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

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
6