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

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

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