Risk Management Annual Report - August 2009 ... - NHS Lanarkshire

Patient
Safety
Patient
Focused
Services
Risk
Management
Clinical
Effectiveness
Fairness &
Consistency
Continuous
Improvement
Risk MANAGEMENT
Annual Report
2008 – 09
Competence &
Continuous
Learning
Governance &
Leadership
Research &
Development
Lead Executive Director:
Report Prepared by:
Dr Alison Graham, Medical Director
Mrs Carol McGhee, Corporate Risk Manager
Submitted to the RMSG: June 2009
Submitted to the Audit
Committee:
June 2009
Endorsed by the RMSG: June 2009
Submitted to the NHSL
Board:
July 2009

Risk Management
Annual Report
2008 – 09
Contents
Introduction 3
Risk Management Department 4
Performance for Year 2008 – 09
Risk Management Strategy Review 5
Organisational Structure: Clinical Governance and Risk 6
Management
Compliance with NHSQIS Standards 6
Electronic Risk Management System: Datix 7
Risk Management Guidance Manual 9
Risk Register Process and Development 10
Training, Education and Development 12
Internal and External Audit 13
Incident Reports 13
Number of Incidents Proportionate to the Operational Divisions 13
Scottish Patient Safety Programme (SPSP) 15
Committees and Groups 15
National and Local Developments 16
Work Plan for Year 2008 – 09 18
Appendices 19
Appendix 1a & 1b: Summary of Risk Management Work Plan Outcomes
2008 – 09
Appendix 2:
Summary of Risk Management Prospective Work Plan
2009 – 10
Contents
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Risk Management
Annual Report
2008 – 09
Introduction
The duty of the NHSL Board is to deliver healthcare both within the law, and without
causing harm or loss to the organisation and all it represents. It does this by ensuring
there is a robust Governance Framework, and operates a system of Internal Control and
Risk Management.
Good risk management has the potential to impact on performance improvement,
leading to:
◦ improvement in service delivery
◦ more efficient and effective use of resources
◦ improved safety of patients, staff and visitors
◦ promotion of innovation within a risk management framework
◦ reduction in management time spent ‘fire fighting’
◦ assurance that information is accurate and that controls and systems are
robust and defensible
The key objective in risk management is to eliminate or control significant risk to an
acceptable level, by creating a culture of risk management founded upon assessment
and prevention rather than reaction and remedy. Staff are empowered to use their
professional judgement in deciding which risks are significant.
The complete elimination of risk will not always be a feasible goal for the Board, however
in certain circumstances, calculated risk management will be required to achieve creative
or innovative solutions that will help to improve the services to patients.
In seeking to deliver these objectives, the Board Risk Management Steering Group will
advise on/oversee and/or support the:
◦ implementation of the Risk Management Strategy
◦ management of risk within the Board
◦ compliance with NHS QIS standards
◦ risk register process
◦ risks highlighted through the organisation
◦ complaints and receive assurance on the implementation of corrective action
◦ assessment of the impact of new legislation
The last few years have seen substantial work both at strategic and at an operational
level to identify risks and to put in place control measures to mitigate their impact. The
contribution of staff at all levels across the Board has been a major factor in bringing
us to where we are now, with well developed processes for the management of risk,
including through comprehensive strategic and operational risk registers.
Continued contributions will be essential as we respond to the many challenges NHSL
will face in delivering on targets and aspiration in the years ahead.
Introduction
3

Risk Management
Annual Report
2008 – 09
Risk Management Department
The Risk Management function has been fully integrated into the Clinical Governance
and Risk Management Department which is part of the Medical Director’s directorate,
providing appropriate professional and competent clinical effectiveness, research and
development and risk management advice, guidance and support to the NHS Board,
its managers and staff. The Clinical Governance and Risk Management Department also
manages the Scottish Patient Safety Programme for NHS Lanarkshire.
The Risk Management staff has increased from 3 wte to 4 wte following successful
recruitment this year to the agreed level of resource required for the department: 1 wte
Risk Management Co-ordinator:
1 wte Corporate Risk Manager
1 wte Risk Management Co-ordinator
1 wte System Administrator
1 wte Secretarial/DATIX Support
Risk Management Department
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Risk Management
Annual Report
2008 – 09
Performance for Year 2008 – 09
Risk Management Strategy Review
The NHSL Risk Management Strategy was reviewed in September 2006, consulted
on through the organisation and endorsed by the Risk Management Steering Group
in December 2006. Further scheduled review was undertaken between October –
December 2008 as part of the updating of the Risk Management Guidance Manual.
The Strategy sets out:
◦ Risk Management Guiding Principles
◦ Aims & Objectives
◦ Scheme of Delegation
◦ Implementation of the Strategy & Framework
◦ Communication of the Strategy Framework Progress
◦ Risk Management Steering Group Terms of Reference
Implementation/Communication
The Strategy has been extensively communicated through Strategic, Divisional &
Operational Groups/Committees and is also available via the Risk Management web
page on Firstport, with wider direct availability across all wards and departments via the
Risk Management Guidance Manual and associated CD Rom.
The dedicated Risk Management web page has been live since May 2007 and enables
access to the Strategy, Risk Management Annual Reports, Annual Work Plans, RMSG
minutes, forthcoming events, relevant risk, safety and governance articles, a ‘How To?’
section and direct links to other associated internal and external web sites:
◦ National Patient Safety Agency (NPSA)
◦ Health & Safety Executive (HSE)
◦ Willis – Clinical Negligence & other Risks Indemnity Scheme (CNORIS)
◦ Occupational Health & Safety (SALUS)
◦ Scottish Patient Safety Alliance (SPSA)
◦ Internal Scottish Patient Safety Programme Page
◦ Institute for Health Improvement (IHI)
◦ NHS Quality Improvement Scotland
◦ DATIX
◦ Internal Medical Education
◦ Internal Clinical Governance
This year, effective from February 2009, the Caledonian University has been added as a
direct link for staff seeking out courses to meet their risk management and governance
training needs, resulting from several requests made to the department from senior
managers.
Performance for Year 2008 – 09
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Risk Management
Annual Report
2008 – 09
The risk management web site was subject to annual review in July 2008 with changes
made to improve the layout and the signposting to other relevant sites. For the period
between November 2008 – March 2009 the ‘hits’ to the site improved from an average
of 230 hits for the same period 2007 – 08 to 1,450 (this excludes the 2 designated
page administrators recorded ‘hits’ to reduce bias). The range of users across NHSL has
continuously increased as has the subject/page being accessed within the web site.
Organisational Structure: Clinical Governance & Risk Management
This year, the Clinical Governance & Risk Management Structure has been subject to
re-organisation, facilitated through a set of development sessions. Concurrently, the
Joint CHP Clinical Governance & Risk Management structure was evaluated, reviewed
and an improved structure implemented.
The reporting function for the Risk Management Department will remain as outlined
in the Risk Management Strategy, with little impact on the Risk Management Steering
Group.
The Audit Committee has overall responsibility to evaluate the System of Internal Control
and Corporate Governance, including the Risk Management Strategy, Framework and
Processes.
Compliance with NHS QIS Standards
The last NHS QIS Peer Review of the Clinical Governance & Risk Management Standards
was undertaken in September 2006 with the expectation that the process would be
repeated every 3 years. In preparation for the September 2009 review, a Standards
Improvement Group was set–up in May 2008, chaired by the Director of Nursing &
AHP’s. Executive Leads, Programme Leads and overseeing Committees and Groups
were identified. All Programme Leads were core members of the Group and a series of
briefing sessions were held to update Executive Leads.
For Standard 1a Risk Management, the following applied:
Executive Lead: Dr A Graham, Medical Director
Programme Lead: Mrs C McGhee, Corporate Risk Manager
Overseeing Group: Risk Management Steering Group
The assessed level of compliance for each standard is measured against a numerical
value ranging from 1 – 4 (development through to review stage).
The Risk Management Standard was assessed as Level 1 in the 2005 NHS QIS Interim
Review. The self–assessed score prior to the 2006 review was assessed at Level 2 and
this was substantiated by the peer review undertaken in September 2006.
Within the year 2007 – 08, the Clinical Governance Manager undertook an independent
review of the Risk Management Standard (1a), as agreed through the Work Plan,
using the same self–assessment tool and guidance. At that point, the self–assessment
outcome confirmed attainment of Level 3. Subsequent to this, improvement work has
continued and resulting from both internal peer assessment and benchmarking with
other Health Boards (Lothian, Forth Valley, Dumfries & Galloway, Scottish Ambulance
Service), the assessed level as at March 2009 was Level 4, with discussion scheduled for
May and June through the RMSG.
This improvement contributes to the overall performance against the 2008 – 09 HEAT
target and Corporate Objectives.
Performance for Year 2008 – 09
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Risk Management
Annual Report
2008 – 09
Electronic Risk Management System: DATIX
Audit to Review the Electronic Management System: DATIX
NHSL currently has a license that covers 6 DATIX modules: Incident Recording, Risk
Register, Complaints, Claims, PALS and Standards.
As part of the overall review of the existing risk management guidance, the DATIX system
was also subject to further audit of effectiveness reviewed in light of the findings.
A report based on the following outcomes was received by the RMSG and improvements
supported and subsequently implemented:
Incidents
The incident module has been in place across Primary Care since 2003 and NHSL–wide
since 2006. With the exception of PSSD, all incidents are now recorded electronically
on the system. PSSD record incidents on paper forms with this information then input
to the Datix system.
Current incident recording process:
Any member of staff witnessing or involved in an incident of any type records
this electronically on the DIF1 (Datix Incident Form).
Incident goes in to holding area ready for verification using a DIF2 electronic
form.
The verifier is the line manager of the individual reporting the incident.
Once verified the incident is automatically added to the main database.
Anecdotal evidence suggested that members of staff completing the DIF1 and those
verifying the DIF2 forms are finding some of the fields confusing and can often wrongly
categorise a number of fields. In July 2008 the Risk Management Department carried
out an audit of completed DIF1 and DIF2, which had remained unverified, to determine
if this is the case and, if so, which fields may require to be reviewed. The results of this
audit established that:
ACTION:
The name of the person involved in the incident was frequently left blank. This
is now a mandatory field, with help text to guide those completing the form.
Many members of staff completing the DIF1 form were completing the Division and
Directorate fields incorrectly. The system is in the process of being reconfigured to
reflect the current Divisional and Directorate structures. ‘Combo’ links reduce the
number of options at each field which should in turn reduce the number of errors.
The ‘type’ of incident is the first window which categorises the risk, if either this field
and/or the next window ‘category’ are completed incorrectly subsequent reports
will be inaccurate. A revised ‘type’ and ‘category’ dataset has been developed and
is to be tested with members of staff recording incidents and with staff who draw
reports from the system.
Performance for Year 2008 – 09
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Risk Management
Annual Report
2008 – 09
The rating of an incident determines the subsequent communication and investigation
levels. Between December 2007 – November 2008, 10% of incidents were rated
with the remaining 90% without rating this may result in poor communications and
investigation levels.
ACTION:
In future, rating will become a mandatory field with the member of staff
recording the incident rating it. This action is in line with the National Patient
Safety Agency (NPSA) guidance and was agreed by the Risk Management
Guidance SLWG. To ensure staff are able to rate the incident, all staff will receive
an aide memoir demonstrating the process. In addition, there will be links from
the incident form to rating guidance.
The incident will only be added to the main database once there is agreement
between the person recording, rand rating the incident and the verifier.
More than a third of incidents remain in the holding area each month, therefore
remaining unverified. One possible outcome of is that incidents are identified but
may not be investigated and timely remedial action taken as a result.
ACTION:
The Risk Management Guidance (SLWG) has agreed a maximum period of 5
working days for incidents to remain in the holding area. The timescales will be
monitored by line managers and governance structures.
Template reports are currently being designed which reflect the generic incident reports
developed by the Risk Management SLWG. This will support committees to provide
assurances on risk management.
In addition to incident management template reports, the system is being configured
to produce reports which will allow NHSL to monitor the risk management key
performance indicators developed by the Risk Management SLWG.
Risks Register
Currently risks are placed on registers in the Datix main application. The Risk
Management Department is currently configuring the web based module so that in
future risk registers will be entered and managed using the web interface.
The Risk Management SLWG agreed a risk escalation process including questions to
be answered at each escalation stage; these have been incorporated into the web Risk
Form. This will allow NHSL to be reassured that risks are being managed at the correct
level in the organisation.
Complaints
Complaints across NHSL are managed through the complaints module. Recent changes
to ISD dataset requirements have resulted in an upgrade to the system to version 9.3a.
This will provide ISD with the revised dataset information from mid January 2009.
Performance for Year 2008 – 09
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Risk Management
Annual Report
2008 – 09
Claims
Having reviewed the claims module there are no changes which could enhance the
module.
PALS
The PALS module allows NHSL to gather information which may be helpful in monitoring
services and which identifies areas where improvements can be made, which can in
turn help avoid possible complaints or claims. The module is currently being trialed and
will be reviewed during 2009.
Standards
Initially this module will be set up to manage the QIS Risk Management Standards. QIS
are currently in discussion with Datix to devise a link from NHSScotland Board's Datix
systems to the QIS database. It is hoped that this will operate in a similar way to the ISD
and Datix complaints module.
General Set–Up
A trigger alert is an automated notification in the form of email which is sent when a
particular field in Datix has been completed matching agreed criteria. A series of trigger
alerts are in place, effective from April 2009, based on the communication processes
and criteria agreed by the Risk Management SLWG. The trigger alert will support
communication but will not take the responsibility for communicating incidents from
members of staff.
Risk Management Guidance Manual
Previously identified through audit as a priority, a Short–Life Working Group was
convened to review existing polices, procedures, guidance, and to identify other areas
for improvement. A full set of improved guidance was produced to further promote the
concept of risk management and set out good practice in managing risk effectively. It
also outlines the key roles and responsibilities of managers and directors in improving
the corporate approach to managing risk. Additionally, it introduces a range of tools,
techniques and checklists to help managers, identify, record and manage risk in a
systematic way.
The Guidance Manual has been produced and launched in hard copy with an attached
CD ROM. Additionally, each section is available on the Risk Management web page on
Firstport: Firstport > Corporate Services > Risk Management.
The Guidance includes:
Foreword by the Chief Executive
Introduction to the Guidance, Short Life Working Group Terms of Reference
Risk Management Strategy
Why Report Incidents
Critical Incident Review using Root Cause Analysis
Investigation Report Writing
Why Develop Risk Registers and How To
Key Performance Indicators
Feedback Mechanism
Performance for Year 2008 – 09
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Risk Management
Annual Report
2008 – 09
The Guidance sets out:
NHSL approach to reporting, recording, managing, investigation, reporting on
outcomes, learning lessons regarding incidents.
The Risk Register section clearly sets out the development process, grading based
on the NHS QIS/AS/NZ Standard Matrix and the escalation process.
Key Performance Indicators (KPI) reporting will be through the RMSG.
In support of the Guidance, a revised and improved ‘Record & Learn’ was distributed
to every member of staff within NHSL attached to payslips in March 2009 and forms
part of the Corporate Induction Information Pack for all new staff. The production of a
supporting poster has commenced and will be displayed in all clinical and non–clinical
areas. The poster has an attached designated polythene pocket designed to hold and
display incident data produced from the DATIX system to support sharing of trend
information and performance against the Key Performance Indicators.
Risk Register Process & Development
Strategic Risk Register
NHSL have an established Strategic Risk Register around the core areas of Governance:
◦ Corporate Governance
◦ Staff Governance
◦ Financial Governance
◦ Health & Clinical Governance
The Risk Register has been monitored and reviewed throughout the year and overseen
by the Risk Management Steering Group.
The Strategic Register identifies high level risks for NHS Lanarkshire that have the
potential to undermine the ability to meet the corporate objectives and include:
◦ Child protection
◦ Clinical service sustainability
◦ Prevention and containment of infection/environmental hazards
◦ Compliance with statutory requirements
◦ Robustness of corporate objectives and performance management systems
◦ Engagement with internal and external stakeholders
◦ Timing of financial allocation through NRAC
◦ External factors affecting financial balance
◦ Financial control framework assurance
◦ Workforce information & planning
◦ Provision of safe working environment
◦ Effective implementation of policies on Diversity
◦ Provision of adequate staff training
◦ Sickness/absence
Performance for Year 2008 – 09
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Risk Management
Annual Report
2008 – 09
Additional risks escalated to the Strategic Risk Register include HAI risk, National Fraud
Initiative implementation risk, Medical Workforce risk specific to the implementation
of MMC, and the recognition that the Year End Finance Surplus Exceeds Threshold for
Carry Over.
The Strategic Risk Register is managed via the electronic DATIX system and the process
for review, changes, production of reports is currently facilitated by the Corporate Risk
Manager on behalf of the lead Executive Directors.
The Strategic Risk Register is part of the information considered in the development of
the Annual Internal Audit Plan.
Divisional Risk Register(s)
The 3 Operating Divisions present their Risk Registers to the RMSG on an annual basis as
agreed through the Schedule of Reporting. The Divisional risk registers are monitored
through existing management and performance structures. The monitoring and review
process is now fully owned by the Divisional Management Teams. This enables best
practice in reviewing/amending/changing the Risk Register with the Management Team.
Locality and Clinical Divisional Risk Registers
Within this year, the CHP localities and the Acute Clinical Divisions have identified their
risk profiles which have been set out as risk registers and monitored through their
respective management and performance systems. This process is evolving and will be
monitored through the DATIX system and KPI’s.
Corporate Services Risk Registers
The Property & Support Services Directorate and the eHealth Directorate developed
and presented their Risk Registers to the Risk Management Steering Group and are
working towards development of specific function registers within the Directorates.
Shared Risk Management
The North Lanarkshire Partnership Board recognised the need to have a shared approach
to identifying the risks that would undermine the success of the implementation of the
Community Plan that was dependent on many services, including Health. A Risk Register
was developed by all stakeholders (Police, Health, Fire Service, Voluntary Service, Local
Authority) and submitted to the NLP Board in 2007. A joint annual review has been
scheduled for April 2009.
Additionally, as agreed through the single–outcome agreements, the NLP Board have
initiated a Short–Life Steering Group to advise on a joint approach to risk assessment
and risk management planning for all within Lanarkshire receiving Community Care.
This group have addressed:
◦ Existing risk assessment tools in routine working practice
◦ Shared risk assessment and risk management in the event of identifying
triggers that could lead to an adverse incident or near miss
◦ Joint response to adverse incident or near miss
◦ Grading of adverse incidents or near–miss
◦ Shared investigation approach
◦ Governance/reporting structures
Performance for Year 2008 – 09
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Risk Management
Annual Report
2008 – 09
A final report will be received by the NLP Board in June 2009 to work towards
implementation of the systems and processes that will be critical to effective joint risk
management for those receiving community care.
The Risk Management Staff from North Lanarkshire Council, South Lanarkshire Council
and NHS Lanarkshire are meeting frequently to improve joint risk approach. Outcomes
impacting on the NHSL Strategy will be considered and changes made to reflect
improvements.
Training, Education & Development
Risk Management, including incident/accident reporting, is core to the NHSL
Corporate Induction Programme, delivered via Organisational Development. This
programme is delivered on Monday and Tuesday of every week for all new employees
including bank staff. On joining the organisation and attending the Corporate
Induction, the opportunity was taken by the Risk Management Co–ordinator to
undertake an audit of the content of the risk presentation. The outcomes indicated
that no material change was required.
Local sessions development and maintenance of Locality Risk Registers continue to
be undertaken on an ad hoc basis.
As part of the implementation of the web–based module within the DATIX system,
there was a series of demonstrations of the system and re-iteration of the Incident
and Accident Reporting requirements. Ad hoc training continues to support this
as staff change positions, new staff are employed and have verifiers role. This is
now managed on a 1:1 basis as the initial cohort of staff have been trained. Group
sessions have extended this year to:
◦ Health Records Senior Manager Group
◦ Infection Control Team
◦ Locality Management Teams
◦ Information Governance Sessions
◦ Older Peoples Services Clinical Governance Group
◦ PSSD dedicated staff on reporting facility
◦ Pharmacy Managers
◦ Community Dental Teams
The Occupational Health & Safety Team deliver a variety of in–house risk training
both accredited training (IOSHH) and in response to department/organisation
needs.
The DATIX system is linked to the DOTS medical staff training/induction
programme.
Through the Medical Education Department, the Systems Administrator continues
to deliver demonstrations on the DATIX system and an overview of clinical incident
reporting for both junior medical staff and Consultants.
A series of awareness sessions have commenced across the Management &
Governance Groups to launch the revised Guidance Manual.
Performance for Year 2008 – 09
12

Risk Management
Annual Report
2008 – 09
Internal & External Audit
In partnership with the Internal Audit Consortium (Bentley Jennison), a thematic review
was undertaken on the risk maturity of NHS Lanarkshire risk system, as part of a wider
benchmarking exercise across a large number of clients. The interim report will be
presented to the Audit Committee in June 2009 and an improvement plan will be
agreed if required. The final benchmark report is expected in September 2009.
Incident Reports
This is the third year that NHS Lanarkshire has had a global view of all incidents and/
or accidents reported with quarterly trends. The report does not include data from
South CHP: Cambuslang/Rutherglen Locality, or North CHP: North Locality (northern
corridor), as this is still held by Greater Glasgow Health Board area. However, this data
will be collated within the year 2009 – 10, effective from 1 st April 2009 as the operational
management of this Locality transfers to NHSL. Preparatory work has been undertaken
and agreed with the General Managers, Health & Safety, Locality Management Teams
and Risk Management to facilitate this.
As at 31 st March 2009, there was 13,965 incidents/accidents recorded within the
DATIX system for the period 1 st April 2008 – 31 st March 2009. Additionally, there are
approximately 800 maternity clinical incidents held locally (awaiting specific DATIX
module).
There has been no real change in the distribution of incidents. The data for this year
demonstrates that 75% are attributable to non–clinical incidents and 24% attributable
to clinical incidents, including near–miss reports, as compared to 70% and 30%
respectively for year 2006 – 07 and 76% and 24% for the year 2007 – 08.
Figure 1: Outlines the number of incidents proportionate to the
Operational Divisions:
1114 1
1202
Acute Operating Division
Community Health Partnership North
1692
Community Health Partnership south
Corporate services
NHs Lanarkshire Board
9259
Sixty–one (61) incidents/accidents were RIDDOR reportable as compared to 55 in 2007
– 09 and 36 in 2006 – 07.
Performance for Year 2008 – 09
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Risk Management
Annual Report
2008 – 09
Figure 2: Incident/Accident Reporting Trends per quarter for the past 3 years
*Corporate Services include IM&T, PSSD, Board, etc
The top ten reported category of incident/accident occurring across NHSL is set
out in Table 1:
Category 2006/07 Category 2007/08 Category 2008/09
Slips, Trips & Falls 4039 Slips, Trips & Falls 4937 Slips, Trips & Falls 4484
Violence/Abuse/
Harassment
1259 Violence/Abuse/
Harassment
1823 Violence/Abuse/
Harassment
1808
Other 729 Other 531 Other 1530
Blood or Blood
Products
Transfusion
Medication Errors:
Prescribing (144)
Dispensing/
Preparation (102)
Administration
(198)
487 Blood or Blood
Products
Transfusion
444 Medication Errors:
Prescribing (156)
Dispensing/
Preparation (221)
Administration
(342)
346 Problem with
Records
754
719 Medication Errors:
Prescribing (189)
Dispensing/
Preparation (206)
Administration
(336)
731
311 Investigation 324
Investigation 320 Problem with
Records
Hit by/Against 266 Hit by/Against 287 Absconded 321
Object
Object
--------------- 204 Investigation 242 Hit by/Against 265
Object
Contact with 198 Contact with 219 Contact with 214
Needle or Other
Needle of Other
Needle or Other
Sharps
Sharps
Sharps
Absconded 164 Accidental
Damage/Loss
to Belongings/
Property
176 Accidental
Damage/Loss
to Belongings/
Property
*Other includes: bed management, staff shortages, trolley waits, etc
190
Performance for Year 2008 – 09
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Risk Management
Annual Report
2008 – 09
Scottish Patient Safety Programme (SPSP)
The Corporate Risk Manager is a core member of the leadership workstream and a
core member of the team identified to undertake the ward/department Walk Arounds.
There has been significant success in achievement within each workstream, including
the Safety Briefings, to reduce risk to patients as reported through NHSL Patient
Safety Reports. This work was shared across NHSL and with partners at the successful
internal ‘Strengthening Quality’ event. Subsequent to demonstration of this success,
NHS Lanarkshire have been invited to present on 3 out of 4 clinical workstreams, 1
leadership workstream and 1 programme management workstream, at the National
Learning Session scheduled for May 2009.
Work has commenced on the development of an incident reporting form to record
adverse events identified from the case note reviews. Whilst this work has been primarily
undertaken in the Acute areas, early discussions are underway to assess the feasibility of
a single-system approach to patient safety, for example high risk medications.
Committees & Groups
The role of the Corporate Risk Manager at key NHSL Committees/Groups continues to
be key to the governance function and is a member of the following:
◦ Risk Management Steering Group
◦ Health & Clinical Governance Committee
◦ Health & Clinical Governance Steering Group
◦ Audit Committee
◦ Lanarkshire Infection Control Committee
◦ Occupational Health & Safety Management Group
◦ Fire Committee
◦ DATIX User Groups
◦ NHSL Business Continuity Group
Additionally, the Corporate Risk Manager attends:
CHP North Divisional Partnership Group
CHP South Divisional Partnership Group
Acute Divisional Management Team
Acute Clinical Board
Acute Risk Groups
CHP Joint Clinical Governance & Risk Management Committee
CHP North Quarterly Locality Performance Reviews
Clinical Governance & Risk Management Standards Improvement Group
Positive Patient Identification Group
Performance for Year 2008 – 09
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Risk Management
Annual Report
2008 – 09
The Risk Management staff attend many Divisional Groups and Short–Life Working
Groups to advise on Risk Issues and support the implementation of the Strategy and
external assessments/audits.
Other key groups essential to the development and leadership for Risk Management
include:
◦ National DATIX Group
◦ NHS QIS Joint Clinical Governance & Risk Management Network
◦ NHS QIS Risk Managers Network
◦ Institute of Risk Management
◦ Institute of Health Service Management
◦ ALARM
National & Local Developments
NHS QIS Endoscopy Decontamination Incident Reporting
NHS QIS, through the Safer Today – Safer Tomorrow Report 2006 – 07, identified the
need to review and improve incident reporting across Scotland. They invited NHS risk
managers to participate in 4 unique workgroups. NHSL supported the Corporate Risk
Manager in participating in the group identifying data sets. The outcomes from this
group identified that concurrent with the monitoring of decontamination incidents
occurring across Scotland that there would be a focus on working with Health Protection
Scotland to take this forward.
Three Health Board areas (Lanarkshire, Lothian and Glasgow & Clyde) were invited to
participate in the development and piloting of a data set specific to incidents relating to
decontamination within endoscopy units. This was undertaken over the period January
– December 2008.
The findings were limited as only 2 health board areas continued participation (Glasgow
withdrew).
The final report is being collated by NHS QIS with a presentation from the Risk Managers
from Lanarkshire and Lothian presenting early findings to the CG&RM Network Group
in preparation for the receipt of the report and recommendations.
The findings will be reported to the RMSG and the NHSL Endoscopy Steering Group on
receipt of the final report.
Developing a Model of Governance & Risk Management within GP Practice
The Corporate Risk Manager and 2 Practice Managers within CHP South have had early
discussions to develop and implement a model of Risk Management within independent
GP Practice.
This work has continued and evolved to involve the Medical and Dental Defence Union
(MDDUS) as partners in developing learning sessions for Independent practitioners on
the feasibility of the use of electronic systems (DATIX) to support risk management in
Independent Practice.
Performance for Year 2008 – 09
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Risk Management
Annual Report
2008 – 09
A review of the DATIX system has been undertaken by a Practice Manager (East Kilbride
Locality), to assess the feasibility of use within practice, the feasibility of independent
licence purchase, with a view to further discussion on extending the NSHL licence. A
Short–Life Working Group has been agreed through the Medical Director and will be
set–up to commence in September 2009. Representation has been agreed and will
include MDDUS, GMP’s Practice Advisors, Medical Director, Practice Manager and Risk
Management.
Publication of the NHSL Risk Assessment for Disclosure
The development of this risk assessment tool enables NHSL to apply a sound system to
manage disclosure checks based on fair, consistent and accountable decision–making
on employment, while ensuring protection of patients is maximised and that the rights
of prospective employees in relation to disclosure are upheld.
The tool and supporting protocols have been applied and tested over a 2 year period
resulting in an established and reliable system which is ‘in Press’ to be published by the
British Journal of Healthcare Management in June 2009. The authors are Anne–Marie
Carr, Associate Nurse Director (Bankaide), Carol McGhee, Corporate Risk Manager and
Kelly–Anne McKendrick, Personnel Officer.
The Corporate Risk Manger will be scheduled to deliver a presentation on the sharing of
the development process of the risk assessment tool and the outcomes to the CG&RM
Network before end of 2009.
A summary of the progress against the Work Plan 2008 – 09 is attached in Appendix 1
and performance graded by the following coloured symbol:
BLUE
GREEN
AMBER
RED
Completed
On Target
Delayed
Unlikely to be achieved
Performance for Year 2008 – 09
17

Risk Management
Annual Report
2008 – 09
Work Plan for Year 2008 – 09
The key developments for the forthcoming year are driven by, and/or underpin:
NHSL Annual Accountability Review
Local Delivery Plan
Corporate Objectives
NHS QIS Standards
Internal & External Audit Reports
Risk Management Steering Group Requirements
Emerging Priorities from NHSL Strengthening Quality Event
The Work Plan forms the basis of the Department Team Meetings and is agreed,
monitored and overseen by the members of the Risk Management Steering Group.
The focus this year will be on:
Key Performance Indicators and Outcomes
Outcomes from CIR to inform top 3 NHS systemic failures
Changing the approach to the DATIX training for access, delivery and
evaluation
Implementing web-based risk register and monitoring effectiveness
Populating and testing the standards module on DATIX
Integration of data with other clinical data to improve Board reporting
Reviewing codes for recording of Violence/Abuse/Harassment
A summary of the prospective Work Plan for 2009 – 2010 is outlined in Appendix 2.
Work Plan for Year 2008 – 09
18

Risk Management
Annual Report
2008 – 09 Appendix 1a
Ref. Recommendation(s) Management Action(s)
2.01 A. Management ensure that
an up-to-date documented
reporting structure and
escalation procedure is
developed and that it is
included as part of the Risk
Management Guidance
Manual.
The NHSL Risk Management
Guidance Manual will
include procedures for
reporting and the escalation
procedures.
B. Management ensure that all
approved groups/committees
for the discussion of incidents,
and implementation of
planned action arising from
incidents, meet at the agreed
time period.
All partnership groups are
in place as per the agreed
Locality Partnership Group.
C. Management should ensure
that all incidents are
recorded timeously and that
contingency arrangements are
put in place when the agreed
inputer is not available.
Within Localities there
has been a contingency
plan effective since 2005.
The Risk Management
Department fast–tracked the
roll out of the web system
within Hamilton Locality
and the CHPS Managers
agreed to cross cover for any
outstanding backlog.
Within the Acute Division,
all back logging was
undertaken over a 3
month period by the RM
Department Oct – Dec 2006
with no known outstanding
backlog.
PSSD have an internal
contingency plan to
maintain inputting.
Management
Comments
In general, the audit has
identified some areas
for improvement at
operational level whilst
acknowledging the
progress at Strategic and
Divisional Level. In terms
of incident recording
and reporting, there is
a demonstrable month
on month increase in
incident reporting.
Management accept that
this was an exceptional
situation at a point in
time resulting from
both organisation
change and sick leave
within the identified
locality, not expected
to recur, following full
implementation of the
web system.
Responsible
Officer(s)
Corporate Risk
Manager on Behalf
of the Divisional
Directors.
CHP Directors
PSSD General
Manager
Implementation Date Performance
Fully implemented by
December 2008.
(includes writing,
consultation, testing,
endorsement,
printing, launching
and refreshing of
procedures).
Completed
Completed
Appendix 1a
19

Risk Management
Annual Report
2008 – 09
Ref. Recommendation(s) Management Action(s)
2.02 A. Management ensure that all
staff verify the incidents on
DATIX, are made aware, and
given the appropriate training,
of the need to complete the
risk grading section entry.
All verifiers are familiarised
with the grading facility
within DATIX during the
training designed for
verifiers only. NHSL requires
to agree and set out the
grading procedure and
identify responsible persons
within the Risk Management
Guidance Manual.
B. Management ensure that all
incidents are risk graded and,
if appropriate, are included in
the operational, divisional or
corporate risk register.
Set–out the escalation
criteria/procedure of risk to
the risk register through the
Risk Management Guidance
Manual.
C. Management ensure that
all departments maintain
a local risk register. We do
recognise that there could
be no entries made for a
considerable period of time.
The risk register should also be
reviewed on a regular basis, at
least annually. If there are no
entries, then the risk register
should be notated as such.
The Risk Management
Work Plan will outline
developments in the Risk
Register Process for 2008–
2009, which will ensure all
GM’s for Acute, Localities
and Corporate Services.
As key risks emerge within
services, the opportunity
will be taken to set–up a risk
register.
Purchase of the Web–based
Risk Register Module within
DATIX to improve access
across NHSL in development
of their own risk registers
Management
Comments
Management have
agreed that each division
and directorate/locality
will have a risk register
in place reflecting their
relevant activities and
service areas. These
registers will be actively
maintained and updated
at regular intervals.
Partial completion with
work in progress in all
areas identified within the
Work Plan.
Responsible
Officer(s)
Corporate Risk
Manager on Behalf
of the Divisional
Directors.
Corporate Risk
Manager on Behalf
of the Divisional
Directors.
Corporate Risk
Manager on Behalf
of the Divisional
Directors.
Implementation Date Performance
December 2008
December 2008
March 2009
Appendix 1a
20

Risk Management
Annual Report
2008 – 09
Ref. Recommendation(s) Management Action(s)
2.03 Management reinforce to all users
the necessity to fully complete the
details on DATIX. Management
may also wish to consider if some
of these aspects require further
training of users or whether the
updating of the Risk Management
Guidance Manual may address
this.
Will be met through the
development and launch
of the Risk Management
Guidance Manual.
Compliance will be audited
by the Risk Management
Department and reports
issued to Divisional Directors
for action.
2.04 A. Management should review
the number of locations still
completing IR1 forms to
ascertain if any further DATIX
access can be achieved, thus
achieving the objectives of an
electronic recording system.
There has been an initial
agreement that staff who are
not site based and have no
immediate electronic access
to report will continue to
report on paper format, e.g.
PSSD.
B. Management investigate
the possibility of limiting the
number of sub–categories that
are available to users when an
incident is being recorded.
Within PSSD there are cohorts
where there is opportunity
emerging to install electronic
reporting. Review scheduled
within the annual Work Plan
2008 – 09
The Systems Administrator
has reviewed potential
of duplicate codes. The
sub–category is dependent
on, and linked to, the main
category of incident, e.g.
a clinical and non–clinical
incident could have
categories, but the same
sub–category.
A series of meetings with
key users to review codes/
categories to ensure “fit
for purpose” is already
progressing with review
plans for radiology complete,
laboratories and theatres
work in progress and code
management within Health
& Safety categories.
Management
Comments
Management accept that
this will be a continuing
feature, however there
is a protocol agreed
within PSSD to maintain
best reporting and
management practice.
Management accept
that on rare occasions,
there will be duplicate
sub–categories within the
system.
Responsible
Officer(s)
Corporate Risk
Manager on Behalf
of the Divisional
Directors
Corporate Risk
Manager & GM PSSD
Corporate risk
Manager & GM
PSSD.
Systems Administrator
Corporate Risk
Manager, Systems
Administrator
Implementation Date Performance
December 2008
Commencing July
2008
Complete
September 2008
July 2008
December 2008
Continuous
Appendix 1a
21

Risk Management
Annual Report
2008 – 09 Appendix 1b
Summary of Progress Against Work
Driver Objective Action Responsible Person Timescale Performance
Local Delivery
Plan/ HEAT
Target
T2.KPM 1
Corporate
Objectives
NHS QIS
Standards
&
Internal Audit
and External
Audit
&
RMSG Agenda
Demonstrate continuous
improvement by
reaching the Trajectory
Scoring Target (7) for
compliance with the
NHS QIS Standards by
March 2009, working
towards scoring of 9
for 2009 – 10 and 2010
– 11.
Refer to 2008 – 09
corporate objective 2.1,
2.2, 2.3 and 2.4.
Development of the Use
of the electronic Risk
Management System
(DATIX)
From the NHS QIS January 2007
final report - influence and agree
the work stream/actions through
the H&CG Steering Group.
Participate in then recently formed
NHSL group to improve the
performance against the national
standards.
Undertake a self–assessment for
the Risk Management Standard
1a to measure improvements.
Scoring currently Level 3 – move
to Level 4.
Influence Performance Review
Process against the Standards at
Operational level.
As above.
Participate in the restructuring of
the Health & Clinical Governance
and Risk Management Directorate.
Maintenance of an up–to–date
NHS Lanarkshire Strategic Risk
Register.
Integrate Modernisation/Service
Improvement Risk Register with
the NHSL Strategic Risk Register
Ensure monitoring procedures
for Divisional Risk Registers is
effective.
Full development of Locality and
Division risk registers.
Implementation of the 2 new
modules:
◦ Web–based risk register
◦ Standards module
Review of Current Practice:
◦ System Codes
◦ Audit and monitor the quality
of data.
Medical Director and
Corporate Risk Manager
Medical Director and
Corporate Risk Manager
Medical Director and
Corporate Risk Manager
Director of Strategic
Planning & Performance
Corporate Risk Manager
and Designated Divisional
Managers
Corporate Risk Manager
and nominated Managers
Corporate Risk Manager
and Designated RM Staff
Systems Administrator
December 2008
Ongoing Review
and Monitoring
through the
RMSG (schedule
of reporting)
December 2008
December 2008
December 2008
Harmonisation of Cam/Glen
and Northern Corrider incident
information with NSHL.
Corporate Risk Manager,
Systems Administrator
and General Managers
March 2009
Appendix 1b
22

Risk Management
Annual Report
2008 – 09
Driver Objective Action Responsible Person Timescale Performance
NHS QIS
Standards
and
Internal Audit
& External
Audit
and
RMSG Agenda
(Cont'd)
Review, Update, Cost
and Launch NHSL Risk
Management Guidance
Manual (based on
former PCT Manual)
providing local guidance
across NHSL on Risk
Management Principles,
techniques (based on
AS/NZ Standards
Review all current sections and
updated Sections 4 and 5 to
reflect QIS Matrix.
Set–up short–life working group to
write the NHSL Incident Reporting
Policy & Procedure.
Corporate Risk Manager
Co-ordinator
Launch to be
completed by
September 2008
To have a fully function
system of internal
control.
Follow–through recommendations
from internal and external audit.
Medical Director and Risk
Manager
March 2009
Monitor the RM
Strategy Framework
Includes single reporting system
incident policy and procedures
Scheme of Delegation, Risk
Management Strategy and
Communication of the RM Data
Corporate Risk Manager
March 2009
National
& Local
Developments
Decontamination of
endoscopes.
Monitor the incident reporting of
decontamination incidents within
endoscopy, reporting within the
external and internal structure.
Corporate Risk Manager
Ongoing to
March 2009
Develop a Model of Governance
& Risk Management within 2
voluntary GP Practices.
Corporate Risk Manager
and
Practice Managers from
Volunteer Practices
December 2008
Review the NHSL Risk Assessment
for Disclosure.
Corporate Risk Manager
July 2008
Scottish
Patient Safety
Programme
(SPSP)
Identify strategic and
operational risks in
implementing this
programme.
Develop a risk register.
Corporate Risk Manager
and
Patient Safety Manager
September 2008
Appendix 1b
23

Appendix 2: Summary of Risk Management Prospective Work Plan
Driver Objective Aim Process Metrics Reponsible Person Timescale Corporate Objective RAG
Stakeholder
Involvement
Involvement of staff
and/or the public
in risk management
arrangements
Through NHSL having
agenda items on the
Stakeholder Group,
the PFPI Group and
use of the SLWG
representatives in
reconvening an annual
monitoring group
Quarterly articles
in 'The Pulse'
relating to risk
activity, including
evaluation of
effectiveness of risk
arrangements
J Allison
In line with Comms
timescales to
ensure 4 articles per
annum
Involvement of
Partners in the
Risk Management
Arrangements
Meet regularly with
North & South LC
Risk Managers and
extended partners, e.g.
police, fire and rescue
Agree a consistent
approach to
joint agenda and
strengthened
processes, e.g. joint
risk assessment for
adverse outcomes
for those receiving
community care
C McGhee/J Allison
January 2010
NHS QIS CG&RM
Standards
Development of
Joint Risk Assessment
Protocols for those
receiving Community
Care
Review effectiveness
of Protocol
C McGhee/Rbt
Peat/Dennis
September 2009
Monitor
Effectiveness
of Stakeholder
Involvement
Ensure safety
and best care for
patients, staff and
the public
Apply the process of
reflection following
each meeting with
the North & South LC
Risk Managers, and
other joint initiatives
and record the agreed
actions and outputs
Consistent and
agreed approach
to joint risk
management
demonstrated
through recorded
process via agreed
strategic objectives
and guiding
principles
C McGhee/J Allison
January 2010
Random Sample
questionnaire to staff
to assess adequacy of
the Quarterly Pulse
articles and assess
requirements for future
articles
Demonstration of
Best Approach to
sharing information
that is relevant to
staff
J Allison
December 2009
Appendix 2
24

Driver Objective Aim Process Metrics Reponsible Person Timescale Corporate Objective RAG
Strategic Risk
Objectives link to
Organisational
Objectives
Ensure that risks
link directly to
corporate objectives
Through CG&RM
department identify
and prioritise
objectives that fully
support the Corporate
Objectives and agree
through RMSG
Available resource
and activity is
directed towards
success of the
corporate objectives
C McGhee
April 2009
Annual update of
corporate objectives
within the DATIX
system
Risks directly
linked to corporate
objectives
J Allison/S Steven
April 2009
Risk is integrated
into NHSL
decision–making
arrangements
Risk management
information
supports decision–
making at exec/
management team
level
Provision of full set of
Guidance for managers
in Risk Management
Risk is identified
and analysed
consistently
across all levels
of management
within NHSL
J Allison
June 2009
NHS QIS CG&RM
Standards
Provide 'awareness'
for all senior teams on
utilising the Guidance
Audit adherence to the
Risk Register Guidance
Confidence in
compliance with
Guidance
Audit outcomes
J Allison
J Allison
June 2009
July 2009 – March
2010
Audit team/
department meeting
minutes to ensure
risk management
is part of learning
and continuous
improvement
Audit outcomes
J Allison
September –
October 2009
Scope need, develop,
test and implement
e–learning package
E–learning package
J Allison
September –
December 2009
Develop a culture
of applying the
principles of risk
analysis and impact
assessment when
there is a moderate/
major change of
clinical practice
Scope feasibility and
methods of impact
analysis, test and
design methodology if
appropriate
Recorded risk
analysis and impact
assessment for
moderate/major
clinical change of
practice.
C McGhee/
P Milliken
March 2010
Appendix 2 25

Driver Objective Aim Process Metrics Reponsible Person Timescale Corporate Objective RAG
Monitor
Effectiveness
of Use of the
Guidance
Ensure risk
management
supports decision
making at senior
level
Risk Management KPI's
Sampling of 1:5 CIR
reports
Compliance with
agreed KPI's
demonstrating a high
level of performance
Compliance with
best practice in
report writing and
sharing information
J Allison/Internal
Audit
C McGhee/
A Sommerville
September 2009
– March 2010
September 2009
– March 2010
Threats and
Challenges within
the Systems are
Risk Managed in
Partnership
Ensure that the
risk management
systems are
effective in
supporting staff
to identify and
manage risks
Refresh principles of risk
register development
through the launch of
the RM Guidance
Undertake Quality
Check of Current
Operational Risk
Registers in partnership
with Owners – Clinical
Divisions and Localities
Staff demonstrate
a competence in
development and
monitoring of risk
registers
Consistency in
description of and
core controls for
business risks
J Allison
Carol McGhee
June 2009
March 2010
NHS QIS CG&RM
Standards
Full Development and
Quality Checks with
Heads of Function for
IM&T and PSSD
Support the
development of
Function Risk Register
for Finance with
Identified Champion
Consistency in
description of and
core controls for
business risks
Maintain progress
towards supporting
all corporate services
in developing and
monitoring risk
registers
J Allison
J Allison
March 2010
March 2010
Support the progression
and monitoring
of Directorate Risk
Registers: Laboratories
Continue training
for DATIX verifiers
for incidents and
assess the need for
risk register module
training. Monitor the
effectiveness of training
Consistent
development
with laboratory
accreditation systems
Those requiring
a higher level
of training are
identified and
training completed
by Systems Admin.
Training schedule for
DATIX
J Allison
March 2010
Appendix 2 26

Driver Objective Aim Process Metrics Reponsible Person Timescale Corporate Objective RAG
Continue training for
DATIX verifiers for
incidents & assess
the need for for
risk register module
training. Monitor the
effectiveness of training
Those requiring
a higher level
of training are
identified and
training completed
by Systems
Administrator.
Training schedule for
DATIX
S Steven March 2010
Adequacy of
risk assessments
and controls are
reviewed regularly
Ongoing review
of risk registers to
ensure risks and
assessments are
reviewed regularly
Maintain facilitation of
the strategic risk register
Strategic Risk Register
is live and reviewed
by the Executive
Directors at agreed
frequencies
C McGhee
March 2010
Quarterly Review of risk
review dates
Risks are reviewed on
or near to the agreed
review date by the
owners/designated
person
S Steven
March 2010
NHS QIS CG&RM
Standards
Ongoing review
of incident
management to
ensure incidents are
managed effectively
KPI's monitored through
risk and governance
committees
Effective
management of
incidents
J Allison
March 2010
Monitor
Effectiveness
of the Incident
Reporting Forms
DIF1 & DIF2
Ensure the DATIX
Incident Reporting
Forms are Fit for
Purpose
National Benchmarking
and Sharing of DATIX
Incident Reporting
Forms with RM
colleagues through
Scottish DATIX Group.
A review of violence
and aggression codes.
Annual one-to-one with
DATIX Consultant
DIF1 & DIF2 are
effective for staff to
use and capture right
information for NHSL
S Steven March 2010
Risk action plans
are prioritised
and reviewed at
regular intervals
To ensure systems
fully support prioritisation
and review
of risk action plans
To configure the DATIX
system to enable audits
of action plans
Quarterly Monitoring
Reports produced
for relevant gov
committees
Compliance
assurance for risk
register management
Compliance
assurance for risk
register management
J Allison
C McGhee
March 2010
March 2010
Appendix 2 27

Driver Objective Aim Process Metrics Reponsible Person Timescale Corporate Objective RAG
Information is
used to drive
improvement,
reduce risk and
stimulate learning
Information
drives quality
improvement and
training needs
Assess level of RCA
training requirements
as revised Guidance is
launched through early
alert through the Staff
Organisational Group,
staff briefing and web
page communication
Organisation
competence in
identifying root
causes of adverse
incidents and a
competence in using
the information to
inform change in
practice
C McGhee March 2010
NHS QIS CG&RM
Standards
Effectiveness
of the risk
management
framework is
reviewed at
regular intervals
and modifications
made
To have an overall
effective risk
management
framework within
NHSL
Review the DATIX
System to assess the
effectiveness of the
escalation process
Provide the RMSG
with all evaluation and
monitoring reports as
scheduled within the
Annual Work Plan as
reports are completed
Effective
measurement of
compliance with the
Escalation Procedure
Alerts on constraints,
reporting of success
is noted by the
RMSG as overseeing
CMT Group. Mid
year Work Plan
progress report to
RMSG
J Allison
C McGhee
March 2010
October 2009
Audit the outcomes
from the Verifiers Role
Audit Report
S Steven
December 2009
Quality Event
& Endorsed
Annual CG&RM
Work Plan
Improve education
and development
opportunities
for clinical staff
in undertaking
critical incident
reviews using root
cause analysis
techniques
Develop a culture
of applying risk
analysis and
impact assessment
when there is a
moderate/major
change in clinical
practice
Monitor emergence
of education/
development
needs following
the launch of
the specific RM
Guidance, identify
with OD suitable
programme of
learning
Review use of
existing guidance
and further develop
guidance to include
impact assessment
Paper to set out
potential requirements
via Strategic OD Group.
Monitor requirements
with OD via PDP
Scope out potential
courses and costs
Scope feasibility and
methods of impact
analysis, test and
design methodology if
appropriate.
Report to RMSG on
the assessed level of
need.
Recorded risk
analysis and impact
assessment for
moderate/major
clinical change of
practice.
C McGhee
C McGhee
C McGhee
CMcGhee/P
Milliken
March 2010
March 2010
March 2010
March 2010
Appendix 2 28

Driver Objective Aim Process Metrics Reponsible Person Timescale Corporate Objective RAG
Emerging
Corporate Risk
Issues
Identify the top
3 breaches of
systems of care
by reviewing CIR's
using RCA
Corporate Process
of Managing,
Cataloging and
Reviewing all
NSHL Policies
Following launch of
the RM Guidance,
review the findings
from CIR reports,
continuously collate
to inform the RMSG
of top 3 breaches
of systems, risk
assess and discuss
solutions and/or
actions.
To have a selfmanaging
process
of managing,
cataloguing,
monitoring and
reviewing of all
NSHL Policies
Review of completed
CIR findings and collate
across NHSL
Resource additional
hours to Risk
Management
Department
Agree PID through
RMSG
Quarterly reporting
to RMSG
Completed self
managing system
with quarterly reports
and compliance
C McGhee March 2010
P Wilson /
C McGhee
C McGhee
May 2009
June 2009
Develop and implement
system
C McGhee
December 2009
Appendix 2 29