Trust Board papers November 2012 - Barking Havering and ...

The Trust recognises the importance of collecting meaningful and relevant data in a statistical
format so the analysis and trends can be monitored and appropriate action taken. Where
possible both qualitative and quantitative information is sought to inform decision-making, and is
aggregated to provide a holistic interpretation of the risks faced by the organisation via the Board
Assurance Framework and quarterly Aggregated Data reports sent to the Directorates and
reviewed by the Quality and Safety Committee.
Each Directorate has an allocated clinical governance lead that attends the Directorates Board
meetings and can assist with risk issues if required, and a named complaints manager that can
offer advice and guidance. Audit advice and guidance can be provided through the Trust’s Audit
Department. Each Directorate also has financial and human resource support from named leads.
It is the policy of the Trust that the impact of its risk management processes should be monitored
continuously via appropriate, quantified key indicators, capable of indicating progress over time.
The following key performance indicators will be used to monitor implementation at both a
corporate and local level.
It is the policy of the Trust that comprehensive quarterly monitoring reports on the identified risks
are produced and considered at each meeting of the Audit Committee. Copies of the reports are
also made available at the appropriate level of detail to internal stakeholders including all levels of
management with responsibilities for risk management and to relevant external stakeholders as
requested.
The matrix below identifies all the monitoring of this policy which will be carried out, how
this will be done (e.g. audit), frequency, who is the lead person responsible for ensuring
that the monitoring is carried out, where reports from monitoring are reported, who
(individual/group/committee) is responsible for ensuring that any gaps or deficiencies are
recorded on an action plan which is followed up and who is responsible for ensuring that
implementation of any changes which follow the action plan completion are implemented
and, where appropriate, information disseminated within the Trust to enable learning from
the experience
What will be
monitored
and/or
Standard To Be
Achieved
How/Method Frequency Lead Reported to Deficiencies/gaps
recommendations
and action plans
followed up by
Implementation
of any required
change
responsibility
of
In date risk
management
strategy in
place with
risk
management
structures
described
Significant
risk register
reviewed by
Audit
Committee
Board
Assurance
Framework is
scrutinised
by the Audit
Strategy in place
and approved
Assurance that
the Trust Board
are aware of the
organisations
significant risks
Minutes of
meetings
evidence review
Every two
years
Quarterly
Clinical
Governance
Director
Audit
Committee
Audit
Committee
Relevant
Directorates
Quarterly Trust Board Relevant
Directorates
/ Relevant
Executive
Policy and
Ratification
Committee
Audit
Committee
Audit
Committee
Barking, Havering & Redbridge University Hospitals NHS Trust Page 24 of 40
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