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

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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
Risk Management Annual Report 2008 – 09 Electronic Risk Management System: DATIX Audit to Review the Electronic Management System: DATIX NHSL currently has a license that covers 6 DATIX modules: Incident Recording, Risk Register, Complaints, Claims, PALS and Standards. As part of the overall review of the existing risk management guidance, the DATIX system was also subject to further audit of effectiveness reviewed in light of the findings. A report based on the following outcomes was received by the RMSG and improvements supported and subsequently implemented: Incidents The incident module has been in place across Primary Care since 2003 and NHSL–wide since 2006. With the exception of PSSD, all incidents are now recorded electronically on the system. PSSD record incidents on paper forms with this information then input to the Datix system. Current incident recording process: Any member of staff witnessing or involved in an incident of any type records this electronically on the DIF1 (Datix Incident Form). Incident goes in to holding area ready for verification using a DIF2 electronic form. The verifier is the line manager of the individual reporting the incident. Once verified the incident is automatically added to the main database. Anecdotal evidence suggested that members of staff completing the DIF1 and those verifying the DIF2 forms are finding some of the fields confusing and can often wrongly categorise a number of fields. In July 2008 the Risk Management Department carried out an audit of completed DIF1 and DIF2, which had remained unverified, to determine if this is the case and, if so, which fields may require to be reviewed. The results of this audit established that: ACTION: The name of the person involved in the incident was frequently left blank. This is now a mandatory field, with help text to guide those completing the form. Many members of staff completing the DIF1 form were completing the Division and Directorate fields incorrectly. The system is in the process of being reconfigured to reflect the current Divisional and Directorate structures. ‘Combo’ links reduce the number of options at each field which should in turn reduce the number of errors. The ‘type’ of incident is the first window which categorises the risk, if either this field and/or the next window ‘category’ are completed incorrectly subsequent reports will be inaccurate. A revised ‘type’ and ‘category’ dataset has been developed and is to be tested with members of staff recording incidents and with staff who draw reports from the system. Performance for Year 2008 – 09 7
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Risk Management Annual Report - August 2009 ... - NHS Lanarkshire

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