there would be a central co-ordinator responsible for administering the process for the Division/Faculty/School/Project, co-ordinating collation, dissemination and receipt of information from participants and preparation of resulting reports and documentation. There are also a range of other documents which have been prepared to assist with the risk assessment process and these are located on the University Audit and Risk intranet site http://www.utas.edu.au/risk-management-audit-assurance/ These include: Risk Management Governance Level Principle (GLP2) Risk Management Policy (CORP 13.1) UTAS Risk Matrix Risk Register Template (updated November 2015) Should you have any specific questions, please contact Alastair McDougall (x1564 Alastair.McDougall@utas.edu.au) Director Audit and Risk. Division/Faculty/School/Project is preparing to undertake a risk assessment in order to identify, assess and document key risks of the Division/Faculty/School/Project. This risk assessment will be conducted in accordance with the approach detailed in this guidance material which has been endorsed by the Executive/Governance Forum. Background and context Guidance (for deletion): Include any necessary background and context relevant to the Division/Faculty/School/Project. This may include: The nature of the operation or activity The environment in which the operation or activity is being conducted – specific influencing factors Why the risk assessment is being undertaken Refer also Appendix C. Risk assessment objectives The objective of this risk assessment is to identify, assess and evaluate the key risks associated with the Division/Faculty/School/Project and formally document outcomes. The outputs of this process will be documented in a Summary Report to be considered initially in draft by relevant Management with the final report to be presented to the Executive/Governance Forum. Purpose of this document The purpose of this document is to brief participants in respect to the process and enable them to fully prepare for their participation. The success of the risk assessment is dependent on active participation from all involved. As such it is important that each participant devotes time to understanding the process and preparing for their participation. University of Tasmania Risk Assessment Guide Division/Faculty/School/Project Risk Assessment Month Year 4 In particular participants will be required to undertake some specific activities during the risk assessment process. These activities are highlighted in this document and include: 2.1 - Project Preparation 2.2 - Risk Identification 2.3 - Risk Analysis 2.4 - Risk Evaluation 2.5 - Finalisation Risk Assessment Participants The process will be conducted through a combination of meetings and off-line activities. The meetings are, scheduled for date and date respectively. Meeting attendees will be: Names of those consulted or workshop attendees if risk assessment process being undertaken as a workshop. The nature and scale of the activity being considered may mean that formal workshops may not be necessary. Risk assessment co-ordinator name has been nominated as the risk assessment co-ordinator and will be responsible for: Ensuring participants are fully briefed on the risk assessment process. General administrative support to the risk assessment process. Supporting participant’s in preparing for relevant phases of the risk assessment process. This includes co-ordinating collation, dissemination and receipt of information from participants and ensuring resulting risk assessment outputs are prepared and presented to relevant forums. Risk Assessment sponsor name has been nominated as the risk assessment sponsor and will provide oversight throughout the process. Should guidance be required in respect to the University’s Risk Management Policy, risk measurement framework or in conducting risk assessments, please contact: Alastair McDougall Director Audit and Risk Alastair.McDougall@utas.edu.au Phone: 03 6226 1564 University of Tasmania Risk Assessment Guide Division/Faculty/School/Project Risk Assessment Month Year 5 2 The risk assessment process The process followed during this risk assessment is visually depicted on the following page. This involves the following key elements: Project Preparation Risk Identification Risk Analysis Risk Evaluation Finalisation. To ensure the process is both relevant and comprehensive to the needs of Division/Faculty/School/Project, the methodology is consistent with the University’s risk management framework and policy and is focused on: Presenting a formal structure of review Recording relevant information in respect to identified key risks Ensuring key risk issues are subject to identification, analysis, evaluation and reporting Assessing existing control effectiveness Assessing residual risk to enable management to consider any further action or resource allocation/reallocation In the balance of this section we provide further detail regarding the process. To assist in understanding the terminology used in this project, a list of key definitions is provided in Appendix A. Guidance (for deletion): While the process may be scaled to meet the specific needs for each circumstance, the process presented in the graphic should be largely followed. Factors to consider in resolving an appropriate scale for the risk assessment process include: The number of people involved in the Division/Faculty/School/Project. Where a broad perspective of views is required, it would be advisable to conduct workshop or group discussions when identifying and evaluating risks. The extent of expected risk exposure to the University/ Division/Faculty/School/Project. The greater the expected risk exposure the greater the rigour required in the risk assessment process. The target audience. In the event that the outputs are to go to parties external to the University or to a formal governance forum or Senior Executive forum within the University then a greater degree of rigour would be advisable. In the event that only a handful of personnel are involved, such as a research project, then while the process should remain consistent there may be opportunity to condense the approach. 6 University of Tasmania Risk Assessment Guide Division/Faculty/School/Project Risk Assessment Month Year University of Tasmania Risk Assessment Guide Division/Faculty/School/Project Risk Assessment Month Year 7 2.1 Project Preparation Objective The objective of this phase is to develop and confirm scope, context and approach for the risk assessment. Process During this phase the following steps are completed: Confirm the need to undertake a structured risk assessment process Establish the risk assessment context – this should be the objectives of what the project, operational unit, school, faculty or division is trying to achieve Collate and review relevant background documentation and prepare any necessary guidance materials to be made available to participants – this guidance is designed to provide all participants with a clear understanding of the process. This document could be tailored to assist with this process Discuss and confirm key risk assessment parameters, including: - Preparing and distributing necessary Participant Guidance or relevant background information - Scheduling meetings (if required) - Identifying factors relevant to the risk assessment via a preparation meeting with Key contact/Project Leader. Identify key personnel to be involved in the risk assessment process to ensure appropriate perspectives are fully considered Participant action required: The preparation carried out during this phase requires all participants to: Review the Risk Assessment Guide to gain a broad understanding of the process, methodology and terminology that will be used throughout the risk assessment process. Be fully aware of the risk assessment context. These are generally the goals or objectives of the Division/Faculty/School/Project. Refer Appendix B. 2.2 Risk Identification Objective The objective of this phase is to populate the standard Risk Register template with identified risks in order to facilitate informed discussion and risk rating during the Risk Evaluation phase. Process During this phase: Participants meet to ‘brainstorm’ key risk issues by reference to Division/Faculty/School/Project objectives. These risk issues should be matters which may constrain the achievement of stated objectives for the University or Division/Faculty/School/Project. This may result in the identification of numerous risk issues. There is consolidation of the brainstormed risk issues into higher level identified risks. This is to ensure that effort is focussed on only key risks. In this regard key risk detail should be captured, documented, appropriately described and assessed. Risks should be appropriately titled and include some brief narrative to describe the risk exposure. There is assignment of risk owners to individual identified risks. Risk owners will be responsible for ensuring the offline population of the standard University Risk Register template for their allocated identified risks. University of Tasmania Risk Assessment Guide Division/Faculty/School/Project Risk Assessment Month Year 8 Participant action required: The preparation carried out during this phase requires participants to: Brainstorm risk issues to be used as a basis for consolidating like themes into identified key risks for inclusion in the standard Risk Register template. In this regard it is noted that: o The number of risks, while not limited, should be manageable in number. By way of guidance any more than approximately 15 may be too many o The focus needs to be on the key risk exposures Assign identified risks to nominated relevant personnel for further detailed analysis and population of the standard University Risk Register template. 2.3 Risk Analysis Objective The objective of the Risk Analysis phase is to populate the Risk Register with relevant risk information. Process During this phase: Nominated risk owners populate the standard Risk Register template with relevant risk information for each identified risk assigned to them Once completed, the draft Risk Register is circulated to all participants for review prior to the Risk Evaluation phase. Participant action required: The preparation carried out during this phase requires: Nominated risk owners are responsible for ensuring that the risk register is populated with the following detail for assigned identified risks: o Potential causes (Hazards) and consequences (Impacts). No more than 5-6 brief issues in dot point form. Potential causes could include both internal and external factors. Potential consequences could include – financial, legal and regulatory, health and safety, reputational, management effort, lost productivity o Consequence and likelihood of inherent and residual risk exposures o Key existing internal controls and mitigations o Any additional internal controls which may be required to reduce risk exposures to acceptable levels – this should form the basis of action planning and resource allocation to reduce risk exposures to acceptable levels All participants to review the populated draft Risk Register and provide feedback to the risk assessment co-ordinator. University of Tasmania Risk Assessment Guide Division/Faculty/School/Project Risk Assessment Month Year 9 2.4 Risk Evaluation Objective The objective of the Risk Evaluation phase is a draft Risk Register which includes risk ratings which have been agreed by participants. Process During this phase: Risk assessment participants meet with nominated risk owners leading a brief group discussion on each identified risk and the preliminary risk ratings Participants collectively agree individual ratings for each identified risk. Each risk should be assessed at both ‘inherent; and ‘residual’ levels and in this regard the risk ratings assigned should be based on a ‘typical’ scenario for the Division/Faculty/School/Project. An assessment of desired ‘Target Risk’ should also be assigned. Refer Appendix D for guidance on each of these terms. Ratings should also be assigned for ‘Controllability’, ‘Control Effectiveness’ and ‘Trending/Outlook’. Refer Appendix D for guidance on each of these terms. Final draft Risk Register is prepared based on the feedback from Participants. Participant action required: The preparation carried out during this phase requires: All participants to review draft Risk Register prior to group discussion Participants meet with nominated risk owners leading a brief group discussion on each identified key risk and the preliminary risk ratings Participants collectively agree individual ratings for each identified key risk Final draft risk register is prepared. 2.5 Finalisation Objective The objective of this phase of the project is a final Summary Report supported by a Risk Register which have been considered by the relevant governance forum. Process The finalisation process is comprised of: Preparing a Summary Report and Risk Register, initially in draft for consideration by the Governance Forum. The Summary Report should provide an overview of key contextual matters, a summary of key risk exposures and heat maps for identified and assessed risks. Guidance (for deletion): The standard University Risk Register template (and excel file available on the Risk Management intranet) will generate some high level output for incorporation into a Summary Report (a standard reporting template is yet to be developed). University of Tasmania Risk Assessment Guide Division/Faculty/School/Project Risk Assessment Month Year 10 Appendix A - Risk Terminology The following risk terminology will be used: Risk Risk is defined as the effect of uncertainty on objectives. Risk assessment Risk assessment is a process that is, in turn, made up of three processes: risk identification, risk analysis, and risk evaluation: Risk identification is a process that is used to find, recognise, and describe the risks that could affect the achievement of objectives Risk analysis is a process that is used to understand the nature, sources, and causes of the risks that you have identified and to estimate the level of risk. It is also used to study impacts and consequences and to examine the controls that currently exist Risk evaluation is a process that is used to compare risk analysis results with risk criteria in order to determine whether or not a specified level of risk is acceptable or tolerable. Consequence The outcome of an event and the impact on objectives. A single event can generate a range of consequences which can have both positive and negative effects on objectives. Initial consequences can also escalate through knock-on effects. Likelihood The chance that something might happen. Likelihood can be defined, determined, or measured objectively or subjectively and can be expressed either qualitatively or quantitatively. Inherent risk Risk rating assessment – a function of the ‘Consequence’ and ‘Likelihood’ ratings. This is an assessment of the risk exposure without reference to specific mitigation strategies or actions. Controllability An assessment to be applied to each identified risk to understand the capacity to influence residual risk exposure. The value of this information is that it assists in informing the nature and extent of mitigations or controls to be implemented. Trending / Outlook An assessment as to how the risk exposure has changed in recent times and how it is expected to change in the immediate future with reference to the prevailing operating environment. Control Effectiveness Is based on a relative assessment of the actual level of control that is currently present and effective compared with that reasonably achievable for an identified risk. This will provide an indicator of whether the University is doing all that it could or should to manage the risk issue. Residual risk is the risk left over after implementation of mitigations or controls. It’s the risk remaining following either; removal of the risk source, modification of consequences, change in probabilities, transferral of the risk, or acceptance of the risk. Residual risk Target risk Target risk is the desired risk exposure after taking into account such matters as: Capacity to influence risk exposure Costs required to implement risk mitigations with reference to anticipated benefits of implementation University of Tasmania Risk Assessment Guide Division/Faculty/School/Project Risk Assessment Month Year 11 Appendix B – Division/Faculty/School/Project objectives As defined in Appendix A, risk is simply the effect of uncertainty on objectives. It is therefore imperative that the Division/Faculty/School/Project objectives are known and understood in order to identify relevant risks. Risk assessment context The objectives of the Division/Faculty/School/Project are to: XXXXX XXXXX XXXXX XXXXX Guidance (for deletion): In practice consideration should be given to those matters which may constrain or prevent from achieving the stated objectives or where opportunity to maximise benefits are forgone or not optimised. 12 University of Tasmania Risk Assessment Guide Division/Faculty/School/Project Risk Assessment Month Year Appendix C – Division/Faculty/School/Project structure and activities Guidance (for deletion): This section is optional but if completed could include any necessary documentation which may assist with the identification and assessment of key risks. This may include: Business model detail/graphic Organisational/project structure Key internal / external influencing factors University of Tasmania Risk Assessment Guide Division/Faculty/School/Project Risk Assessment Month Year Appendix D - Risk assessment parameters Assessing the likelihood ranking The likelihood that the business will be exposed to each specific risk is determined considering factors such as: anticipated frequency the external environment the procedures, tools, skills currently in place staff commitment, morale, attitude history of previous events For the purposes of assessing likelihood the following scale will be used: Likelihood rating Scale Almost certain The event is expected to occur: in most circumstances or commonly repeating or occurs weekly The event will probably occur: in most circumstances or known to occur or occurs monthly The event might occur: say yearly or has a 1 in 20 chance of occurring The event could occur at some time, say: once in every 10 years or 1 in 100 chance of occurring Event may only occur: in only exceptional circumstances or less than a 1% chance of occurring Likely Possible Unlikely Rare 13 University of Tasmania Risk Assessment Guide Division/Faculty/School/Project Risk Assessment Month Year 14 Assessing the consequence ranking Risks are assessed in terms of the consequence of their impact on business objectives. Indirect financial consequences such as reputation, management effort and productivity are also key considerations. The following table is used to guide the assessment of consequences of each identified risk. HR, OHS Service Quality, Operations, Business Interruption and Infrastructure Political, Reputation and Image Environmental and Community Up to $5000 for Faculties, Institutes, Schools, Centres, Divisions and Sections (Up to $500K for a UTAS wide corporate governance risk) or 0.5% of budget. Unlikely to result in adverse regulatory response or action. Injury report and/or first aid only, and/or may include substantial stress event reducing work effectiveness without lost time. An event the impact of which can easily be absorbed through normal activity. Repeat theme complaints at a school level and /or one or more registered formal complaints. Up to 10 recommendations from accreditation/ licensing body. Loss of <1 days lectures or research or other operational activity or work from such activity. Negligible impact business interruption, brief loss of service. Issue resolved promptly by day to day management processes/little or no stakeholder interest. Brief pollution - no discernable impact or measurable impairment - for example, not exceeding published guideline values for normal or background levels. Internally reported. Environmental liability or remediation cost < $A5,000. Small potential for cost impacts 0.5% of budget, no time impact, no quality impact. There may issues that impact on the ability of the University to fully operate services or activities proposed for the building at time of delivery. $5,001 to $50,000 for Faculties, Institutes, Schools, Centres, Divisions and Sections, ($.5m to $2.5m for a UTAS wide corporate governance risk) or 0.5-1% of budget. Minor non-compliances and breaches of Acts, regulations or consent conditions. Not likely to result in regulatory action, may result in infringement notice. Incident reportable to regulatory authorities. Medical Treatment Injury and/or may include substantial stress event requiring professional clinical support. An event, the consequences of which can be absorbed but management effort is required to minimise impact. Minor delivery delays. Service issue causing/contributing to loss of up to 10 EFSLs or loss of research or consultancy project < $10,000. Up to 2 non-compliance recommendations but accreditation/licence not immediately threatened. Loss of 1-5 days lectures or research or other operational activity or work from such activity Local interruption only, service loss for minimum period. Issue raised by students and/or local press/ minor, adverse local public or media attention and complaints. Reputation is adversely affected with a small number of affected people. Transient harm - minor effects on biological or physical environment. Minor short- medium term damage to a localised area or that ceases once the event is over. Environmental liability or remediation cost $A5,000 - 50,000. Small potential for cost impacts 0.5-1% of budget, no time impact, no quality impact. There may issues that impact on the ability of the University to fully operate services or activities proposed for the building at time of delivery. Minor Insignificant Financial, Legal, Commercial Project Catastrophic Major Moderate University of Tasmania Risk Assessment Guide Division/Faculty/School/Project Risk Assessment Month Year Service Quality, Operations, Business Interruption and Infrastructure 15 Political, Reputation and Image Environmental and Community Financial, Legal, Commercial HR, OHS Project $50K-$0.5m for Faculties, Institutes, Schools, Centres, Divisions and Sections, ($2.5m to $10m for a UTAS wide corporate governance risk) or 1-5% of budget. Serious breach of Act, regulation or consent conditions with potential for regulatory action such as issuance of a formal notice, a fine or prosecution. Hospital treatment injury less than 3 days/lost time/ serious temporary disability/minor permanent disability. Significant event, which can be managed under special circumstances. Service issue causing/contributing to loss of 10 - 100 EFSLs, or loss of research or consultancy project ($10,000 - $500,000). More than 2 non-compliance recommendations and /or ongoing accreditation and licensing under immediate threat. Loss of 5 days - 6 weeks lectures or research or other operational activity or work from such activity. Critical service interruption not back in agreed time. Student and or community concern, heavy local media coverage/criticism by NGOs. Reputation impacted with some stakeholders. Moderate harm measurable impairment on biological or physical environment but not affecting ecosystem function. Short-medium term impacts, where the ecosystem will recover quickly and without intervention. Environmental liability or remediation cost $A50,000- 500,000. Medium potential for cost or time impact. 1 - 5% of budget, manageable impact on time, cost, resources and quality. Minimal impact on operation of services or activities proposed for the building. $0.5m to $5m for Faculties, Institutes, Schools, Centres, Divisions and Sections ($10m to $20m for a UTAS wide corporate governance risk) or 5 - 10% of budget. Major breach of Act, regulations, or consent conditions that is expected to attract regulatory attention. Investigation prosecution and/or major fine possible. Single death/ longer term hospitalisation/ permanent disabilities multiple persons. Major event that - with prioritised and focused management - will be endured. Service issue causing/contributing to loss of more than 100 EFSLs/subject viability threatened or loss of some research and consultancy clients. Limited accreditation of Faculty or School with conditions of accreditation and limitations applied. Loss of 6 -13 weeks lectures or research or other operational activity or work from such activity. Critical infrastructure service loss for <1 month. Embarrassment for the University, including adverse media coverage/significant adverse national media/ public coverage/ reputation impacted with a significant number of stakeholders/ breakdown in strategic and/or business partnership. Significant harm - serious environmental effects with some impairment of ecosystem function. Relatively widespread medium - long term impacts, requiring remediation, where ecosystem will recover over time once clean-up has been completed. Environmental liability or remediation cost $A0.5m $A5m. Major potential for cost or time impact. 5 - 10% of budget, will impact on time, cost, resources or quality. Potential impact on multiple work streams, projects or stakeholders. University will need to operate service or activity in another location for an extended period of time or delay commencement of service or activity for >3 months or Practical Completion Date increased by >25%. Above $5m for Faculties, Institutes, Schools, Centres, Divisions and Sections (or above $20m for a UTAS wide corporate governance type risk) or 10% of budget may be considered wilful or negligent by regulator. Significant prosecution and fines likely. May result in significant litigation, including class actions. May jeopardise future approvals, registration, licensing and funding. Multiple deaths/ permanent disability 5 plus persons Extreme event with potential to lead to failure of most objectives or collapse of part of the business. School viability threatened by loss /lack of students or loss of a significant number of research or consultancy clients (more than 10% of budget or 5 clients). Non accreditation of Faculty or School. Loss of 13+ weeks lectures or research or other operational activity or work from such activity. Critical infrastructure service loss for >1 month. Reputation and standing of the University affected nationally and internationally/serious public or media outcry (International coverage)/ Reputation impacted with majority of key stakeholders/ Significant breakdown in strategic and/or business partnerships. Long term harm - Very serious environmental effects with significant impairment of ecosystem function. Long term, widespread effects. Remediation required. Environmental liability or remediation cost >$A5m Major potential for cost or time impact - >10% of budget. Will have an unmanageable impact on time, cost, resources and quality. Potential impact on multiple work streams, projects or stakeholders. University cannot operate service or activity proposed in new/refurbished building. Potential showstopper. University of Tasmania Risk Assessment Guide Division/Faculty/School/Project Risk Assessment Month Year 16 Assessing the risk rating Through this analysis of likelihood and consequence the risk rating for each of the identified risks is then calculated using the product of these rankings. The relationship of these factors and the resultant risk rating is demonstrated in the table below: Consequence Likelihood Negligible Minor Moderate Major Severe Almost certain Mod 11 High 13 Ext 20 Ext 23 Ext 25 Likely Mod 7 High 12 High 17 Ext 21 Ext 24 Moderate Low 4 Mod 8 High 16 Ext 18 Ext 22 Unlikely Low 2 Low 5 Mod 9 High 15 Ext 19 Rare Low 1 Low 3 Mod 6 Mod 10 High 14 Controllability The following three levels are used to rate the capacity of the University to influence the risk: Controllable Organisation has the capacity to significantly influence the risk rating. Partially controllable Not controllable Organisation has some capacity to influence the risk rating. Organisation has limited or no capacity to influence the risk rating. Control Effectiveness Control (or mitigation) is understood to mean: A control is any measure or action that modifies risk. Controls include any policy, procedure, practice, process, technology, technique, method, or device that modifies or manages risk. Risk treatments become controls, or modify existing controls, once they have been implemented. A three tiered self-assessment to be applied to each key risk to understand management’s view of the strength of mitigating actions currently in operation. Satisfactory Controls are strong and operating properly, providing a reasonable level of assurance that objectives are being achieved. Some weakness Some control weaknesses/inefficiencies have been identified. Although these are not considered to present a serious risk exposure, improvements are required to provide a reasonable assurance that objectives will be achieved. Weak Controls do not meet an acceptable standard, as many weaknesses/inefficiencies exist. Controls do not provide reasonable assurance that objectives will be achieved. University of Tasmania Risk Assessment Guide Division/Faculty/School/Project Risk Assessment Month Year Trending / Outlook A three tiered assessment to be applied to each identified risk to understand the trend in risk exposure, in light of recent history and the prevailing environment. Consideration should be given to both internal (Strength and Weakness) and external factors (Opportunity and Threat). Up Recent history and the prevailing environment is tending to increase risk exposure for the organisational unit (i.e. unfavourable for the organisation). Down Recent history and the prevailing environment is tending to decrease risk exposure for the organisational unit (i.e. favourable for the organisation). Stable Recent history and the prevailing environment is not impacting risk exposure to any great extent.