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

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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 10
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 11
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Risk Management Annual Report - August 2009 ... - NHS Lanarkshire

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