Risk Management Annual Report - August 2009 ... - NHS Lanarkshire
Risk Management Annual Report - August 2009 ... - NHS Lanarkshire
Risk Management Annual Report - August 2009 ... - NHS Lanarkshire
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<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 />
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