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

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