Risk Management Annual Report - August 2009 ... - NHS Lanarkshire
Risk Management Annual Report - August 2009 ... - NHS Lanarkshire
Risk Management Annual Report - August 2009 ... - NHS Lanarkshire
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
Patient<br />
Safety<br />
Patient<br />
Focused<br />
Services<br />
<strong>Risk</strong><br />
<strong>Management</strong><br />
Clinical<br />
Effectiveness<br />
Fairness &<br />
Consistency<br />
Continuous<br />
Improvement<br />
<strong>Risk</strong> MANAGEMENT<br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
Competence &<br />
Continuous<br />
Learning<br />
Governance &<br />
Leadership<br />
Research &<br />
Development<br />
Lead Executive Director:<br />
<strong>Report</strong> Prepared by:<br />
Dr Alison Graham, Medical Director<br />
Mrs Carol McGhee, Corporate <strong>Risk</strong> Manager<br />
Submitted to the RMSG: June <strong>2009</strong><br />
Submitted to the Audit<br />
Committee:<br />
June <strong>2009</strong><br />
Endorsed by the RMSG: June <strong>2009</strong><br />
Submitted to the <strong>NHS</strong>L<br />
Board:<br />
July <strong>2009</strong>
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
Contents<br />
Introduction 3<br />
<strong>Risk</strong> <strong>Management</strong> Department 4<br />
Performance for Year 2008 – 09<br />
<strong>Risk</strong> <strong>Management</strong> Strategy Review 5<br />
Organisational Structure: Clinical Governance and <strong>Risk</strong> 6<br />
<strong>Management</strong><br />
Compliance with <strong>NHS</strong>QIS Standards 6<br />
Electronic <strong>Risk</strong> <strong>Management</strong> System: Datix 7<br />
<strong>Risk</strong> <strong>Management</strong> Guidance Manual 9<br />
<strong>Risk</strong> Register Process and Development 10<br />
Training, Education and Development 12<br />
Internal and External Audit 13<br />
Incident <strong>Report</strong>s 13<br />
Number of Incidents Proportionate to the Operational Divisions 13<br />
Scottish Patient Safety Programme (SPSP) 15<br />
Committees and Groups 15<br />
National and Local Developments 16<br />
Work Plan for Year 2008 – 09 18<br />
Appendices 19<br />
Appendix 1a & 1b: Summary of <strong>Risk</strong> <strong>Management</strong> Work Plan Outcomes<br />
2008 – 09<br />
Appendix 2:<br />
Summary of <strong>Risk</strong> <strong>Management</strong> Prospective Work Plan<br />
<strong>2009</strong> – 10<br />
Contents<br />
2
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
Introduction<br />
The duty of the <strong>NHS</strong>L Board is to deliver healthcare both within the law, and without<br />
causing harm or loss to the organisation and all it represents. It does this by ensuring<br />
there is a robust Governance Framework, and operates a system of Internal Control and<br />
<strong>Risk</strong> <strong>Management</strong>.<br />
Good risk management has the potential to impact on performance improvement,<br />
leading to:<br />
◦ improvement in service delivery<br />
◦ more efficient and effective use of resources<br />
◦ improved safety of patients, staff and visitors<br />
◦ promotion of innovation within a risk management framework<br />
◦ reduction in management time spent ‘fire fighting’<br />
◦ assurance that information is accurate and that controls and systems are<br />
robust and defensible<br />
The key objective in risk management is to eliminate or control significant risk to an<br />
acceptable level, by creating a culture of risk management founded upon assessment<br />
and prevention rather than reaction and remedy. Staff are empowered to use their<br />
professional judgement in deciding which risks are significant.<br />
The complete elimination of risk will not always be a feasible goal for the Board, however<br />
in certain circumstances, calculated risk management will be required to achieve creative<br />
or innovative solutions that will help to improve the services to patients.<br />
In seeking to deliver these objectives, the Board <strong>Risk</strong> <strong>Management</strong> Steering Group will<br />
advise on/oversee and/or support the:<br />
◦ implementation of the <strong>Risk</strong> <strong>Management</strong> Strategy<br />
◦ management of risk within the Board<br />
◦ compliance with <strong>NHS</strong> QIS standards<br />
◦ risk register process<br />
◦ risks highlighted through the organisation<br />
◦ complaints and receive assurance on the implementation of corrective action<br />
◦ assessment of the impact of new legislation<br />
The last few years have seen substantial work both at strategic and at an operational<br />
level to identify risks and to put in place control measures to mitigate their impact. The<br />
contribution of staff at all levels across the Board has been a major factor in bringing<br />
us to where we are now, with well developed processes for the management of risk,<br />
including through comprehensive strategic and operational risk registers.<br />
Continued contributions will be essential as we respond to the many challenges <strong>NHS</strong>L<br />
will face in delivering on targets and aspiration in the years ahead.<br />
Introduction<br />
3
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
<strong>Risk</strong> <strong>Management</strong> Department<br />
The <strong>Risk</strong> <strong>Management</strong> function has been fully integrated into the Clinical Governance<br />
and <strong>Risk</strong> <strong>Management</strong> Department which is part of the Medical Director’s directorate,<br />
providing appropriate professional and competent clinical effectiveness, research and<br />
development and risk management advice, guidance and support to the <strong>NHS</strong> Board,<br />
its managers and staff. The Clinical Governance and <strong>Risk</strong> <strong>Management</strong> Department also<br />
manages the Scottish Patient Safety Programme for <strong>NHS</strong> <strong>Lanarkshire</strong>.<br />
The <strong>Risk</strong> <strong>Management</strong> staff has increased from 3 wte to 4 wte following successful<br />
recruitment this year to the agreed level of resource required for the department: 1 wte<br />
<strong>Risk</strong> <strong>Management</strong> Co-ordinator:<br />
<br />
<br />
<br />
<br />
1 wte Corporate <strong>Risk</strong> Manager<br />
1 wte <strong>Risk</strong> <strong>Management</strong> Co-ordinator<br />
1 wte System Administrator<br />
1 wte Secretarial/DATIX Support<br />
<strong>Risk</strong> <strong>Management</strong> Department<br />
4
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
Performance for Year 2008 – 09<br />
<strong>Risk</strong> <strong>Management</strong> Strategy Review<br />
The <strong>NHS</strong>L <strong>Risk</strong> <strong>Management</strong> Strategy was reviewed in September 2006, consulted<br />
on through the organisation and endorsed by the <strong>Risk</strong> <strong>Management</strong> Steering Group<br />
in December 2006. Further scheduled review was undertaken between October –<br />
December 2008 as part of the updating of the <strong>Risk</strong> <strong>Management</strong> Guidance Manual.<br />
The Strategy sets out:<br />
◦ <strong>Risk</strong> <strong>Management</strong> Guiding Principles<br />
◦ Aims & Objectives<br />
◦ Scheme of Delegation<br />
◦ Implementation of the Strategy & Framework<br />
◦ Communication of the Strategy Framework Progress<br />
◦ <strong>Risk</strong> <strong>Management</strong> Steering Group Terms of Reference<br />
Implementation/Communication<br />
The Strategy has been extensively communicated through Strategic, Divisional &<br />
Operational Groups/Committees and is also available via the <strong>Risk</strong> <strong>Management</strong> web<br />
page on Firstport, with wider direct availability across all wards and departments via the<br />
<strong>Risk</strong> <strong>Management</strong> Guidance Manual and associated CD Rom.<br />
The dedicated <strong>Risk</strong> <strong>Management</strong> web page has been live since May 2007 and enables<br />
access to the Strategy, <strong>Risk</strong> <strong>Management</strong> <strong>Annual</strong> <strong>Report</strong>s, <strong>Annual</strong> Work Plans, RMSG<br />
minutes, forthcoming events, relevant risk, safety and governance articles, a ‘How To?’<br />
section and direct links to other associated internal and external web sites:<br />
◦ National Patient Safety Agency (NPSA)<br />
◦ Health & Safety Executive (HSE)<br />
◦ Willis – Clinical Negligence & other <strong>Risk</strong>s Indemnity Scheme (CNORIS)<br />
◦ Occupational Health & Safety (SALUS)<br />
◦ Scottish Patient Safety Alliance (SPSA)<br />
◦ Internal Scottish Patient Safety Programme Page<br />
◦ Institute for Health Improvement (IHI)<br />
◦ <strong>NHS</strong> Quality Improvement Scotland<br />
◦ DATIX<br />
◦ Internal Medical Education<br />
◦ Internal Clinical Governance<br />
This year, effective from February <strong>2009</strong>, the Caledonian University has been added as a<br />
direct link for staff seeking out courses to meet their risk management and governance<br />
training needs, resulting from several requests made to the department from senior<br />
managers.<br />
Performance for Year 2008 – 09<br />
5
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
The risk management web site was subject to annual review in July 2008 with changes<br />
made to improve the layout and the signposting to other relevant sites. For the period<br />
between November 2008 – March <strong>2009</strong> the ‘hits’ to the site improved from an average<br />
of 230 hits for the same period 2007 – 08 to 1,450 (this excludes the 2 designated<br />
page administrators recorded ‘hits’ to reduce bias). The range of users across <strong>NHS</strong>L has<br />
continuously increased as has the subject/page being accessed within the web site.<br />
Organisational Structure: Clinical Governance & <strong>Risk</strong> <strong>Management</strong><br />
This year, the Clinical Governance & <strong>Risk</strong> <strong>Management</strong> Structure has been subject to<br />
re-organisation, facilitated through a set of development sessions. Concurrently, the<br />
Joint CHP Clinical Governance & <strong>Risk</strong> <strong>Management</strong> structure was evaluated, reviewed<br />
and an improved structure implemented.<br />
The reporting function for the <strong>Risk</strong> <strong>Management</strong> Department will remain as outlined<br />
in the <strong>Risk</strong> <strong>Management</strong> Strategy, with little impact on the <strong>Risk</strong> <strong>Management</strong> Steering<br />
Group.<br />
The Audit Committee has overall responsibility to evaluate the System of Internal Control<br />
and Corporate Governance, including the <strong>Risk</strong> <strong>Management</strong> Strategy, Framework and<br />
Processes.<br />
Compliance with <strong>NHS</strong> QIS Standards<br />
The last <strong>NHS</strong> QIS Peer Review of the Clinical Governance & <strong>Risk</strong> <strong>Management</strong> Standards<br />
was undertaken in September 2006 with the expectation that the process would be<br />
repeated every 3 years. In preparation for the September <strong>2009</strong> review, a Standards<br />
Improvement Group was set–up in May 2008, chaired by the Director of Nursing &<br />
AHP’s. Executive Leads, Programme Leads and overseeing Committees and Groups<br />
were identified. All Programme Leads were core members of the Group and a series of<br />
briefing sessions were held to update Executive Leads.<br />
For Standard 1a <strong>Risk</strong> <strong>Management</strong>, the following applied:<br />
Executive Lead: Dr A Graham, Medical Director<br />
Programme Lead: Mrs C McGhee, Corporate <strong>Risk</strong> Manager<br />
Overseeing Group: <strong>Risk</strong> <strong>Management</strong> Steering Group<br />
The assessed level of compliance for each standard is measured against a numerical<br />
value ranging from 1 – 4 (development through to review stage).<br />
The <strong>Risk</strong> <strong>Management</strong> Standard was assessed as Level 1 in the 2005 <strong>NHS</strong> QIS Interim<br />
Review. The self–assessed score prior to the 2006 review was assessed at Level 2 and<br />
this was substantiated by the peer review undertaken in September 2006.<br />
Within the year 2007 – 08, the Clinical Governance Manager undertook an independent<br />
review of the <strong>Risk</strong> <strong>Management</strong> Standard (1a), as agreed through the Work Plan,<br />
using the same self–assessment tool and guidance. At that point, the self–assessment<br />
outcome confirmed attainment of Level 3. Subsequent to this, improvement work has<br />
continued and resulting from both internal peer assessment and benchmarking with<br />
other Health Boards (Lothian, Forth Valley, Dumfries & Galloway, Scottish Ambulance<br />
Service), the assessed level as at March <strong>2009</strong> was Level 4, with discussion scheduled for<br />
May and June through the RMSG.<br />
This improvement contributes to the overall performance against the 2008 – 09 HEAT<br />
target and Corporate Objectives.<br />
Performance for Year 2008 – 09<br />
6
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
Electronic <strong>Risk</strong> <strong>Management</strong> System: DATIX<br />
Audit to Review the Electronic <strong>Management</strong> System: DATIX<br />
<strong>NHS</strong>L currently has a license that covers 6 DATIX modules: Incident Recording, <strong>Risk</strong><br />
Register, Complaints, Claims, PALS and Standards.<br />
As part of the overall review of the existing risk management guidance, the DATIX system<br />
was also subject to further audit of effectiveness reviewed in light of the findings.<br />
A report based on the following outcomes was received by the RMSG and improvements<br />
supported and subsequently implemented:<br />
Incidents<br />
The incident module has been in place across Primary Care since 2003 and <strong>NHS</strong>L–wide<br />
since 2006. With the exception of PSSD, all incidents are now recorded electronically<br />
on the system. PSSD record incidents on paper forms with this information then input<br />
to the Datix system.<br />
Current incident recording process:<br />
Any member of staff witnessing or involved in an incident of any type records<br />
this electronically on the DIF1 (Datix Incident Form).<br />
Incident goes in to holding area ready for verification using a DIF2 electronic<br />
form.<br />
The verifier is the line manager of the individual reporting the incident.<br />
Once verified the incident is automatically added to the main database.<br />
Anecdotal evidence suggested that members of staff completing the DIF1 and those<br />
verifying the DIF2 forms are finding some of the fields confusing and can often wrongly<br />
categorise a number of fields. In July 2008 the <strong>Risk</strong> <strong>Management</strong> Department carried<br />
out an audit of completed DIF1 and DIF2, which had remained unverified, to determine<br />
if this is the case and, if so, which fields may require to be reviewed. The results of this<br />
audit established that:<br />
ACTION:<br />
The name of the person involved in the incident was frequently left blank. This<br />
is now a mandatory field, with help text to guide those completing the form.<br />
Many members of staff completing the DIF1 form were completing the Division and<br />
Directorate fields incorrectly. The system is in the process of being reconfigured to<br />
reflect the current Divisional and Directorate structures. ‘Combo’ links reduce the<br />
number of options at each field which should in turn reduce the number of errors.<br />
The ‘type’ of incident is the first window which categorises the risk, if either this field<br />
and/or the next window ‘category’ are completed incorrectly subsequent reports<br />
will be inaccurate. A revised ‘type’ and ‘category’ dataset has been developed and<br />
is to be tested with members of staff recording incidents and with staff who draw<br />
reports from the system.<br />
Performance for Year 2008 – 09<br />
7
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
The rating of an incident determines the subsequent communication and investigation<br />
levels. Between December 2007 – November 2008, 10% of incidents were rated<br />
with the remaining 90% without rating this may result in poor communications and<br />
investigation levels.<br />
ACTION:<br />
In future, rating will become a mandatory field with the member of staff<br />
recording the incident rating it. This action is in line with the National Patient<br />
Safety Agency (NPSA) guidance and was agreed by the <strong>Risk</strong> <strong>Management</strong><br />
Guidance SLWG. To ensure staff are able to rate the incident, all staff will receive<br />
an aide memoir demonstrating the process. In addition, there will be links from<br />
the incident form to rating guidance.<br />
The incident will only be added to the main database once there is agreement<br />
between the person recording, rand rating the incident and the verifier.<br />
More than a third of incidents remain in the holding area each month, therefore<br />
remaining unverified. One possible outcome of is that incidents are identified but<br />
may not be investigated and timely remedial action taken as a result.<br />
ACTION:<br />
The <strong>Risk</strong> <strong>Management</strong> Guidance (SLWG) has agreed a maximum period of 5<br />
working days for incidents to remain in the holding area. The timescales will be<br />
monitored by line managers and governance structures.<br />
Template reports are currently being designed which reflect the generic incident reports<br />
developed by the <strong>Risk</strong> <strong>Management</strong> SLWG. This will support committees to provide<br />
assurances on risk management.<br />
In addition to incident management template reports, the system is being configured<br />
to produce reports which will allow <strong>NHS</strong>L to monitor the risk management key<br />
performance indicators developed by the <strong>Risk</strong> <strong>Management</strong> SLWG.<br />
<strong>Risk</strong>s Register<br />
Currently risks are placed on registers in the Datix main application. The <strong>Risk</strong><br />
<strong>Management</strong> Department is currently configuring the web based module so that in<br />
future risk registers will be entered and managed using the web interface.<br />
The <strong>Risk</strong> <strong>Management</strong> SLWG agreed a risk escalation process including questions to<br />
be answered at each escalation stage; these have been incorporated into the web <strong>Risk</strong><br />
Form. This will allow <strong>NHS</strong>L to be reassured that risks are being managed at the correct<br />
level in the organisation.<br />
Complaints<br />
Complaints across <strong>NHS</strong>L are managed through the complaints module. Recent changes<br />
to ISD dataset requirements have resulted in an upgrade to the system to version 9.3a.<br />
This will provide ISD with the revised dataset information from mid January <strong>2009</strong>.<br />
Performance for Year 2008 – 09<br />
8
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
Claims<br />
Having reviewed the claims module there are no changes which could enhance the<br />
module.<br />
PALS<br />
The PALS module allows <strong>NHS</strong>L to gather information which may be helpful in monitoring<br />
services and which identifies areas where improvements can be made, which can in<br />
turn help avoid possible complaints or claims. The module is currently being trialed and<br />
will be reviewed during <strong>2009</strong>.<br />
Standards<br />
Initially this module will be set up to manage the QIS <strong>Risk</strong> <strong>Management</strong> Standards. QIS<br />
are currently in discussion with Datix to devise a link from <strong>NHS</strong>Scotland Board's Datix<br />
systems to the QIS database. It is hoped that this will operate in a similar way to the ISD<br />
and Datix complaints module.<br />
General Set–Up<br />
A trigger alert is an automated notification in the form of email which is sent when a<br />
particular field in Datix has been completed matching agreed criteria. A series of trigger<br />
alerts are in place, effective from April <strong>2009</strong>, based on the communication processes<br />
and criteria agreed by the <strong>Risk</strong> <strong>Management</strong> SLWG. The trigger alert will support<br />
communication but will not take the responsibility for communicating incidents from<br />
members of staff.<br />
<strong>Risk</strong> <strong>Management</strong> Guidance Manual<br />
Previously identified through audit as a priority, a Short–Life Working Group was<br />
convened to review existing polices, procedures, guidance, and to identify other areas<br />
for improvement. A full set of improved guidance was produced to further promote the<br />
concept of risk management and set out good practice in managing risk effectively. It<br />
also outlines the key roles and responsibilities of managers and directors in improving<br />
the corporate approach to managing risk. Additionally, it introduces a range of tools,<br />
techniques and checklists to help managers, identify, record and manage risk in a<br />
systematic way.<br />
The Guidance Manual has been produced and launched in hard copy with an attached<br />
CD ROM. Additionally, each section is available on the <strong>Risk</strong> <strong>Management</strong> web page on<br />
Firstport: Firstport > Corporate Services > <strong>Risk</strong> <strong>Management</strong>.<br />
The Guidance includes:<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
Foreword by the Chief Executive<br />
Introduction to the Guidance, Short Life Working Group Terms of Reference<br />
<strong>Risk</strong> <strong>Management</strong> Strategy<br />
Why <strong>Report</strong> Incidents<br />
Critical Incident Review using Root Cause Analysis<br />
Investigation <strong>Report</strong> Writing<br />
Why Develop <strong>Risk</strong> Registers and How To<br />
Key Performance Indicators<br />
Feedback Mechanism<br />
Performance for Year 2008 – 09<br />
9
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
The Guidance sets out:<br />
<br />
<br />
<br />
<strong>NHS</strong>L approach to reporting, recording, managing, investigation, reporting on<br />
outcomes, learning lessons regarding incidents.<br />
The <strong>Risk</strong> Register section clearly sets out the development process, grading based<br />
on the <strong>NHS</strong> QIS/AS/NZ Standard Matrix and the escalation process.<br />
Key Performance Indicators (KPI) reporting will be through the RMSG.<br />
In support of the Guidance, a revised and improved ‘Record & Learn’ was distributed<br />
to every member of staff within <strong>NHS</strong>L attached to payslips in March <strong>2009</strong> and forms<br />
part of the Corporate Induction Information Pack for all new staff. The production of a<br />
supporting poster has commenced and will be displayed in all clinical and non–clinical<br />
areas. The poster has an attached designated polythene pocket designed to hold and<br />
display incident data produced from the DATIX system to support sharing of trend<br />
information and performance against the Key Performance Indicators.<br />
<strong>Risk</strong> Register Process & Development<br />
Strategic <strong>Risk</strong> Register<br />
<strong>NHS</strong>L have an established Strategic <strong>Risk</strong> Register around the core areas of Governance:<br />
◦ Corporate Governance<br />
◦ Staff Governance<br />
◦ Financial Governance<br />
◦ Health & Clinical Governance<br />
The <strong>Risk</strong> Register has been monitored and reviewed throughout the year and overseen<br />
by the <strong>Risk</strong> <strong>Management</strong> Steering Group.<br />
The Strategic Register identifies high level risks for <strong>NHS</strong> <strong>Lanarkshire</strong> that have the<br />
potential to undermine the ability to meet the corporate objectives and include:<br />
◦ Child protection<br />
◦ Clinical service sustainability<br />
◦ Prevention and containment of infection/environmental hazards<br />
◦ Compliance with statutory requirements<br />
◦ Robustness of corporate objectives and performance management systems<br />
◦ Engagement with internal and external stakeholders<br />
◦ Timing of financial allocation through NRAC<br />
◦ External factors affecting financial balance<br />
◦ Financial control framework assurance<br />
◦ Workforce information & planning<br />
◦ Provision of safe working environment<br />
◦ Effective implementation of policies on Diversity<br />
◦ Provision of adequate staff training<br />
◦ Sickness/absence<br />
Performance for Year 2008 – 09<br />
10
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
Additional risks escalated to the Strategic <strong>Risk</strong> Register include HAI risk, National Fraud<br />
Initiative implementation risk, Medical Workforce risk specific to the implementation<br />
of MMC, and the recognition that the Year End Finance Surplus Exceeds Threshold for<br />
Carry Over.<br />
The Strategic <strong>Risk</strong> Register is managed via the electronic DATIX system and the process<br />
for review, changes, production of reports is currently facilitated by the Corporate <strong>Risk</strong><br />
Manager on behalf of the lead Executive Directors.<br />
The Strategic <strong>Risk</strong> Register is part of the information considered in the development of<br />
the <strong>Annual</strong> Internal Audit Plan.<br />
Divisional <strong>Risk</strong> Register(s)<br />
The 3 Operating Divisions present their <strong>Risk</strong> Registers to the RMSG on an annual basis as<br />
agreed through the Schedule of <strong>Report</strong>ing. The Divisional risk registers are monitored<br />
through existing management and performance structures. The monitoring and review<br />
process is now fully owned by the Divisional <strong>Management</strong> Teams. This enables best<br />
practice in reviewing/amending/changing the <strong>Risk</strong> Register with the <strong>Management</strong> Team.<br />
Locality and Clinical Divisional <strong>Risk</strong> Registers<br />
Within this year, the CHP localities and the Acute Clinical Divisions have identified their<br />
risk profiles which have been set out as risk registers and monitored through their<br />
respective management and performance systems. This process is evolving and will be<br />
monitored through the DATIX system and KPI’s.<br />
Corporate Services <strong>Risk</strong> Registers<br />
The Property & Support Services Directorate and the eHealth Directorate developed<br />
and presented their <strong>Risk</strong> Registers to the <strong>Risk</strong> <strong>Management</strong> Steering Group and are<br />
working towards development of specific function registers within the Directorates.<br />
Shared <strong>Risk</strong> <strong>Management</strong><br />
The North <strong>Lanarkshire</strong> Partnership Board recognised the need to have a shared approach<br />
to identifying the risks that would undermine the success of the implementation of the<br />
Community Plan that was dependent on many services, including Health. A <strong>Risk</strong> Register<br />
was developed by all stakeholders (Police, Health, Fire Service, Voluntary Service, Local<br />
Authority) and submitted to the NLP Board in 2007. A joint annual review has been<br />
scheduled for April <strong>2009</strong>.<br />
Additionally, as agreed through the single–outcome agreements, the NLP Board have<br />
initiated a Short–Life Steering Group to advise on a joint approach to risk assessment<br />
and risk management planning for all within <strong>Lanarkshire</strong> receiving Community Care.<br />
This group have addressed:<br />
◦ Existing risk assessment tools in routine working practice<br />
◦ Shared risk assessment and risk management in the event of identifying<br />
triggers that could lead to an adverse incident or near miss<br />
◦ Joint response to adverse incident or near miss<br />
◦ Grading of adverse incidents or near–miss<br />
◦ Shared investigation approach<br />
◦ Governance/reporting structures<br />
Performance for Year 2008 – 09<br />
11
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
A final report will be received by the NLP Board in June <strong>2009</strong> to work towards<br />
implementation of the systems and processes that will be critical to effective joint risk<br />
management for those receiving community care.<br />
The <strong>Risk</strong> <strong>Management</strong> Staff from North <strong>Lanarkshire</strong> Council, South <strong>Lanarkshire</strong> Council<br />
and <strong>NHS</strong> <strong>Lanarkshire</strong> are meeting frequently to improve joint risk approach. Outcomes<br />
impacting on the <strong>NHS</strong>L Strategy will be considered and changes made to reflect<br />
improvements.<br />
Training, Education & Development<br />
<br />
<br />
<br />
<strong>Risk</strong> <strong>Management</strong>, including incident/accident reporting, is core to the <strong>NHS</strong>L<br />
Corporate Induction Programme, delivered via Organisational Development. This<br />
programme is delivered on Monday and Tuesday of every week for all new employees<br />
including bank staff. On joining the organisation and attending the Corporate<br />
Induction, the opportunity was taken by the <strong>Risk</strong> <strong>Management</strong> Co–ordinator to<br />
undertake an audit of the content of the risk presentation. The outcomes indicated<br />
that no material change was required.<br />
Local sessions development and maintenance of Locality <strong>Risk</strong> Registers continue to<br />
be undertaken on an ad hoc basis.<br />
As part of the implementation of the web–based module within the DATIX system,<br />
there was a series of demonstrations of the system and re-iteration of the Incident<br />
and Accident <strong>Report</strong>ing requirements. Ad hoc training continues to support this<br />
as staff change positions, new staff are employed and have verifiers role. This is<br />
now managed on a 1:1 basis as the initial cohort of staff have been trained. Group<br />
sessions have extended this year to:<br />
◦ Health Records Senior Manager Group<br />
◦ Infection Control Team<br />
◦ Locality <strong>Management</strong> Teams<br />
◦ Information Governance Sessions<br />
◦ Older Peoples Services Clinical Governance Group<br />
◦ PSSD dedicated staff on reporting facility<br />
◦ Pharmacy Managers<br />
◦ Community Dental Teams<br />
<br />
<br />
<br />
<br />
The Occupational Health & Safety Team deliver a variety of in–house risk training<br />
both accredited training (IOSHH) and in response to department/organisation<br />
needs.<br />
The DATIX system is linked to the DOTS medical staff training/induction<br />
programme.<br />
Through the Medical Education Department, the Systems Administrator continues<br />
to deliver demonstrations on the DATIX system and an overview of clinical incident<br />
reporting for both junior medical staff and Consultants.<br />
A series of awareness sessions have commenced across the <strong>Management</strong> &<br />
Governance Groups to launch the revised Guidance Manual.<br />
Performance for Year 2008 – 09<br />
12
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
Internal & External Audit<br />
In partnership with the Internal Audit Consortium (Bentley Jennison), a thematic review<br />
was undertaken on the risk maturity of <strong>NHS</strong> <strong>Lanarkshire</strong> risk system, as part of a wider<br />
benchmarking exercise across a large number of clients. The interim report will be<br />
presented to the Audit Committee in June <strong>2009</strong> and an improvement plan will be<br />
agreed if required. The final benchmark report is expected in September <strong>2009</strong>.<br />
Incident <strong>Report</strong>s<br />
This is the third year that <strong>NHS</strong> <strong>Lanarkshire</strong> has had a global view of all incidents and/<br />
or accidents reported with quarterly trends. The report does not include data from<br />
South CHP: Cambuslang/Rutherglen Locality, or North CHP: North Locality (northern<br />
corridor), as this is still held by Greater Glasgow Health Board area. However, this data<br />
will be collated within the year <strong>2009</strong> – 10, effective from 1 st April <strong>2009</strong> as the operational<br />
management of this Locality transfers to <strong>NHS</strong>L. Preparatory work has been undertaken<br />
and agreed with the General Managers, Health & Safety, Locality <strong>Management</strong> Teams<br />
and <strong>Risk</strong> <strong>Management</strong> to facilitate this.<br />
As at 31 st March <strong>2009</strong>, there was 13,965 incidents/accidents recorded within the<br />
DATIX system for the period 1 st April 2008 – 31 st March <strong>2009</strong>. Additionally, there are<br />
approximately 800 maternity clinical incidents held locally (awaiting specific DATIX<br />
module).<br />
There has been no real change in the distribution of incidents. The data for this year<br />
demonstrates that 75% are attributable to non–clinical incidents and 24% attributable<br />
to clinical incidents, including near–miss reports, as compared to 70% and 30%<br />
respectively for year 2006 – 07 and 76% and 24% for the year 2007 – 08.<br />
Figure 1: Outlines the number of incidents proportionate to the<br />
Operational Divisions:<br />
1114 1<br />
1202<br />
Acute Operating Division<br />
Community Health Partnership North<br />
1692<br />
Community Health Partnership south<br />
Corporate services<br />
NHs <strong>Lanarkshire</strong> Board<br />
9259<br />
Sixty–one (61) incidents/accidents were RIDDOR reportable as compared to 55 in 2007<br />
– 09 and 36 in 2006 – 07.<br />
Performance for Year 2008 – 09<br />
13
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
Figure 2: Incident/Accident <strong>Report</strong>ing Trends per quarter for the past 3 years<br />
*Corporate Services include IM&T, PSSD, Board, etc<br />
<br />
The top ten reported category of incident/accident occurring across <strong>NHS</strong>L is set<br />
out in Table 1:<br />
Category 2006/07 Category 2007/08 Category 2008/09<br />
Slips, Trips & Falls 4039 Slips, Trips & Falls 4937 Slips, Trips & Falls 4484<br />
Violence/Abuse/<br />
Harassment<br />
1259 Violence/Abuse/<br />
Harassment<br />
1823 Violence/Abuse/<br />
Harassment<br />
1808<br />
Other 729 Other 531 Other 1530<br />
Blood or Blood<br />
Products<br />
Transfusion<br />
Medication Errors:<br />
Prescribing (144)<br />
Dispensing/<br />
Preparation (102)<br />
Administration<br />
(198)<br />
487 Blood or Blood<br />
Products<br />
Transfusion<br />
444 Medication Errors:<br />
Prescribing (156)<br />
Dispensing/<br />
Preparation (221)<br />
Administration<br />
(342)<br />
346 Problem with<br />
Records<br />
754<br />
719 Medication Errors:<br />
Prescribing (189)<br />
Dispensing/<br />
Preparation (206)<br />
Administration<br />
(336)<br />
731<br />
311 Investigation 324<br />
Investigation 320 Problem with<br />
Records<br />
Hit by/Against 266 Hit by/Against 287 Absconded 321<br />
Object<br />
Object<br />
--------------- 204 Investigation 242 Hit by/Against 265<br />
Object<br />
Contact with 198 Contact with 219 Contact with 214<br />
Needle or Other<br />
Needle of Other<br />
Needle or Other<br />
Sharps<br />
Sharps<br />
Sharps<br />
Absconded 164 Accidental<br />
Damage/Loss<br />
to Belongings/<br />
Property<br />
176 Accidental<br />
Damage/Loss<br />
to Belongings/<br />
Property<br />
*Other includes: bed management, staff shortages, trolley waits, etc<br />
190<br />
Performance for Year 2008 – 09<br />
14
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
Scottish Patient Safety Programme (SPSP)<br />
The Corporate <strong>Risk</strong> Manager is a core member of the leadership workstream and a<br />
core member of the team identified to undertake the ward/department Walk Arounds.<br />
There has been significant success in achievement within each workstream, including<br />
the Safety Briefings, to reduce risk to patients as reported through <strong>NHS</strong>L Patient<br />
Safety <strong>Report</strong>s. This work was shared across <strong>NHS</strong>L and with partners at the successful<br />
internal ‘Strengthening Quality’ event. Subsequent to demonstration of this success,<br />
<strong>NHS</strong> <strong>Lanarkshire</strong> have been invited to present on 3 out of 4 clinical workstreams, 1<br />
leadership workstream and 1 programme management workstream, at the National<br />
Learning Session scheduled for May <strong>2009</strong>.<br />
Work has commenced on the development of an incident reporting form to record<br />
adverse events identified from the case note reviews. Whilst this work has been primarily<br />
undertaken in the Acute areas, early discussions are underway to assess the feasibility of<br />
a single-system approach to patient safety, for example high risk medications.<br />
Committees & Groups<br />
The role of the Corporate <strong>Risk</strong> Manager at key <strong>NHS</strong>L Committees/Groups continues to<br />
be key to the governance function and is a member of the following:<br />
◦ <strong>Risk</strong> <strong>Management</strong> Steering Group<br />
◦ Health & Clinical Governance Committee<br />
◦ Health & Clinical Governance Steering Group<br />
◦ Audit Committee<br />
◦ <strong>Lanarkshire</strong> Infection Control Committee<br />
◦ Occupational Health & Safety <strong>Management</strong> Group<br />
◦ Fire Committee<br />
◦ DATIX User Groups<br />
◦ <strong>NHS</strong>L Business Continuity Group<br />
Additionally, the Corporate <strong>Risk</strong> Manager attends:<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
CHP North Divisional Partnership Group<br />
CHP South Divisional Partnership Group<br />
Acute Divisional <strong>Management</strong> Team<br />
Acute Clinical Board<br />
Acute <strong>Risk</strong> Groups<br />
CHP Joint Clinical Governance & <strong>Risk</strong> <strong>Management</strong> Committee<br />
CHP North Quarterly Locality Performance Reviews<br />
Clinical Governance & <strong>Risk</strong> <strong>Management</strong> Standards Improvement Group<br />
Positive Patient Identification Group<br />
Performance for Year 2008 – 09<br />
15
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
The <strong>Risk</strong> <strong>Management</strong> staff attend many Divisional Groups and Short–Life Working<br />
Groups to advise on <strong>Risk</strong> Issues and support the implementation of the Strategy and<br />
external assessments/audits.<br />
Other key groups essential to the development and leadership for <strong>Risk</strong> <strong>Management</strong><br />
include:<br />
◦ National DATIX Group<br />
◦ <strong>NHS</strong> QIS Joint Clinical Governance & <strong>Risk</strong> <strong>Management</strong> Network<br />
◦ <strong>NHS</strong> QIS <strong>Risk</strong> Managers Network<br />
◦ Institute of <strong>Risk</strong> <strong>Management</strong><br />
◦ Institute of Health Service <strong>Management</strong><br />
◦ ALARM<br />
National & Local Developments<br />
<strong>NHS</strong> QIS Endoscopy Decontamination Incident <strong>Report</strong>ing<br />
<strong>NHS</strong> QIS, through the Safer Today – Safer Tomorrow <strong>Report</strong> 2006 – 07, identified the<br />
need to review and improve incident reporting across Scotland. They invited <strong>NHS</strong> risk<br />
managers to participate in 4 unique workgroups. <strong>NHS</strong>L supported the Corporate <strong>Risk</strong><br />
Manager in participating in the group identifying data sets. The outcomes from this<br />
group identified that concurrent with the monitoring of decontamination incidents<br />
occurring across Scotland that there would be a focus on working with Health Protection<br />
Scotland to take this forward.<br />
Three Health Board areas (<strong>Lanarkshire</strong>, Lothian and Glasgow & Clyde) were invited to<br />
participate in the development and piloting of a data set specific to incidents relating to<br />
decontamination within endoscopy units. This was undertaken over the period January<br />
– December 2008.<br />
The findings were limited as only 2 health board areas continued participation (Glasgow<br />
withdrew).<br />
The final report is being collated by <strong>NHS</strong> QIS with a presentation from the <strong>Risk</strong> Managers<br />
from <strong>Lanarkshire</strong> and Lothian presenting early findings to the CG&RM Network Group<br />
in preparation for the receipt of the report and recommendations.<br />
The findings will be reported to the RMSG and the <strong>NHS</strong>L Endoscopy Steering Group on<br />
receipt of the final report.<br />
Developing a Model of Governance & <strong>Risk</strong> <strong>Management</strong> within GP Practice<br />
The Corporate <strong>Risk</strong> Manager and 2 Practice Managers within CHP South have had early<br />
discussions to develop and implement a model of <strong>Risk</strong> <strong>Management</strong> within independent<br />
GP Practice.<br />
This work has continued and evolved to involve the Medical and Dental Defence Union<br />
(MDDUS) as partners in developing learning sessions for Independent practitioners on<br />
the feasibility of the use of electronic systems (DATIX) to support risk management in<br />
Independent Practice.<br />
Performance for Year 2008 – 09<br />
16
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
A review of the DATIX system has been undertaken by a Practice Manager (East Kilbride<br />
Locality), to assess the feasibility of use within practice, the feasibility of independent<br />
licence purchase, with a view to further discussion on extending the NSHL licence. A<br />
Short–Life Working Group has been agreed through the Medical Director and will be<br />
set–up to commence in September <strong>2009</strong>. Representation has been agreed and will<br />
include MDDUS, GMP’s Practice Advisors, Medical Director, Practice Manager and <strong>Risk</strong><br />
<strong>Management</strong>.<br />
Publication of the <strong>NHS</strong>L <strong>Risk</strong> Assessment for Disclosure<br />
The development of this risk assessment tool enables <strong>NHS</strong>L to apply a sound system to<br />
manage disclosure checks based on fair, consistent and accountable decision–making<br />
on employment, while ensuring protection of patients is maximised and that the rights<br />
of prospective employees in relation to disclosure are upheld.<br />
The tool and supporting protocols have been applied and tested over a 2 year period<br />
resulting in an established and reliable system which is ‘in Press’ to be published by the<br />
British Journal of Healthcare <strong>Management</strong> in June <strong>2009</strong>. The authors are Anne–Marie<br />
Carr, Associate Nurse Director (Bankaide), Carol McGhee, Corporate <strong>Risk</strong> Manager and<br />
Kelly–Anne McKendrick, Personnel Officer.<br />
The Corporate <strong>Risk</strong> Manger will be scheduled to deliver a presentation on the sharing of<br />
the development process of the risk assessment tool and the outcomes to the CG&RM<br />
Network before end of <strong>2009</strong>.<br />
A summary of the progress against the Work Plan 2008 – 09 is attached in Appendix 1<br />
and performance graded by the following coloured symbol:<br />
BLUE<br />
GREEN<br />
AMBER<br />
RED<br />
Completed<br />
On Target<br />
Delayed<br />
Unlikely to be achieved<br />
Performance for Year 2008 – 09<br />
17
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
Work Plan for Year 2008 – 09<br />
The key developments for the forthcoming year are driven by, and/or underpin:<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<strong>NHS</strong>L <strong>Annual</strong> Accountability Review<br />
Local Delivery Plan<br />
Corporate Objectives<br />
<strong>NHS</strong> QIS Standards<br />
Internal & External Audit <strong>Report</strong>s<br />
<strong>Risk</strong> <strong>Management</strong> Steering Group Requirements<br />
Emerging Priorities from <strong>NHS</strong>L Strengthening Quality Event<br />
The Work Plan forms the basis of the Department Team Meetings and is agreed,<br />
monitored and overseen by the members of the <strong>Risk</strong> <strong>Management</strong> Steering Group.<br />
The focus this year will be on:<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
Key Performance Indicators and Outcomes<br />
Outcomes from CIR to inform top 3 <strong>NHS</strong> systemic failures<br />
Changing the approach to the DATIX training for access, delivery and<br />
evaluation<br />
Implementing web-based risk register and monitoring effectiveness<br />
Populating and testing the standards module on DATIX<br />
Integration of data with other clinical data to improve Board reporting<br />
Reviewing codes for recording of Violence/Abuse/Harassment<br />
A summary of the prospective Work Plan for <strong>2009</strong> – 2010 is outlined in Appendix 2.<br />
Work Plan for Year 2008 – 09<br />
18
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09 Appendix 1a<br />
Ref. Recommendation(s) <strong>Management</strong> Action(s)<br />
2.01 A. <strong>Management</strong> ensure that<br />
an up-to-date documented<br />
reporting structure and<br />
escalation procedure is<br />
developed and that it is<br />
included as part of the <strong>Risk</strong><br />
<strong>Management</strong> Guidance<br />
Manual.<br />
The <strong>NHS</strong>L <strong>Risk</strong> <strong>Management</strong><br />
Guidance Manual will<br />
include procedures for<br />
reporting and the escalation<br />
procedures.<br />
B. <strong>Management</strong> ensure that all<br />
approved groups/committees<br />
for the discussion of incidents,<br />
and implementation of<br />
planned action arising from<br />
incidents, meet at the agreed<br />
time period.<br />
All partnership groups are<br />
in place as per the agreed<br />
Locality Partnership Group.<br />
C. <strong>Management</strong> should ensure<br />
that all incidents are<br />
recorded timeously and that<br />
contingency arrangements are<br />
put in place when the agreed<br />
inputer is not available.<br />
Within Localities there<br />
has been a contingency<br />
plan effective since 2005.<br />
The <strong>Risk</strong> <strong>Management</strong><br />
Department fast–tracked the<br />
roll out of the web system<br />
within Hamilton Locality<br />
and the CHPS Managers<br />
agreed to cross cover for any<br />
outstanding backlog.<br />
Within the Acute Division,<br />
all back logging was<br />
undertaken over a 3<br />
month period by the RM<br />
Department Oct – Dec 2006<br />
with no known outstanding<br />
backlog.<br />
PSSD have an internal<br />
contingency plan to<br />
maintain inputting.<br />
<strong>Management</strong><br />
Comments<br />
In general, the audit has<br />
identified some areas<br />
for improvement at<br />
operational level whilst<br />
acknowledging the<br />
progress at Strategic and<br />
Divisional Level. In terms<br />
of incident recording<br />
and reporting, there is<br />
a demonstrable month<br />
on month increase in<br />
incident reporting.<br />
<strong>Management</strong> accept that<br />
this was an exceptional<br />
situation at a point in<br />
time resulting from<br />
both organisation<br />
change and sick leave<br />
within the identified<br />
locality, not expected<br />
to recur, following full<br />
implementation of the<br />
web system.<br />
Responsible<br />
Officer(s)<br />
Corporate <strong>Risk</strong><br />
Manager on Behalf<br />
of the Divisional<br />
Directors.<br />
CHP Directors<br />
PSSD General<br />
Manager<br />
Implementation Date Performance<br />
Fully implemented by<br />
December 2008.<br />
(includes writing,<br />
consultation, testing,<br />
endorsement,<br />
printing, launching<br />
and refreshing of<br />
procedures).<br />
Completed<br />
Completed<br />
Appendix 1a<br />
19
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
Ref. Recommendation(s) <strong>Management</strong> Action(s)<br />
2.02 A. <strong>Management</strong> ensure that all<br />
staff verify the incidents on<br />
DATIX, are made aware, and<br />
given the appropriate training,<br />
of the need to complete the<br />
risk grading section entry.<br />
All verifiers are familiarised<br />
with the grading facility<br />
within DATIX during the<br />
training designed for<br />
verifiers only. <strong>NHS</strong>L requires<br />
to agree and set out the<br />
grading procedure and<br />
identify responsible persons<br />
within the <strong>Risk</strong> <strong>Management</strong><br />
Guidance Manual.<br />
B. <strong>Management</strong> ensure that all<br />
incidents are risk graded and,<br />
if appropriate, are included in<br />
the operational, divisional or<br />
corporate risk register.<br />
Set–out the escalation<br />
criteria/procedure of risk to<br />
the risk register through the<br />
<strong>Risk</strong> <strong>Management</strong> Guidance<br />
Manual.<br />
C. <strong>Management</strong> ensure that<br />
all departments maintain<br />
a local risk register. We do<br />
recognise that there could<br />
be no entries made for a<br />
considerable period of time.<br />
The risk register should also be<br />
reviewed on a regular basis, at<br />
least annually. If there are no<br />
entries, then the risk register<br />
should be notated as such.<br />
The <strong>Risk</strong> <strong>Management</strong><br />
Work Plan will outline<br />
developments in the <strong>Risk</strong><br />
Register Process for 2008–<br />
<strong>2009</strong>, which will ensure all<br />
GM’s for Acute, Localities<br />
and Corporate Services.<br />
As key risks emerge within<br />
services, the opportunity<br />
will be taken to set–up a risk<br />
register.<br />
Purchase of the Web–based<br />
<strong>Risk</strong> Register Module within<br />
DATIX to improve access<br />
across <strong>NHS</strong>L in development<br />
of their own risk registers<br />
<strong>Management</strong><br />
Comments<br />
<strong>Management</strong> have<br />
agreed that each division<br />
and directorate/locality<br />
will have a risk register<br />
in place reflecting their<br />
relevant activities and<br />
service areas. These<br />
registers will be actively<br />
maintained and updated<br />
at regular intervals.<br />
Partial completion with<br />
work in progress in all<br />
areas identified within the<br />
Work Plan.<br />
Responsible<br />
Officer(s)<br />
Corporate <strong>Risk</strong><br />
Manager on Behalf<br />
of the Divisional<br />
Directors.<br />
Corporate <strong>Risk</strong><br />
Manager on Behalf<br />
of the Divisional<br />
Directors.<br />
Corporate <strong>Risk</strong><br />
Manager on Behalf<br />
of the Divisional<br />
Directors.<br />
Implementation Date Performance<br />
December 2008<br />
December 2008<br />
March <strong>2009</strong><br />
Appendix 1a<br />
20
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
Ref. Recommendation(s) <strong>Management</strong> Action(s)<br />
2.03 <strong>Management</strong> reinforce to all users<br />
the necessity to fully complete the<br />
details on DATIX. <strong>Management</strong><br />
may also wish to consider if some<br />
of these aspects require further<br />
training of users or whether the<br />
updating of the <strong>Risk</strong> <strong>Management</strong><br />
Guidance Manual may address<br />
this.<br />
Will be met through the<br />
development and launch<br />
of the <strong>Risk</strong> <strong>Management</strong><br />
Guidance Manual.<br />
Compliance will be audited<br />
by the <strong>Risk</strong> <strong>Management</strong><br />
Department and reports<br />
issued to Divisional Directors<br />
for action.<br />
2.04 A. <strong>Management</strong> should review<br />
the number of locations still<br />
completing IR1 forms to<br />
ascertain if any further DATIX<br />
access can be achieved, thus<br />
achieving the objectives of an<br />
electronic recording system.<br />
There has been an initial<br />
agreement that staff who are<br />
not site based and have no<br />
immediate electronic access<br />
to report will continue to<br />
report on paper format, e.g.<br />
PSSD.<br />
B. <strong>Management</strong> investigate<br />
the possibility of limiting the<br />
number of sub–categories that<br />
are available to users when an<br />
incident is being recorded.<br />
Within PSSD there are cohorts<br />
where there is opportunity<br />
emerging to install electronic<br />
reporting. Review scheduled<br />
within the annual Work Plan<br />
2008 – 09<br />
The Systems Administrator<br />
has reviewed potential<br />
of duplicate codes. The<br />
sub–category is dependent<br />
on, and linked to, the main<br />
category of incident, e.g.<br />
a clinical and non–clinical<br />
incident could have<br />
categories, but the same<br />
sub–category.<br />
A series of meetings with<br />
key users to review codes/<br />
categories to ensure “fit<br />
for purpose” is already<br />
progressing with review<br />
plans for radiology complete,<br />
laboratories and theatres<br />
work in progress and code<br />
management within Health<br />
& Safety categories.<br />
<strong>Management</strong><br />
Comments<br />
<strong>Management</strong> accept that<br />
this will be a continuing<br />
feature, however there<br />
is a protocol agreed<br />
within PSSD to maintain<br />
best reporting and<br />
management practice.<br />
<strong>Management</strong> accept<br />
that on rare occasions,<br />
there will be duplicate<br />
sub–categories within the<br />
system.<br />
Responsible<br />
Officer(s)<br />
Corporate <strong>Risk</strong><br />
Manager on Behalf<br />
of the Divisional<br />
Directors<br />
Corporate <strong>Risk</strong><br />
Manager & GM PSSD<br />
Corporate risk<br />
Manager & GM<br />
PSSD.<br />
Systems Administrator<br />
Corporate <strong>Risk</strong><br />
Manager, Systems<br />
Administrator<br />
Implementation Date Performance<br />
December 2008<br />
Commencing July<br />
2008<br />
Complete<br />
September 2008<br />
July 2008<br />
December 2008<br />
Continuous<br />
Appendix 1a<br />
21
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09 Appendix 1b<br />
Summary of Progress Against Work<br />
Driver Objective Action Responsible Person Timescale Performance<br />
Local Delivery<br />
Plan/ HEAT<br />
Target<br />
T2.KPM 1<br />
Corporate<br />
Objectives<br />
<strong>NHS</strong> QIS<br />
Standards<br />
&<br />
Internal Audit<br />
and External<br />
Audit<br />
&<br />
RMSG Agenda<br />
Demonstrate continuous<br />
improvement by<br />
reaching the Trajectory<br />
Scoring Target (7) for<br />
compliance with the<br />
<strong>NHS</strong> QIS Standards by<br />
March <strong>2009</strong>, working<br />
towards scoring of 9<br />
for <strong>2009</strong> – 10 and 2010<br />
– 11.<br />
Refer to 2008 – 09<br />
corporate objective 2.1,<br />
2.2, 2.3 and 2.4.<br />
Development of the Use<br />
of the electronic <strong>Risk</strong><br />
<strong>Management</strong> System<br />
(DATIX)<br />
From the <strong>NHS</strong> QIS January 2007<br />
final report - influence and agree<br />
the work stream/actions through<br />
the H&CG Steering Group.<br />
Participate in then recently formed<br />
<strong>NHS</strong>L group to improve the<br />
performance against the national<br />
standards.<br />
Undertake a self–assessment for<br />
the <strong>Risk</strong> <strong>Management</strong> Standard<br />
1a to measure improvements.<br />
Scoring currently Level 3 – move<br />
to Level 4.<br />
Influence Performance Review<br />
Process against the Standards at<br />
Operational level.<br />
As above.<br />
Participate in the restructuring of<br />
the Health & Clinical Governance<br />
and <strong>Risk</strong> <strong>Management</strong> Directorate.<br />
Maintenance of an up–to–date<br />
<strong>NHS</strong> <strong>Lanarkshire</strong> Strategic <strong>Risk</strong><br />
Register.<br />
Integrate Modernisation/Service<br />
Improvement <strong>Risk</strong> Register with<br />
the <strong>NHS</strong>L Strategic <strong>Risk</strong> Register<br />
Ensure monitoring procedures<br />
for Divisional <strong>Risk</strong> Registers is<br />
effective.<br />
Full development of Locality and<br />
Division risk registers.<br />
Implementation of the 2 new<br />
modules:<br />
◦ Web–based risk register<br />
◦ Standards module<br />
Review of Current Practice:<br />
◦ System Codes<br />
◦ Audit and monitor the quality<br />
of data.<br />
Medical Director and<br />
Corporate <strong>Risk</strong> Manager<br />
Medical Director and<br />
Corporate <strong>Risk</strong> Manager<br />
Medical Director and<br />
Corporate <strong>Risk</strong> Manager<br />
Director of Strategic<br />
Planning & Performance<br />
Corporate <strong>Risk</strong> Manager<br />
and Designated Divisional<br />
Managers<br />
Corporate <strong>Risk</strong> Manager<br />
and nominated Managers<br />
Corporate <strong>Risk</strong> Manager<br />
and Designated RM Staff<br />
Systems Administrator<br />
December 2008<br />
Ongoing Review<br />
and Monitoring<br />
through the<br />
RMSG (schedule<br />
of reporting)<br />
December 2008<br />
December 2008<br />
December 2008<br />
Harmonisation of Cam/Glen<br />
and Northern Corrider incident<br />
information with NSHL.<br />
Corporate <strong>Risk</strong> Manager,<br />
Systems Administrator<br />
and General Managers<br />
March <strong>2009</strong><br />
Appendix 1b<br />
22
<strong>Risk</strong> <strong>Management</strong><br />
<strong>Annual</strong> <strong>Report</strong><br />
2008 – 09<br />
Driver Objective Action Responsible Person Timescale Performance<br />
<strong>NHS</strong> QIS<br />
Standards<br />
and<br />
Internal Audit<br />
& External<br />
Audit<br />
and<br />
RMSG Agenda<br />
(Cont'd)<br />
Review, Update, Cost<br />
and Launch <strong>NHS</strong>L <strong>Risk</strong><br />
<strong>Management</strong> Guidance<br />
Manual (based on<br />
former PCT Manual)<br />
providing local guidance<br />
across <strong>NHS</strong>L on <strong>Risk</strong><br />
<strong>Management</strong> Principles,<br />
techniques (based on<br />
AS/NZ Standards<br />
Review all current sections and<br />
updated Sections 4 and 5 to<br />
reflect QIS Matrix.<br />
Set–up short–life working group to<br />
write the <strong>NHS</strong>L Incident <strong>Report</strong>ing<br />
Policy & Procedure.<br />
Corporate <strong>Risk</strong> Manager<br />
Co-ordinator<br />
Launch to be<br />
completed by<br />
September 2008<br />
To have a fully function<br />
system of internal<br />
control.<br />
Follow–through recommendations<br />
from internal and external audit.<br />
Medical Director and <strong>Risk</strong><br />
Manager<br />
March <strong>2009</strong><br />
Monitor the RM<br />
Strategy Framework<br />
Includes single reporting system<br />
incident policy and procedures<br />
Scheme of Delegation, <strong>Risk</strong><br />
<strong>Management</strong> Strategy and<br />
Communication of the RM Data<br />
Corporate <strong>Risk</strong> Manager<br />
March <strong>2009</strong><br />
National<br />
& Local<br />
Developments<br />
Decontamination of<br />
endoscopes.<br />
Monitor the incident reporting of<br />
decontamination incidents within<br />
endoscopy, reporting within the<br />
external and internal structure.<br />
Corporate <strong>Risk</strong> Manager<br />
Ongoing to<br />
March <strong>2009</strong><br />
Develop a Model of Governance<br />
& <strong>Risk</strong> <strong>Management</strong> within 2<br />
voluntary GP Practices.<br />
Corporate <strong>Risk</strong> Manager<br />
and<br />
Practice Managers from<br />
Volunteer Practices<br />
December 2008<br />
Review the <strong>NHS</strong>L <strong>Risk</strong> Assessment<br />
for Disclosure.<br />
Corporate <strong>Risk</strong> Manager<br />
July 2008<br />
Scottish<br />
Patient Safety<br />
Programme<br />
(SPSP)<br />
Identify strategic and<br />
operational risks in<br />
implementing this<br />
programme.<br />
Develop a risk register.<br />
Corporate <strong>Risk</strong> Manager<br />
and<br />
Patient Safety Manager<br />
September 2008<br />
Appendix 1b<br />
23
Appendix 2: Summary of <strong>Risk</strong> <strong>Management</strong> Prospective Work Plan<br />
Driver Objective Aim Process Metrics Reponsible Person Timescale Corporate Objective RAG<br />
Stakeholder<br />
Involvement<br />
Involvement of staff<br />
and/or the public<br />
in risk management<br />
arrangements<br />
Through <strong>NHS</strong>L having<br />
agenda items on the<br />
Stakeholder Group,<br />
the PFPI Group and<br />
use of the SLWG<br />
representatives in<br />
reconvening an annual<br />
monitoring group<br />
Quarterly articles<br />
in 'The Pulse'<br />
relating to risk<br />
activity, including<br />
evaluation of<br />
effectiveness of risk<br />
arrangements<br />
J Allison<br />
In line with Comms<br />
timescales to<br />
ensure 4 articles per<br />
annum<br />
Involvement of<br />
Partners in the<br />
<strong>Risk</strong> <strong>Management</strong><br />
Arrangements<br />
Meet regularly with<br />
North & South LC<br />
<strong>Risk</strong> Managers and<br />
extended partners, e.g.<br />
police, fire and rescue<br />
Agree a consistent<br />
approach to<br />
joint agenda and<br />
strengthened<br />
processes, e.g. joint<br />
risk assessment for<br />
adverse outcomes<br />
for those receiving<br />
community care<br />
C McGhee/J Allison<br />
January 2010<br />
<strong>NHS</strong> QIS CG&RM<br />
Standards<br />
Development of<br />
Joint <strong>Risk</strong> Assessment<br />
Protocols for those<br />
receiving Community<br />
Care<br />
Review effectiveness<br />
of Protocol<br />
C McGhee/Rbt<br />
Peat/Dennis<br />
September <strong>2009</strong><br />
Monitor<br />
Effectiveness<br />
of Stakeholder<br />
Involvement<br />
Ensure safety<br />
and best care for<br />
patients, staff and<br />
the public<br />
Apply the process of<br />
reflection following<br />
each meeting with<br />
the North & South LC<br />
<strong>Risk</strong> Managers, and<br />
other joint initiatives<br />
and record the agreed<br />
actions and outputs<br />
Consistent and<br />
agreed approach<br />
to joint risk<br />
management<br />
demonstrated<br />
through recorded<br />
process via agreed<br />
strategic objectives<br />
and guiding<br />
principles<br />
C McGhee/J Allison<br />
January 2010<br />
Random Sample<br />
questionnaire to staff<br />
to assess adequacy of<br />
the Quarterly Pulse<br />
articles and assess<br />
requirements for future<br />
articles<br />
Demonstration of<br />
Best Approach to<br />
sharing information<br />
that is relevant to<br />
staff<br />
J Allison<br />
December <strong>2009</strong><br />
Appendix 2<br />
24
Driver Objective Aim Process Metrics Reponsible Person Timescale Corporate Objective RAG<br />
Strategic <strong>Risk</strong><br />
Objectives link to<br />
Organisational<br />
Objectives<br />
Ensure that risks<br />
link directly to<br />
corporate objectives<br />
Through CG&RM<br />
department identify<br />
and prioritise<br />
objectives that fully<br />
support the Corporate<br />
Objectives and agree<br />
through RMSG<br />
Available resource<br />
and activity is<br />
directed towards<br />
success of the<br />
corporate objectives<br />
C McGhee<br />
April <strong>2009</strong><br />
<strong>Annual</strong> update of<br />
corporate objectives<br />
within the DATIX<br />
system<br />
<strong>Risk</strong>s directly<br />
linked to corporate<br />
objectives<br />
J Allison/S Steven<br />
April <strong>2009</strong><br />
<strong>Risk</strong> is integrated<br />
into <strong>NHS</strong>L<br />
decision–making<br />
arrangements<br />
<strong>Risk</strong> management<br />
information<br />
supports decision–<br />
making at exec/<br />
management team<br />
level<br />
Provision of full set of<br />
Guidance for managers<br />
in <strong>Risk</strong> <strong>Management</strong><br />
<strong>Risk</strong> is identified<br />
and analysed<br />
consistently<br />
across all levels<br />
of management<br />
within <strong>NHS</strong>L<br />
J Allison<br />
June <strong>2009</strong><br />
<strong>NHS</strong> QIS CG&RM<br />
Standards<br />
Provide 'awareness'<br />
for all senior teams on<br />
utilising the Guidance<br />
Audit adherence to the<br />
<strong>Risk</strong> Register Guidance<br />
Confidence in<br />
compliance with<br />
Guidance<br />
Audit outcomes<br />
J Allison<br />
J Allison<br />
June <strong>2009</strong><br />
July <strong>2009</strong> – March<br />
2010<br />
Audit team/<br />
department meeting<br />
minutes to ensure<br />
risk management<br />
is part of learning<br />
and continuous<br />
improvement<br />
Audit outcomes<br />
J Allison<br />
September –<br />
October <strong>2009</strong><br />
Scope need, develop,<br />
test and implement<br />
e–learning package<br />
E–learning package<br />
J Allison<br />
September –<br />
December <strong>2009</strong><br />
Develop a culture<br />
of applying the<br />
principles of risk<br />
analysis and impact<br />
assessment when<br />
there is a moderate/<br />
major change of<br />
clinical practice<br />
Scope feasibility and<br />
methods of impact<br />
analysis, test and<br />
design methodology if<br />
appropriate<br />
Recorded risk<br />
analysis and impact<br />
assessment for<br />
moderate/major<br />
clinical change of<br />
practice.<br />
C McGhee/<br />
P Milliken<br />
March 2010<br />
Appendix 2 25
Driver Objective Aim Process Metrics Reponsible Person Timescale Corporate Objective RAG<br />
Monitor<br />
Effectiveness<br />
of Use of the<br />
Guidance<br />
Ensure risk<br />
management<br />
supports decision<br />
making at senior<br />
level<br />
<strong>Risk</strong> <strong>Management</strong> KPI's<br />
Sampling of 1:5 CIR<br />
reports<br />
Compliance with<br />
agreed KPI's<br />
demonstrating a high<br />
level of performance<br />
Compliance with<br />
best practice in<br />
report writing and<br />
sharing information<br />
J Allison/Internal<br />
Audit<br />
C McGhee/<br />
A Sommerville<br />
September <strong>2009</strong><br />
– March 2010<br />
September <strong>2009</strong><br />
– March 2010<br />
Threats and<br />
Challenges within<br />
the Systems are<br />
<strong>Risk</strong> Managed in<br />
Partnership<br />
Ensure that the<br />
risk management<br />
systems are<br />
effective in<br />
supporting staff<br />
to identify and<br />
manage risks<br />
Refresh principles of risk<br />
register development<br />
through the launch of<br />
the RM Guidance<br />
Undertake Quality<br />
Check of Current<br />
Operational <strong>Risk</strong><br />
Registers in partnership<br />
with Owners – Clinical<br />
Divisions and Localities<br />
Staff demonstrate<br />
a competence in<br />
development and<br />
monitoring of risk<br />
registers<br />
Consistency in<br />
description of and<br />
core controls for<br />
business risks<br />
J Allison<br />
Carol McGhee<br />
June <strong>2009</strong><br />
March 2010<br />
<strong>NHS</strong> QIS CG&RM<br />
Standards<br />
Full Development and<br />
Quality Checks with<br />
Heads of Function for<br />
IM&T and PSSD<br />
Support the<br />
development of<br />
Function <strong>Risk</strong> Register<br />
for Finance with<br />
Identified Champion<br />
Consistency in<br />
description of and<br />
core controls for<br />
business risks<br />
Maintain progress<br />
towards supporting<br />
all corporate services<br />
in developing and<br />
monitoring risk<br />
registers<br />
J Allison<br />
J Allison<br />
March 2010<br />
March 2010<br />
Support the progression<br />
and monitoring<br />
of Directorate <strong>Risk</strong><br />
Registers: Laboratories<br />
Continue training<br />
for DATIX verifiers<br />
for incidents and<br />
assess the need for<br />
risk register module<br />
training. Monitor the<br />
effectiveness of training<br />
Consistent<br />
development<br />
with laboratory<br />
accreditation systems<br />
Those requiring<br />
a higher level<br />
of training are<br />
identified and<br />
training completed<br />
by Systems Admin.<br />
Training schedule for<br />
DATIX<br />
J Allison<br />
March 2010<br />
Appendix 2 26
Driver Objective Aim Process Metrics Reponsible Person Timescale Corporate Objective RAG<br />
Continue training for<br />
DATIX verifiers for<br />
incidents & assess<br />
the need for for<br />
risk register module<br />
training. Monitor the<br />
effectiveness of training<br />
Those requiring<br />
a higher level<br />
of training are<br />
identified and<br />
training completed<br />
by Systems<br />
Administrator.<br />
Training schedule for<br />
DATIX<br />
S Steven March 2010<br />
Adequacy of<br />
risk assessments<br />
and controls are<br />
reviewed regularly<br />
Ongoing review<br />
of risk registers to<br />
ensure risks and<br />
assessments are<br />
reviewed regularly<br />
Maintain facilitation of<br />
the strategic risk register<br />
Strategic <strong>Risk</strong> Register<br />
is live and reviewed<br />
by the Executive<br />
Directors at agreed<br />
frequencies<br />
C McGhee<br />
March 2010<br />
Quarterly Review of risk<br />
review dates<br />
<strong>Risk</strong>s are reviewed on<br />
or near to the agreed<br />
review date by the<br />
owners/designated<br />
person<br />
S Steven<br />
March 2010<br />
<strong>NHS</strong> QIS CG&RM<br />
Standards<br />
Ongoing review<br />
of incident<br />
management to<br />
ensure incidents are<br />
managed effectively<br />
KPI's monitored through<br />
risk and governance<br />
committees<br />
Effective<br />
management of<br />
incidents<br />
J Allison<br />
March 2010<br />
Monitor<br />
Effectiveness<br />
of the Incident<br />
<strong>Report</strong>ing Forms<br />
DIF1 & DIF2<br />
Ensure the DATIX<br />
Incident <strong>Report</strong>ing<br />
Forms are Fit for<br />
Purpose<br />
National Benchmarking<br />
and Sharing of DATIX<br />
Incident <strong>Report</strong>ing<br />
Forms with RM<br />
colleagues through<br />
Scottish DATIX Group.<br />
A review of violence<br />
and aggression codes.<br />
<strong>Annual</strong> one-to-one with<br />
DATIX Consultant<br />
DIF1 & DIF2 are<br />
effective for staff to<br />
use and capture right<br />
information for <strong>NHS</strong>L<br />
S Steven March 2010<br />
<strong>Risk</strong> action plans<br />
are prioritised<br />
and reviewed at<br />
regular intervals<br />
To ensure systems<br />
fully support prioritisation<br />
and review<br />
of risk action plans<br />
To configure the DATIX<br />
system to enable audits<br />
of action plans<br />
Quarterly Monitoring<br />
<strong>Report</strong>s produced<br />
for relevant gov<br />
committees<br />
Compliance<br />
assurance for risk<br />
register management<br />
Compliance<br />
assurance for risk<br />
register management<br />
J Allison<br />
C McGhee<br />
March 2010<br />
March 2010<br />
Appendix 2 27
Driver Objective Aim Process Metrics Reponsible Person Timescale Corporate Objective RAG<br />
Information is<br />
used to drive<br />
improvement,<br />
reduce risk and<br />
stimulate learning<br />
Information<br />
drives quality<br />
improvement and<br />
training needs<br />
Assess level of RCA<br />
training requirements<br />
as revised Guidance is<br />
launched through early<br />
alert through the Staff<br />
Organisational Group,<br />
staff briefing and web<br />
page communication<br />
Organisation<br />
competence in<br />
identifying root<br />
causes of adverse<br />
incidents and a<br />
competence in using<br />
the information to<br />
inform change in<br />
practice<br />
C McGhee March 2010<br />
<strong>NHS</strong> QIS CG&RM<br />
Standards<br />
Effectiveness<br />
of the risk<br />
management<br />
framework is<br />
reviewed at<br />
regular intervals<br />
and modifications<br />
made<br />
To have an overall<br />
effective risk<br />
management<br />
framework within<br />
<strong>NHS</strong>L<br />
Review the DATIX<br />
System to assess the<br />
effectiveness of the<br />
escalation process<br />
Provide the RMSG<br />
with all evaluation and<br />
monitoring reports as<br />
scheduled within the<br />
<strong>Annual</strong> Work Plan as<br />
reports are completed<br />
Effective<br />
measurement of<br />
compliance with the<br />
Escalation Procedure<br />
Alerts on constraints,<br />
reporting of success<br />
is noted by the<br />
RMSG as overseeing<br />
CMT Group. Mid<br />
year Work Plan<br />
progress report to<br />
RMSG<br />
J Allison<br />
C McGhee<br />
March 2010<br />
October <strong>2009</strong><br />
Audit the outcomes<br />
from the Verifiers Role<br />
Audit <strong>Report</strong><br />
S Steven<br />
December <strong>2009</strong><br />
Quality Event<br />
& Endorsed<br />
<strong>Annual</strong> CG&RM<br />
Work Plan<br />
Improve education<br />
and development<br />
opportunities<br />
for clinical staff<br />
in undertaking<br />
critical incident<br />
reviews using root<br />
cause analysis<br />
techniques<br />
Develop a culture<br />
of applying risk<br />
analysis and<br />
impact assessment<br />
when there is a<br />
moderate/major<br />
change in clinical<br />
practice<br />
Monitor emergence<br />
of education/<br />
development<br />
needs following<br />
the launch of<br />
the specific RM<br />
Guidance, identify<br />
with OD suitable<br />
programme of<br />
learning<br />
Review use of<br />
existing guidance<br />
and further develop<br />
guidance to include<br />
impact assessment<br />
Paper to set out<br />
potential requirements<br />
via Strategic OD Group.<br />
Monitor requirements<br />
with OD via PDP<br />
Scope out potential<br />
courses and costs<br />
Scope feasibility and<br />
methods of impact<br />
analysis, test and<br />
design methodology if<br />
appropriate.<br />
<strong>Report</strong> to RMSG on<br />
the assessed level of<br />
need.<br />
Recorded risk<br />
analysis and impact<br />
assessment for<br />
moderate/major<br />
clinical change of<br />
practice.<br />
C McGhee<br />
C McGhee<br />
C McGhee<br />
CMcGhee/P<br />
Milliken<br />
March 2010<br />
March 2010<br />
March 2010<br />
March 2010<br />
Appendix 2 28
Driver Objective Aim Process Metrics Reponsible Person Timescale Corporate Objective RAG<br />
Emerging<br />
Corporate <strong>Risk</strong><br />
Issues<br />
Identify the top<br />
3 breaches of<br />
systems of care<br />
by reviewing CIR's<br />
using RCA<br />
Corporate Process<br />
of Managing,<br />
Cataloging and<br />
Reviewing all<br />
NSHL Policies<br />
Following launch of<br />
the RM Guidance,<br />
review the findings<br />
from CIR reports,<br />
continuously collate<br />
to inform the RMSG<br />
of top 3 breaches<br />
of systems, risk<br />
assess and discuss<br />
solutions and/or<br />
actions.<br />
To have a selfmanaging<br />
process<br />
of managing,<br />
cataloguing,<br />
monitoring and<br />
reviewing of all<br />
NSHL Policies<br />
Review of completed<br />
CIR findings and collate<br />
across <strong>NHS</strong>L<br />
Resource additional<br />
hours to <strong>Risk</strong><br />
<strong>Management</strong><br />
Department<br />
Agree PID through<br />
RMSG<br />
Quarterly reporting<br />
to RMSG<br />
Completed self<br />
managing system<br />
with quarterly reports<br />
and compliance<br />
C McGhee March 2010<br />
P Wilson /<br />
C McGhee<br />
C McGhee<br />
May <strong>2009</strong><br />
June <strong>2009</strong><br />
Develop and implement<br />
system<br />
C McGhee<br />
December <strong>2009</strong><br />
Appendix 2 29