bod feb 10 f - risk strategy update - poole hospital feb 10 f - risk strategy... · 2012. 10....

BOARD OF DIRECTORS PAPER – COVER SHEET

Meeting Date: 24 February 2010 Agenda Item: 9 Paper No: F Title:

RISK MANAGEMENT STRATEGY 2009 - UPDATE

Purpose:

The Risk Management Strategy has been amended to reflect the additional monitoring requirements for NHSLA level 3 and to also strengthen the reference to the process for assessing of strategic risk.

Summary:

The process for assessing strategic risks within the Trust has been clarified (page10/3.3) and a strategic risk register process flow chart introduced (Appendix k) The process flow describes how strategic risks identified at Care group level, through the business planning process or via the assurance framework are identified, risk assessed, action plans put in place and the risk register reviewed accordingly. Through the review of the corporate risks process an additional category of strategic risks (high level business risks linked to the trusts ability to deliver the annual plan and strategic objectives) has been added to the DATIX system. The category of Corporate risk remains (risks identified at Care group/Directorate level that have trust wide implications) The monitoring section (page 18/7) has been expanded to include specific details of how the components of the NHSLA Risk Management standards will be monitored, the frequency of the monitoring, who is responsible for ensuring the monitoring takes place and to which key committee will the reports be submitted to.

Recommendation:

The Board of Directors is asked to acknowledge and approve the above amendments to the Risk Management Strategy

Prepared by:

MANDY RANN Assistant Director of Nursing

Presented by:

MARTIN SMITS Director of Nursing

This report is relevant to: (Please tick relevant box) Assurance Framework

Risk Register I/D No.

Healthcare Standards: NHSLA Level 3 Please specify which standard

Financial implications YES / NO

Monitor compliance

Human Resources implications YES / NO

Internal monitoring

Legal implications YES / NO

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Date: November 2009 Author: Mandy Rann, Assistant Director of Nursing – Governance

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RISK MANAGEMENT

STRATEGY

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SUMMARY POINTS

This procedure: The Risk Management Strategy incorporates both clinical and non-clinical risk management: the whole being a key focus of quality. The overall objectives of the Strategy are to:

• Develop safer systems of work • Reduce injuries to patients and all staff • Ensure a safer environment, and • Enhance staff awareness • Support “The Poole Approach”

DOCUMENT DETAIL

Author: Mandy Rann Job Title: Assistant Director of Nursing – Governance Signed: Date: Version No: (Author Allocated) 3

Document Reference No: (Allocate from Directorate Policy Register)

RM 001

Next Review Date: May 2011 Approving Body/Committee: Board of Directors Chair: Peter Harvey Signed: Date Approved: 27th May 2009 Target Audience: Whole Trust Date Equality Impact Assessment Complete: 1st May 2009

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DOCUMENT HISTORY

Date of Issue

Version No.

Next Review

Date

Date Approved

Director Responsible for

Change

Nature of Change

May 2007 1 May 2009 Oct 2008 Director of Nursing & Patient Services

Minor amendments

May 2009 2 May 2011 May 2009 Director of Nursing & Patient Services

Review and update strategy

Sept 2009

3 May 2011 Nov 2009 Director of Nursing & Patient Services

Review of monitoring tool - Section 7. Process for assessing strategic risk updated – Section 3.

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TABLE OF CONTENTS

Page

1 INTRODUCTION 6

1.1 Relevant to: All Staff 6

1.2

Consultation

6

2 MANAGEMENT OF RISK 7

2.1 Key Indicators 7

2.2 Key Risks 7

2.3 Definitions - Strategy 9

2.4 Document Development 8

3 RESPONSIBILITIES AND REPORTING ARRANGEMENTS 8

3.1 Process for Board and High-Level Committee Review of the

organisation-wide Risk Register 9

3.2 Trust’s Assurance Framework 9

3.3 Process for assessing strategic risks 10

3.4 Relationships between the various Trust Committees with

responsibilities for Risk Management 10

3.5 Process for the management of risk locally 10

4 THE RISK MANAGEMENT PROCESS AND INFORMATION

REQUIREMENTS 12

4.1 Risk Assessment 13

4.2 Risk Register 15

4.3 Incident Management 16

4.4 Health & Safety 17

4.5 Infection Control

5 LINKS TO QUALITY 17

6 SPECIFIC OBJECTIVES AND TRAINING SUPPORT 18

6.1 Development of a Risk Management Focus within other initiatives 18

6.2 Education & Training 18

6.3 Dissemination

7 MONITORING EFFECTIVENESS AND REVIEW 18

7.1 The Strategy 18

7.2 Monitoring Compliance 19

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7.3 Monitoring Details 19

7.4 Incident Reporting Process 19

8 ARCHIVING

9 REFERENCES

9.1 National Health Service Litigation Authority (NHSLA) Risk

Management Standards 2009

APPENDICES:

A Governance and Risk Management Committee Structure 24

B Roles and Responsibilities for Risk management 25

C Executive Leads for Specific Areas of Risk 29

Terms of Reference:

D − Risk Management and Safety Committee 30

E − Clinical Governance Committee 34

F − Audit and Governance Committee 42

G Risk Register Assessment Tools 45

H Equality Impact assessment 49

I Policy Intent 50

J Document control checklist 51

K Strategic Risk Register Process 52

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1. INTRODUCTION

The Risk Management Strategy incorporates clinical, corporate and non-clinical risk

management the whole being a key focus of quality. The clinical risk element is an

integral part of Clinical Governance, whilst the non-clinical risk activity must meet the

statutory obligations of the Health & Safety at Work Act. The overall objectives of the

Strategy are to:

• Develop safer systems of work

• Reduce injuries to patients and all staff

• Ensure a safer environment, and

• Enhance staff awareness

• Support “The Poole Approach”

• Integrate clinical, corporate and non-clinical risks

In order for Risk Management to mature and progress, it must be recognised by all

members of the Trust to take individual ownership of Risk in their particular area.

The Trust recognises that Risk Management forms an integral part of its philosophy,

practices and business plans. It is committed to taking all reasonable steps in the

management of risk with the overall aim of providing a safe, risk controlled

environment for its patients, staff, contractors and the general public. The Trust’s

Risk Management Strategy reflects the principles set out in the Trust’s Corporate

Objectives which include:

• Ensure effective and efficient use of resources and where appropriate evidenced

by benchmarking

• Meet National and Local access, quality and safety standards including meeting

milestones towards achieving the 18-week target

• Develop infection control measures and reduce levels of hospital acquired MRSA

and Clostridium Difficile

• Meet ‘Standards for Better Health’ requirements

• Continue to take forward work to implement the National Service Frameworks

• Maintain a safe environment for all patients, visitors and staff and meeting

National Health Service Litigation Authority (NHSLA) Level 2 requirements and

plan for Level 3

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Date: November 2009 Author: Mandy Rann, Assistant Director of Nursing (Governance)

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• Develop governance systems and processes including the assurance framework,

which supports requirements of Foundation Trust authorisation and ensure

inclusive and active Foundation Trust membership arrangements

• Ensure the positive reputation of the Trust and strengthen both internal and

external communication systems, and further develop collaborative working

across the Healthcare community.

1.1 Relevant to All Staff

1.2 Consultation The consultation process for this Strategy is via the members of the Trust’s Risk

Management and Safety Committee.

2. MANAGEMENT OF RISK

Risk is the likelihood of an untoward event happening that may either cause harm or

have an impact upon the Trust’s patients, staff, contractors, visitors (including the

general public) assets and/or reputation.

Poole Hospital Foundation NHS Trust aims to ensure a co-ordinated and holistic

process, which includes the following steps to:

• Assess the risk by a logical and systematic method of identifying, quantifying,

analysing and evaluating potential risks, followed by a decision to accept,

reduce or eliminate those risks

• Record the residual significant risk onto the Trust Risk Register

• Communicate the risk to stakeholders and inform the business planning, risk

and governance processes of the Trust

• Take action to control (or treat) the risk via prioritised Action Plans

• Review the Risk Management Performance via indicators and via compliance

with validated Standards such as the NHSLA (National Health Service

Litigation Authority) risk management standards.

• This Risk Management Strategy applies to the management of all risk within

the Trust associated with the services, operations and business of the Trust.

These include:

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• Corporate risk – threats to the achievement of the key aims of the Trust,

both strategic and operational (e.g. development of the site, waiting list

targets, performance targets, etc.) financial risks, information technology

risk (e.g. of computer systems failures) human resource risks, risks to the

reputation of the Trust.

• Clinical risk – the risk of harm to patients, staff and relatives in carrying

out clinical activities (e.g., the control of infection)

• Non-clinical risk – includes health and safety risks – the range of risks

associated with the personal health and safety of staff, patients and

visitors; employer’s legal responsibility to maintain a safe and secure

workplace.

The Strategy identifies clear lines of accountability for managing risk throughout the

Trust and the structure within which this will occur.

The Strategy also assists the Trust in achieving compliance with Care Quality

Commission (CQC) Registration requirements, National Patient Safety Agency

(NPSA) requirements and other national risk management standards, such as the

National Health Service Litigation authority (NHSLA).

2.1 A number of key indicators that support implementation of this strategy have been

identified and are reported by Clinical Care groups/Directorates via the Quarterly

performance review process to the Executive team with summary reports to the

Board of Directors and by Quarterly summary report to the Risk Management and

Safety committee. The key indicators are also subject to the Trusts internal audit

process.

2.2 Key risk related indicators are listed below:

• Adverse incidents by category and subcategory

• Reported incidents by grade/severity of harm

• Number of Serious untoward incidents (SUI’s)

• Actions taken resulting from an incident

• Risk assessments and review / additions to the risk register

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2.3 Definitions – Strategy

A Strategy is a Board Level document which identifies the aims and objectives for the

Trust in a given subject area, i.e., Risk Management Strategy.

2.4 Document Development

The Risk Management Strategy is an essential element in ensuring the Trust has

robust risk management systems in place to manage and reduce risks. The

presence of a Risk management Strategy is a requirement of the NHSLA Risk

Management standards.

3. RESPONSIBILITIES AND REPORTING ARRANGEMENTS

The focus for risk management is the Risk Management and Safety Committee. This

is chaired by the Director of Nursing & Patient Services and has representatives from

all Care Groups and Directorates, Clinical and Non-clinical, Trust-wide. The Risk

Management and Safety Committee reports to the Hospital Executive Committee,

and through the Hospital Executive to the Board of Directors. Its minutes are

scrutinised by the Audit and Governance Committee. In addition, information is

exchanged with other committees, for example; Clinical Governance Committee,

Education Committee, Infection Control Committee and Information Committee. The

organisational risk management structure detailing all those committees/

subgroups/groups which have some responsibility for risk can be found in appendix A

Members of the Risk Management and Safety Committee are responsible for liaising

with their Care Group (Clinical or Non-clinical) to ensure a two-way flow of

information.

• The Director of Nursing & Patient Services, in conjunction with the Medical

Director, has executive responsibility for all aspects of Risk Management and

operational Clinical Governance. The Director of Nursing & Patient Services has

overall responsibility for the day-to-day administration of the Risk Management

Department through the Assistant Director of Nursing (Governance).

• The Director of Finance and Information oversees financial risk

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• The Director of Finance and Information is responsible for operational risk that

includes physical infrastructure of the Trust.

• The Chief Executive is responsible for all aspects of organisation risk.

• The Director of Operations is responsible for Business Continuity Risks

The duties, roles and responsibilities for key staff involved in risk management

activities are shown in Appendices B and C.

3.1 Process for Board and high level committee review of the organisation wide risk register

3.2 The Director of Nursing & Patient Services is responsible for the development and

maintenance of the Trust’s Assurance Framework and Risk Register. The

Assurance Framework will be updated biannually and presented to the Board of

Directors. The Risk Register (Red and Amber risks) is reported to the Board of

Directors biannually by the Director of Nursing & Patient Services. New risk and

risks beyond the review date are reviewed by the Risk Review Group and all new risk

are reported to the monthly Risk Management and Safety Committee by the

Assistant Director of Nursing (Governance). New risks are reported on a quarterly

basis to the Audit and Governance Committee. Incidents and risk are closely

monitored locally by the individual risk groups within each Care Group and reported

via the Trust’s Quarterly Performance Review process.

3.3 Process for assessing Strategic Risks

The Trust’s Assurance Framework is produced annually and reviewed at least 6

monthly by the Board of Directors. The Framework contains the identification of the

strategic risks that could affect the Trust’s ability to meet its strategic goals, the

controls in place and Risk Register reference. Strategic risk process Appendix K.

Strategic risks are reviewed at the Bi-monthly high level Risk Register Review Group,

by the Director of Nursing and Patient Services, which reports to the Risk

Management and Safety Committee and by Internal Audit annually which reports to

the Audit and Governance Committee.

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A strategic risk review meeting, including all the Non-Executive Directors will be held

once a year to ensure the Strategic Risk Register is robust and appropriately

scrutinised.

Risks identified at Care Group level deemed to affect more than one Care

Group/Directorate will be considered by the high level Risk Register Review Group

for inclusion on the Corporate Risk Register (Risks that affect departments/staff

groups across the organisation or the strategic risk register (for all business or

financial risk that affect the Trust’s ability to meet its Strategic objectives.

All risks will be subject to the Trust’s Risk Assessment process (Appendix G) and

development of action plans, monitored via the local risk groups, high level risk group

and Board of Directors.

Please see 4.2 for the process for assessing all other types of risk.

3.4 Relationships between the various Trust Committees with responsibilities for Risk Management.

All the Trust Committees that have a risk management and governance remit are

responsible directly to the Hospital Executive Committee and through the Hospital

Executive Committee to the Board of Directors. The Audit and Governance

Committee scrutinises the work of all Trust Committees.

3.5 Process for the management of risk locally.

Individual Clinical Care Group Risk Management Groups are responsible for the local

implementation of the Risk management Strategy and management of risk locally.

Annual WASH (Workplace assessment of safety and health) risk assessments will

also be completed by wards and departments (please refer to section 4.1) which are

then reported via the QPR process and quarterly risk reports to the risk management

and safety committee.

Risk groups will meet at least quarterly and meetings will be conducted in line with

their terms of reference. Minutes will be recorded and summarised into a formal risk

and safety report as part of the Quarterly Performance Review (QPR) process and

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also submitted to the Risk Management and Safety Committee on a quarterly basis

via the nominated Clinical Leads or representative who are responsible for the

exchange of information (both to and from) the Care Group or Directorate they

represent. Risk Groups will review their Terms of Reference and Attendance

records annually. A summary of the risk groups can be found below:

Clinical Care Group Risk meetings:

Care Group Risk Group title Chairperson Frequency

MEDICINE Medicine and Specialist Medicine Specialty Manager Bi Monthly

Department of Elderly Medicine Specialty Manager Bi monthly

Emergency Care Specialty Manager Quarterly

Oncology Governance and Risk. Consultant Oncologist Monthly

SURGICAL Surgery and Anaesthetics Consultant Anaesthetist Monthly

Trauma and Orthopaedics Specialty Manager Monthly

MC & POD Radiology and IRIS Radiology Manager Quarterly

Outpatients Risk and Clinical Governance.

Matron Monthly

NICU Matron Monthly

Medication Incident Review Group Chief Pharmacist Monthly

Obstetric Lead Clinician for Risk Bi Monthly

All Non-Executive Directors of the Board of Directors have an open invitation to

attend the Risk Management and Safety Committee meetings. Attendance will be

recorded and reviewed annually. Executive Directors attend meetings of the Audit

and Governance Committee by invitation.

There is overlapping membership of all the key Risk Committees including Health &

Safety, Infection Control, Clinical Governance and Risk Management & Safety. See

individual Terms of Reference – APPENDIX D-F.

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4. THE RISK MANAGEMENT PROCESS AND INFORMATION REQUIREMENTS

There are many ways in which the risk within Poole Hospital NHS Foundation Trust

can be identified so that it is possible to assess and manage them. The most

important aspects of risk identification are outlined in the table below (FIGURE 1),

along with the specific identification mechanisms relating to each.

Aspects of Risk

Identification

Examples of Specific Mechanisms

for Identifying Risks Occurrences

• Incidents • Claims • Complaints • Sickness and absence records • Staff turnover • Patient and staff satisfaction measures • Environmental walkabouts • Hotline reporting

External Scrutiny and Inspections

• Insurers • IWL and other accreditation bodies’ reports • Care Quality Commission Improvement Reviews • Specialist Inspections, e.g., NHSLA, HSE, Peer Reviews

Internal Assessments

• Specialist Committees *(e.g. Infection Control, Drug &

Therapeutics, Resuscitation, Health & Safety, Occupational Health)

• Clinical Audit and Records Review • Risk assessments in wards and departments (WASH

audits) • Networking use of media reports and information from

other Trusts • Internal Audit Reports

Figure 1

Each of the mechanisms listed is an important source of risk information, and it is full

and accurate risk information that drives the risk management process. Also changes

in Legislation or National Guidelines may well occur, resulting in additional risks to

the organisation.

4.1 Risk Assessment

Risk Assessments will be carried out on an annual basis or earlier where major

changes have taken place. A risk assessment will also be undertaken prior to a new

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risk being added to the Risk Register. Please see 3.3 for the process for assessing

Strategic risks.

To fulfil this requirement, each Ward/Department Manager will identify (as a

minimum) a named person to undergo Risk Assessment training provided by the

Education and Development Team. Details of the tools in use, in order to carry out

risk assessments can be found in the Incident Management Policy.

Workplace Assessment of Safety & Health (WASH) (formerly the H&S Audit

document is used as a comprehensive workplace assessment tool and when

completed will identify the need for further specific established assessments, e.g.

Display Screen Equipment, Manual Handling, COSHH, Violence and Aggression.

Identified hazards that are not covered by the established Risk Assessments will be

assessed using the generic Risk Assessment Tool and may include:

• Health and Safety risks (e.g., accident / injury risks to staff, patients and others)

• Operational risks (e.g., service delivery, IT, waste management, environmental,

facilities management and Estates Management risks)

• Clinical risks (e.g., infection control, medication, surgical/anaesthetic risks)

• Corporate risks (e.g., assurance framework objectives, financial, HR and service development risks).

The Risk Consequence Table (APPENDIX G) involves rating risk according to their

consequence (severity) and the likelihood that those consequences will occur. A risk

rating is then assigned by combining the two factors (severity and likelihood) in the

context of what existing control measures are currently implemented. The matrix

forms a simple approach to quantifying risks using a 5 x 5 risk rating and provides a

colour coded risk score of likelihood x severity.

Once risks have been identified, they must be assessed and prioritised using the

tools shown in Appendix G. The “Risk Consequence Table” refers to the relative

seriousness of different types of risk should they occur. The “Finance” column refers

to financial losses from all sources and is not a specific reference to damages

payments.

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The Trust acknowledges that some of its activities may, unless properly controlled,

create organisational risks, and/or risks to staff, patients and others. The Trust will,

therefore, make all effort to either eliminate risk or ensure that risks are as low as

reasonably practicable.

However, it is not possible to reduce all risk to zero and it is sometimes necessary to

make judgments about achieving the correct balance between benefit and risk, i.e.,

sometimes the benefits to be gained by taking a risk outweighs the risk itself, on

other occasions the latter may be the case or, the cost of controlling the risk

outweighs the level of risk involved.

To deal with these complexities, the Trust Risk Assessment Process provides a basis

for defining “acceptable” risk.

“Acceptability” implies that we are prepared to accept a risk as it is. In order to

provide a framework for identifying acceptable risk, a standard risk matrix is used for

risk assessment. The matrix (based upon the NPSA guidelines and NHS Standards

for Risk Grading [AS/N25, 4360: 1999]) applies to the assessment of all types of risk.

4.2 Risk Register

Risks are graded “Red”, “Amber”, “Yellow” or “Green”. Responsibility for maintaining

and managing the Care Group/Directorate Risk Register lies with the Associate

Director of Operations / Assistant Director / Lead. All identified risk must be

forwarded to the Risk Management Department. Risks identified as “Red” or

“Amber” following grading must be reported to the Risk Management team for

inclusion on the Trust Risk Register. Risks are then reviewed bi monthly by the Risk

Review Group and actions to investigate the risk considered. The Assistant Director

of Nursing (Governance) reports new risks graded “Red” or “Amber” to the monthly

Risk Management and Safety Committee, and the Director of Nursing reports to the

Board of Directors at least six-monthly. All new red and amber risks are scrutinised

by the Audit and Governance committee quarterly. This allows for the key risks to

influence ongoing strategic planning and the review of corporate objectives. Key

Business risks are also included in the Trust Assurance Framework which is

reviewed annually as part of the Trusts annual planning cycle.

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4.3 Incident Management

The Trust has in place an Adverse Incident Reporting System (AIRs). The AIRs

system is used by staff to report all clinical and non-clinical adverse incidents and

near misses. The Risk Management Department manages the AIRs system and

associated Database. A copy of the Trust’s Adverse Incident Reporting and

Management Policy is available as a separate document. The adverse incident

management process if outlined in figure 2.

In the circumstances of a major Serious Untoward Incident (graded as RED outcome

using the NPSA grading tool for Adverse Incidents) the Serious Untoward Incident

Policy should be followed.

The successful implementation of the Trust-wide Adverse Incident Reporting system

has required the generation of a culture that accepts that the reporting of Adverse

Incidents and Near-misses is, on a “fair blame” basis with a few exceptions that

would have carefully defined and agreed by the Board of Directors, Staff-side and

Consultant Body.

A copy of the AIRs form is automatically passed to the appropriate line manager the

purpose is to trigger action to prevent or reduce the risk of repeated incidents as

possible. The adverse incident, or near-miss, will be graded in the Risk Management

Department. The adverse Incident or Near Miss will be investigated as appropriate;

the Trust process for this is detailed in the Adverse Incident Reporting Management

Policy.

Clinical Care Group, Directorate and Corporate residual risks which are identified as

having the potential for a high level of adverse consequence are placed on the Trust

Risk Register. The management and process for this is detailed Appendix G, Risk

Register Assessment Tool.

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Adverse Incident Management

Figure 2

The Trust's nominated Fire officer is responsible for all fire related matters across the

Trust. Individual wards/departments have responsibility at local level for fire related

procedures. Fire reports are forwarded to the appropriate Risk Manager and to the

Nominated Officer for Fire.

4.4 Health and Safety

In addition to its statutory requirements in terms of Health & Safety, Poole Hospital

NHS Foundation Trust seeks to deliver a high quality health care service in a work

environment that is conducive to securing the safety, health and welfare of its

employees.

The Trust has a Risk Manager (Health & Safety) supported by a team of local Health

& Safety representatives. The Risk Management Department provides support,

advice and practical assistance to management and staff in meeting the legal

obligations under the Health & Safety at Work Act, 1974 and related legislation.

The Trust’s Fire Officer has responsibility for undertaking fire risk assessments at

Trust and local levels. The results of these assessments are fed to the Director of

Adverse Incident or

Near Miss Prevent further harm

Line Manager informed

Complete AIRS Form within 24 hours

Middle copy to be keep for originator’s records

ACTION ACTION

Root Cause Analysis (If necessary)

APPROPRIATE RESPONSE

APPROPRIATE RESPONSE

Learn lessons Change practice

Improve Safety and Quality of Care

YES NO YESNO

Top Copy to Risk Management

Department

Bottom Copy to Manager

(Risk graded)

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Finance. In addition, a copy of this assessment is forwarded to the appropriate Risk

Manager.

It is important that these structures and processes for Health & Safety integrate

closely with the other risk management functions defined in this document. As far as

possible, common approaches to issues such as incident reporting and risk

assessments have been adopted. The Health & Safety Committee reports directly to

the Risk Management & Safety Committee.

4.5 Infection Control

Risks associated with Infection Control are managed and monitored by the monthly

Infection Control Committee chaired by the Director of Nursing Patient Services. The

Director of Infection Prevention and Control also provides monthly reports to the Risk

Management and Safety Committee and the Board of Directors.

5. LINKS TO QUALITY

The Complaints, Claims and Incident Review Group will be responsible for the

integration and analysis of statistical information from all clinical and non-clinical

incident reports, claims and complaints in order to learn from errors, reduce risks and

focus resources more effectively.

The role of the Review Group is to promote a culture of learning from complaints,

claims and incidents through the review of trends and joint themes on an aggregated

basis. This will ensure that recommendations arising from the investigation of

complaints, claims and incidents are implemented across the Trust, and to monitor

progress accordingly.

6. SPECIFIC OBJECTIVES AND TRAINING SUPPORT

6.1 Development of a Risk Management Focus within Other Initiatives

The risk management approaches adopted by the Trust are equally applicable in all

areas and are built into all future planning and development. In particular, the

methodologies for identifying, assessing and prioritising risk will be used by the

relevant Directors, or their nominated deputy, to undertake risk assessments in the

following areas:

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• Capital planning, and in particular the National Development Plan

• Procurement

• Service Planning

• Re-organisation and re-structuring

6.2 Education and Training

Poole Hospital NHS Foundation Trust is committed to the provision of risk

management training for staff to ensure the establishment and ongoing maintenance

of safe systems of care. Training will be appropriate to the staff groups receiving it

and the range of training events can be found in the Trusts annual training

prospectus. This training includes;

• Annual Board seminars, Executive briefings and other specific risk related training events for Executive and Non-Executive Directors, and Senior Managers

• Training is aimed to raise awareness of clinical and non clinical risk issues,

incident reporting and risk assessment; and to provide key skills that can then be

tailored to each clinical specialty or department

6.3 This Strategy is underpinned by a number of key Policies – Appendix I.

7. MONITORING EFFECTIVENESS AND REVIEW

7.1 This Strategy will be reviewed by the Board every two years or sooner if major alterations are required. Minor amendments can be approved by the Chair of the

Risk Management and Safety Committee or full committee if appropriate. (As per

the Document Control procedure). Minor amendments could include changes to

related committee terms of reference, committee reporting framework or Roles and

responsibilities for Risk.

7.2 Monitoring compliance of this Strategy will be via the Risk Management Strategy

Annual policy review (APRR) compiled by the Assistant Director of Nursing

(Governance) and submitted to the Risk management and Safety committee and the

Board of Directors annually. Monitoring the process for managing risk locally will also

be undertaken by the Trusts Internal Audit process, with audit findings,

recommendations and action plans reported to and monitored by the Risk

Management and Safety committee and Audit and Governance committee (for

scrutiny).

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7.3 The full monitoring details can be found in the following templates:-

• Risk Management Strategy Monitoring Tool • High-Level committees with responsibility for risk • Risk Assessment process • Risk Register

7.4 The Incident Reporting process is subject to monitoring via the Incident Reporting

Policy – Annual Policy Review Report (APRR).

8. ARCHIVING

8.1 Current and future versions of this document will be stored on the Intranet Web

Asset Management System.

8.2 All versions of the document created prior to migration to the new intranet will be

archived within the Clinical Development Section of the ‘S’ Drive.

9. REFERENCES

9.1 National Health Service Litigation Authority (NHSLA) Risk Management Standards

2009.

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What will be monitored How will it be monitored Frequency Who is responsible Where will this be reported to

3.1.1 a)

Organisational risk management structure detailing all those committees/sub committees/groups which have some responsibility for risk.

Review and update the Risk Management committee reporting structure via the APRR.

Annually Assistant Director of Nursing ( Governance)

Risk Management and Safety Committee and Hospital Executive Committee

b) Process for board or high level committee review of the organisation wide risk register

Risk register reviewed by the High level Risk Register review group Internal Audit of the Risk Register process

Bi monthly

Assistant Director of Nursing ( Governance)

*Risk Management and Safety Committee *Audit and Governance Committee

c) Process for the management of risk locally which reflects the organisation wide risk management strategy

Annual Review of local risk group terms of reference and attendance records. Care Group Risk reports via the QPR process and Risk extract to Risk Management and Safety committee. Reported via the APRR process, Internal Audit Reports

Annually Quarterly

Assistant Director of Nursing (Governance)

Risk Management and Safety Committee

d) Duties of key individuals for risk management activities

Review of local risk group terms of reference and attendance records.

Annually Assistant Director of Nursing (Governance )


e) Authority of all managers with regard to managing risk

Review of local risk group terms of reference and attendance records via the APRR

Annually Assistant Director of Nursing (Governance )


f) Process for monitoring compliance with all of the above

Annual policy review report Annually Assistant Director of Nursing (Governance)

*Risk Management and Safety Committee *Board of Directors

RISK MANAGEMENT STRATEGY MONITORING TOOL 2009-2010 NHSLA ref: 3.1.1

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Process for the monitoring of Committees with responsibility for risk NHSLA ref 3.1.3

What will be monitored How will it be monitored Frequency Who is responsible Where will this be reported to

1.1.3a duties Annual terms of reference review Annually Assistant Director of

Nursing (Governance) Risk Management and Safety committee

b reporting arrangements to the board

Annual Policy review report and action plan

Annually with 6 monthly action plan review


Board of Directors and Risk Management and Safety Committee

c membership, including nominated deputy where appropriate

Annual terms of reference review Annually Assistant Director of


d required frequency of attendance by members

Annual terms of reference review Annually Assistant Director of


e review arrangements into the high level committee(s)

Annual terms of reference review and minute reporting spreadsheet via APRR process

Annually Assistant Director of Nursing (Governance)


f requirements for a quorum Annual terms of reference review Annually Assistant Director of


g frequency of meetings Annual terms of reference review Annually Assistant Director of


h

the process for monitoring compliance with all of the above

Annual Policy review report and action plan (to be completed by Dec 09)



Risk Management and Safety committee

__________________________________________________________________________________________


23 of 53

Process for the monitoring of the Risk assessment process

NHSLA ref 3.1.5

Please return to Helen Taylor by 30th October 2009

What will be monitored How will it be monitored Frequency Who is responsible

Where will this be reported to

1.1.5a Process for assessing

all types of risk

Annual policy review report and Internal Audit process

Annually Assistant Director of Nursing


b

Process for ensuring continual, systematic approach to all risk assessments is followed throughout the organisation

Annual policy review report and Internal Audit process

Annually Assistant Director of Nursing


c

Assignment of the management responsibility for different levels of risk within the organisation

Annual policy review Annually

Assistant Director of Nursing


d

Process for monitoring compliance with all of the above

Annual policy review report and action plan


Assistant Director of Nursing


__________________________________________________________________________________________


24 of 53

PROCESS FOR THE MONITORING OF THE RISK REGISTER NHSLA ref: 3.1.6

What will be monitored How will it be monitored Frequency Who is responsible Where will this be

reported to

1.1.6a

source of the risk (including, but not limited to, incident reports, risk assessment and directorate risk registers)

High level Risk register review group. Internal audit programme Bi-monthly Assistant Director of

Nursing (Governance) Risk Management and Safety Committee

b description of the risk High level Risk register review group. Internal audit programme Annually Assistant Director of


c risk score High level Risk register review group. Internal audit programme Annually Assistant Director of


d summary risk treatment plan High level Risk register review group. Internal audit programme Annually Assistant Director of


e date of review High level Risk register review group. Internal audit programme Annually Assistant Director of


f residual risk rating High level Risk register review group. Internal audit programme Annually Assistant Director of

Nursing

Board of Directors and Risk Managemtn and Safety Committee

_________________________________________________________________________________________________


25 of 53

BOARD OF DIRECTORS COUNCIL OF GOVERNORS

REMUNERATION AUDIT & GOVERNANCE

HOSPITAL EXECUTIVE COMMITTEE

ACADEMIC CANCER

CLINICAL GOVERNANCE

DRUGS & THERAPEUTICS

INFECTIONCONTROL

INFORMATION

RISKMANAGEMENT

& SAFETY

Clinical Audit & Effectiveness

Clinical Ethics

Education & Funding

Patient Group Directions

Pandemic Flu

NOMINATIONS, REMUNERATION &

EVALUATIONS

Clinical Practice Development

(Policies)

Patient & Public Involvement

Resuscitation

Research Governance

CaMIS User Group

Data Quality Group

EPR User Group

IT Programme Board

Blood Transfusion

Care Group Risk Management

Health & Safety

Radiation Protection

Emergency Preparedness

FINANCE & INVESTMENT

IT Steering Group

WORKFORCE

Clinical Education

Medical Education

NVQ & Competencies

Workforce Planning

Medical Workforce Planning

Management of Medical Records

Academic Strategy

Education

APPENDIX A – Governance Framework / Risk Management Structure

APPENDIX B

ROLES AND RESPONSIBILITIES FOR RISK MANAGEMENT Clarity regarding the roles and responsibilities of individuals for risk management will be critical in the successful delivery of this Plan. The key staff are listed below, along with a summary of roles and responsibilities for Risk Managers. Chief Executive • To take overall leadership of risk management within the Board of Directors stated aim of

providing safe systems of healthcare and related services for patients and clients in providing a safe working environment for staff

• To ensure that this Strategy is implemented and to take particular responsibility for

fostering a culture which is fair and does not seek to blame and promotes risk management

Executive and Non-Executive members The Trust has identified Executive leads for each of the main areas of Risk. APPENDIX C Medical Director • To provide the focus for leadership of the Clinical Governance agenda within the Trust. • To ensure that the required resources and training to deliver effective risk management is

available Director of Nursing and Patient Services • To be accountable to the Chief Executive and the Board for ensuring that this Strategy is

implemented effectively • To be the Board of Directors Executive lead for Risk Management Trust wide including

Maternity services • To provide leadership and management to the Risk Management Department, ensuring

that the Trust’s key objectives are met. The Assistant Director of Nursing (Governance) is accountable to the Director of Nursing for the day-to-day management of the Department.

• To ensure that the process for risk management is continuously updated and driven

forward within the Trust • To be responsible for the determination of risk strategies, evaluation and developments. Assistant Director of Nursing (Governance) • To ensure that systems and processes are in place across the Trust so that risks are

identified, assessed, recorded, reported and managed in a way that minimises the risk of injury, damage or financial loss to the Trust, its staff, patients and visitors

• To support the Medical Director and Director of Nursing in the investigation process of

“Red” or “Amber” clinical incidents

• To promote a culture of learning lessons, and sharing best practice, exists in the Trust; making links across key areas of Risk Management and Clinical Governance

• To advise Trust Management and the Board on trends and statistical analysis of incidents

and near-misses in accordance with the Trust reporting requirements Complaints and Legal Services Manager • To lead and manage all legal services across the Trust • To ensure the equitable and cost-effective resolution of claims, thus ensuring the financial

consequences to the Trust are minimised • To ensure the contract with the Trust’s legal advisors is managed efficiently and

effectively • To lead in the investigation and analysis of complaints, resolving complex and difficult

complaints to avoid unnecessary litigation • To ensure lessons are learned from mistakes in order to reduce the risk of repetition and

to improve the quality and safety of patient care as part of the trust’s Clinical Governance Strategy

• To take a lead role in the investigation of Serious Untoward Incidents Governance and Patient Safety Manager (Including Clinical Risk) • Manage the development and implementation of the Trust’s Clinical Risk Management

Strategy • Lead, in conjunction with the Assistant Director of Nursing (Governance) the

implementation of the NHSLA Risk Management standards ensuring Trust compliance thereby reducing the clinical risk to the Trust and promoting high standards of patient safety

• Provide expert advice and leadership on clinical risk issues • Support Clinical Care Groups in developing clinical risk managements systems • Manage the Adverse Incident Reporting Policy for Clinical Incidents Risk Manager (Health & Safety) • To fulfil the requirements of Health & Safety Advisor for the Trust • To ensure managers (and staff) are provided with non-clinical risk management

information and support • To promote the understanding and use of Risk Assessment and audit processes and

techniques • To investigate and report on all non-clinical accidents and incidents

Risk Manager (Emergency Planning and Security) • To develop and ensure that the Trust’s Major Incident Plan remains up-to-date and

effective and that staff are aware of their roles and responsibilities within it • To investigate incidents relating to security and crime issues • To liaise with outside agencies and represent the Trust on crime prevention and major

incident preparedness Risk Trainer • To manage, design and deliver to the required consistent standards in Risk, Fire, Health &

Safety, Minimal Handling & Conflict Management Training at Poole Hospital NHS Trust

• To be the Minimal Handling Co-ordinator for Poole Hospital NHS Trust

• To ensure fire training is delivered to the required standards at Poole Hospital NHS Trust

Responsibilities for Associate Medical Directors & Associate Directors Operations and Managers • Associate Medical Directors and Associate Directors of Operations are responsible for risk

management and clinical governance in their respective Care Groups. They are also responsible for their areas of authority, and will monitor effective implementation of Care Group Risk Management and Development Plans.

• Each Care Group will have a Risk Management Group with responsibility for monitoring

Incident trends and outcomes, for updating and reviewing the Care Group Risk Register and leading on implementing Trust-wide risk management strategies within the Care Group. Risk issues will be reported via the Care Group Quarterly Performance Report and the Risk Management Committee.

• Ultimately, the Trust Board will directly agree the prioritisation and allocation of resources

to address corporate risks. The risk identified in Part II relate to individual Care Groups. It is the responsibility of the individual Associate Medical Director/Associate Director of Operations to assess these risks. If the risk is unacceptable, it is necessary to show the current resource allocation and means by which this risk is controlled. If the current management of the risk is insufficient, an Action Plan must be drawn up to show what further resource is required.

Care Group Risk Representatives • To provide risk advice locally • To gather and collate risk information in conjunction with the Risk Management

Department and with the Legal Services Manager • Care Group Risk Representatives will report to the Associate Medical Director/Associate

Director of Operations and will ensure that they have an accurate view of the risk profile within their Care Group.

Infection Control Consultant

• To ensure that the Infection Control Team meets monthly, with minutes being circulated to

the Chief Executive and Trust Board representatives, Risk Management & Safety Committee and representatives in each of the Care Groups, as a record of current infection control activity and problems

• To ensure that the Infection Control Committee meets six-monthly with the presentation of

a report to the Trust Board and Hospital Executive Committee • The writing of Outbreak of Infection Reports, during outbreaks, and ensuring these reports

are sent to the relevant ward and clinical staff • Care Group specific infection control issues or audit findings are presented to the Care

Group Clinical Governance meetings whenever necessary, but at least once annually. Trust Fire Officer • To submit copies of Fire Risk Assessments (Fire Code HTM 86) undertaken by the Fire

Department. Submit copies of Building Fire Defect reports which identify and recommend corrective action.

• Through the Nominated Fire Officer, the Trust Fire Officer will advise on any prioritisation

and submit copies of these incidents through the Nominated Fire Officer to the Risk Management Department.

All Staff Every member of staff (including Contractors and Agency Staff) must be aware of the Trust Risk Management Strategy and their individual responsibilities with regard to maintaining safety and reporting concerns or incidents. All staff have a responsibility for risk management and a commitment to identifying and minimising risk. In particular, key responsibilities are to: • Report adverse incidents in accordance with the Trust's Adverse Incident Policy • Bringing immediate risk issues to the attention of their line manager • Provide safe clinical practice in diagnosis and treatment • Act safely to self and others • Comply with Trust policies, procedures and guidelines in place to protect the health,

safety and welfare of anyone affected by the Trust activities • Be familiar and comply with the Trust's Risk Management and Health & Safety procedures• Neither intentionally, nor recklessly interfere with, nor misuse any work equipment, nor

with equipment provided for the protection of health and safety • Be aware of emergency procedures (e.g. resuscitation, evacuation, fire and major incident

procedures) relevant to their roles and work area(s) • Attend mandatory training and any other risk training deemed necessary for their role

and/or area of work • Comply with professional guidelines (as applicable to their role and profession) and acting

in accordance with such guidelines and codes of practice.

APPENDIX C

EXECUTIVE LEADS FOR SPECIFIC AREAS OF RISK

RISK AREA

EXECUTIVE DIRECTOR LEAD

FINANCE

DIRECTOR OF FINANCE

HUMAN RESOURCES

DIRECTOR OF HUMAN

RESOURCES

SECURITY

DIRECTOR OF FINANCE

HEALTH & SAFETY

DIRECTOR OF NURSING AND PATIENT

SERVICES

FIRE

DIRECTOR OF FINANCE

CLINICAL GOVERNANCE PATIENT SAFETY

RISK

MEDICAL DIRECTOR/

DIRECTOR OF NURSING AND PATIENT SERVICES

CORPORATE RISK

CHIEF EXECUTIVE/

DIRECTOR OF OPERATIONS

INFORMATION TECHNOLOGY (IT)

DIRECTOR OF FINANCE

INFECTION CONTROL

DIRECTOR OF NURSING AND PATIENT

SERVICES

APPENDIX D

TERMS OF REFERENCE

Terms of Reference

Risk Management & Safety Committee

Author: Martin Smits Job Title: Director of Nursing & Patient Services Signed: Date: December 2009 Version No: (Author Allocated)

2

Document Reference No: (Allocate from Directorate Policy Register)

Next Review Date: Approving Body/Committee: HEC Chair: Sue Sutherland Signed: Date Approved: June 2009 Target Audience: All Staff Date Equality Impact Assessment Complete:

Document History

Date of Issue

Version

No:

Next

Review Date:

Date

Approved:

Director responsible for Change

Nature of Change

23.08.06 July 2009 Director of Nursing & Patient Services

31.05.09 2 July 2010 June 2009 Director of Nursing & Patient Services

DOCUMENT DETAILS

1. CONSTITUTION

2. MEMBERSHIP

3. FREQUENCY OF MEETINGS

4. QUORUM

5. ACCOUNTABILITY

6. RESPONSIBLITIES

7. RELATIONSHIP WITH OTHER COMMITTEES

8. COMMUNICATIONS

9. REVIEW INDIVIDUAL APPROVAL Job Title Date Print Name Signature COMMITTEE APPROVAL If the committee is happy to approve this document, please sign and date it and forward copies for inclusion on the Intranet. Name of Committee Date

Print Name Signature of Chair

TABLE OF CONTENTS

POOLE HOSPITAL NHS FOUNDATION TRUST

RISK MANAGEMENT & SAFETY COMMITTEE

TERMS OF REFERENCE 1. CONSTITUTION

1.1 The Risk Management & Safety Committee is responsible for ensuring robust

mechanisms are in place for the implementation of the management of risk

and the delivery of safety, monitoring the Trust’s Risk Register and ensuring

appropriate actions are taken to minimise and manage risk within the Trust

for monitoring compliance against national and local standards. The Risk

Management & Safety Committee is a formally constituted Committee of

Poole Hospital NHS Foundation Trust Hospital Executive Committee.

1.2 The Hospital Executive Committee will receive the minutes of the Risk

Management & Safety Committee meetings.

1.3 The Committee is authorised by the Hospital Executive Committee to

investigate any activity within the Terms of Reference. It is authorised to

seek any information it requires from any employee of the Trust.

2. MEMBERSHIP

2.1 • Director of Nursing - Chair

• Medical Director - Vice-Chair

• Director of Finance

• Associate Director for Capital and Estates

• Chief Pharmacist

• Assistant Director of Nursing (Governance)

• Legal Services Manager

• Care Group Representative

- Medicine

- Surgery

- Maternity, Children, Pharmacy, Outpatients and Diagnostic Services

• Patient & Public Involvement Manager

• Director of Infection Control

• Chair of Blood Transfusion Committee

• Risk Managers

• Patient Representative

• Matron

2.2 The Committee may invite others (this includes internal staff or external

partners) any Director or Employee to attend meetings. A standing invitation

will be issued to Non-Executive Directors.

2.3 The Chief Executive will be invited to attend at least once annually.

3. FREQUENCY OF MEETINGS

3.1 The Committee will meet at least ten times a year.

4. QUORUM

4.1 At least one-third of the membership, including Chair or Vice-Chair and two

clinical members of staff.

4.2 A matrix (see Appendix A) of membership attendees will be used for monitory

purposes.

4.3 It is expected that representation at these meetings is considered to be

compulsory. Regular non attendance will result in a review of the continued

membership of the Committee. Membership will be reviewed on an annual

basis.

5. ACCOUNTABILITY 5.1 The Committee is accountable through the Hospital Executive Committee to

investigate any activity within its Terms of Reference.

5.2 The Committee is authorised to seek any information it requires from any employee of the Trust.

5.3 The Committee will oversee the Trust’s compliance against the relevant risk management and safety standards of external bodies.

6. RESPONSIBILITIES

6.1 The Committee will approve and receive quarterly reports to monitor the

Trust’s risk and safety issues across the Trust and review the action plan as

appropriate.

6.2 The Committee will co-ordinate and prioritise risk and safety issues enabling

recommendations to be made and reported as necessary to the Hospital

Executive Committee.

6.3 The Committee will Identify and ensure that risks are being dealt with in the

most appropriate way across the Trust.

6.4 The Committee will Monitor, through the Risk Management Team, a live Risk

Register. Monitor new risks.

6.5 The Committee will review trends and analysis of incidents reported across

the Trust.

6.6 The Committee will review and ensure appropriate action is taken on safety

issues identified either externally or internally.

6.7 The Committee will co-ordinate the reception and dissemination of risk/safety

related alerts and broadcasts.

6.8 The Committee will steer the Trust through the assessment against risk

management and safety standards.

6.9 The Committee will work with other groups/committees in the Trust on

delivery of the Trust’s objectives.

7. RELATIONSHIP WITH OTHER COMMITTEES 7.1 The Committee will receive the minutes of the following committees/groups:

• Health & Safety Committee

• Radiation Protection Committee

• Blood Transfusion Committee

• Major Incident Planning Group

8. COMMUNICATION

8.1 The minutes of each meeting of the Committee will be formally recorded and

submitted to the Hospital Executive Committee for approval and the Audit &

Governance Committee for scrutiny.

8.2 An annual Risk Management & Safety Committee report will be produced and

approved by the Committee prior to submission to the Hospital Executive

Committee.

8.3 Risk Management & Safety Committee members will be responsible for

ensuring that staff within their Clinical Care Group or Directorate are fully

informed about Trust issues and decisions.

9. REVIEW

9.1 The Terms of Reference of this Committee will be reviewed by the Director of

Nursing & Patient Services no less than bi-annually and all amendments will

be put to the Hospital Executive Committee for approval.

9.2 The position of Chairman will be reviewed at least every 3 years.

APPENDIX E

TERMS OF REFERENCE

Terms of Reference

CLINICAL GOVERNANCE COMMITTEE

Author: Mandy Rann

Job Title: Assistant Director of Nursing (Governance)

Signed:

Date: June 2009

Version No:

(Author Allocated)

Version 3

Document Reference No:

(Allocate from Directorate Policy Register)

CGC.001

Next Review Date: June 2010

Document History

Date of issue Version no: Next review date Date approved

Director responsible for

change Nature of change

18.05.06 1 June 2009 30.05.06 Medical Director Revision

June 2008 2 June 2009 June 2008 Medical Director Revision

June 2009 3 June 2010 September 2009 Medical Director Revision

DOCUMENT DETAILS

1. CONSTITUTION 2. MEMBERSHIP 3. FREQUENCY OF MEETINGS 4. QUORUM 5. AUTHORITY 6. REPORTING MECHANISM 7. PROCESS 8. REVIEW INDIVIDUAL APPROVAL

Job Title Date

Print Name Signature

COMMITTEE APPROVAL

If the committee is happy to approve this document, please sign and date it and forward

copies for inclusion on the intranet

Name of Committee Date

Print Name Signature of Chair

Table of Contents

1.

CONSTITUTION

1.1 The Clinical Governance Committee is responsible for ensuring robust mechanisms

are in place for the implementation of Clinical Governance within the Trust and for

monitoring compliance against national and local standards, including the Care

Quality Commission Standards for Better Health. The Clinical Governance

Committee is a formally constituted Committee of Poole Hospital NHS Foundation

Trust Hospital Executive Committee.

1.2 The Clinical Governance Committee will receive the minutes of: • Clinical Audit & Effectiveness Committee

• Research & Innovations Committee

• Complaints, Claims Incident and PALs Quarterly reports

• Patient & Public Involvement Steering Group

• Clinical Ethics Group (Annual report only)

• Critical Care, Resuscitation & Outreach Services Committee

• Equality & Diversity Group

1.3 The Committee is authorised by the Hospital Executive Committee to investigate any

activity within the Terms of reference. It is authorised to seek any information it

requires from any employee within the Trust.

1.4 The Committee will approve and receive quarterly reports to monitor the Trust’s

Clinical Governance Development Plan and review the action plan as appropriate.

1.5 The Committee will oversee the Trust’s compliance against the relevant

core/developmental Standards for Better Health.

1.6 The Committee will oversee implementation of the Trust’s Clinical Governance

Strategy with the aim of ensuring good quality patient care, endorsing best practice

Trust-wide whilst supporting the need to remain within budget in delivering patient

care in all areas of the hospital.

2. MEMBERSHIP 2.1 Medical Director (Chair)

Director of Nursing & Patient Services (Vice-Chair)

Director of Finance / representative

Director of Communications / representative

Clinical Leads:

Research and Innovations

Clinical Audit and Effectiveness

Clinical Care Group:

Associate Medical Directors and Associate Directors of Operations:

Medicine

Surgery

Diagnostics, Clinical Support Services and

Child Health

Associate Director of Education


Assistant Director of Nursing (Practice Development) as Chair of Clinical Practice

Development Group

Chair of Critical Care, Resuscitation & Outreach Services Committee

Legal Services Manager

PCT representative

Non-Executive Directors have an open invitation

Clinical Governance Co-ordinator/PA to Medical Director in attendance

A deputy may be nominated to attend to represent a full member.

2.2 The Committee may invite any Director of Employee to attend meetings. A standing

invitation will be issued to local Social Services and the South West Strategic Health

Authority.

2.3 If a member does not attend two consecutive meetings their membership will be

reviewed by the Chairman.

3. FREQUENCY OF MEETINGS The Committee will meet quarterly, with a minimum of 3 meetings per year.

4. QUORUM 4.1 At least one-third of the membership, including Chair or Vice-Chair (Vice-Chair to be

the Director of Nursing & Patient Services) and at least two clinicians.

4.2 A matrix of membership attendees will be used for monitoring purposes.

4.3 It is expected that representation at these meetings is considered to be compulsory.

Regular non-attendance will result in a review of the continued membership of the

committee. Membership will be reviewed on an annual basis.

5. ACCOUNTABILITY

The committee is accountable through the Medical Director for the clinical

governance of the care group/department to meet the Trust’s corporate objectives.

6. RESPONSIBILITIES

6.1 The committee will approve and receive quarterly reports to monitor the Trust’s

clinical governance development plan and review the action plan as appropriate.

6.2 To ensure that the clinical performance, quality monitoring and reporting mechanisms

and structures are properly established and work.

6.3 The Committee will be directly responsible for overseeing the following Trust-wide

activities:

• Clinical Practice (including Clinical Policies/Guidelines, integrated Care Pathways,

NICE Guidance, Clinical Audit)

• Patient and Public Involvement

• Research and Innovations

• Clinical Ethics

• Critical Care, Resuscitation & Outreach Services

• Patient Information

• Equality and Diversity

6.4 To ensure that the clinical performance, quality monitoring and reporting mechanisms

and structures are properly established and working.

6.5 To monitor the Patient and Public Involvement Strategy in Clinical Governance

activities.

6.6 To test the framework and process for delivering Clinical Governance and identify

areas in need of strengthening.

6.7 To monitor key performance standards to ensure the effectiveness of clinical

services, including Standards for Better Health where relevant.

6.8 To agree and monitor the Trust’s Clinical Governance Development Plan, Annual

Report and Standards for Better Health compliance.

6.9 To engage with the Strategic Health Authority, Primary Care, Social Services and

other local health groups in pursuit of the development and maintenance of

appropriate frameworks for seamless Clinical Governance in Primary, Secondary and

Tertiary care.

6.10 To liaise appropriate with other Trust Committees.

7. COMMUNICATION

The minutes of each meeting of the Committee will be formally recorded and

submitted to the Hospital Executive Committee (for approval) and the Audit &

Governance Committee (for scrutiny). A copy of the minutes will also be sent to the

PCT for information.

An annual Clinical Governance Report will be produced and approved by the

Committee prior to submission to the Hospital Executive Committee, Trust Board and

South West Strategic Health Authority.

The Clinical Governance Committee members will be responsible for ensuring that

staff within their clinical care group or directorate are fully informed about Trust issues

and decisions.

8. MONITORING

Attendance will be monitored as part of the agenda at each committee meeting.

An annual report will be produced and submitted to the committee detailing

compliance with the Terms of Reference. The report will include membership

attendance, frequency of meetings, whether meetings were held in quorum, dates

when minutes were reported to the reporting committee.

9. REVIEW

9.1 These Terms of Reference will be reviewed by the Medical Director annually, and no

later than three-yearly, and all amendments will be put to the Clinical Governance

Committee for approval.

9.2 The position of Chairman will be reviewed at least every 3 years.

APPENDIX F TERMS OF REFERENCE

POOLE HOSPITAL NHS FOUNDATION TRUST

AUDIT AND GOVERNANCE COMMITTEE

TERMS OF REFERENCE 1. CONSTITUTION 1.1 The Audit and Governance Committee is a Non-Executive Committee of the Board of

Directors. 1.2 The Audit and Governance Committee is responsible for reviewing the establishment

and maintenance of effective systems of:

• Integrated Governance; • Risk Management; • Internal Control; • Internal Audit; • Board Assurance; • Production of the Annual Report

across the whole of the organisation’s activities (clinical and non-clinical).

1.3 The Committee will seek the views of the Trust’s External Auditor and consider the

Executives’ response to the auditors work. 1.4 The Committee will seek the views of the Trust’s Executive Committees, looking for

assurance on systems. 2. MEMBERSHIP

2.1 Membership of the Audit and Governance Committee comprises all the Non-Executive

Directors of the Trust, with the exception of the Chairman of the Trust. At least one member must have significant financial experience.

2.2 The Non-Executive members of the Trust will appoint the Chair of the Committee from

the Non-Executive Directors. A nominated deputy will be identified from the Non-Executive group, if the Chair is unable to attend a meeting.

2.3 The Committee will invite relevant Executive Directors and Internal and External

auditors to attend meetings, specifically to discuss areas of risk or operation within their sphere of operation.

3. FREQUENCY OF MEETINGS 3.1 The Committee will meet a minimum of five times a year. 3.2 At least one meeting a year will be with the Internal and External Auditors in private. 3.3 At one meeting a year the Chief Executive should be invited to attend to discuss the

process for Assurance that supports the statement on Internal Control. 3.4 The Trust’s auditors may request to be present at an audit meeting to raise any aspect

of their work.

4 QUORUM 4.1 The quorum of the Committee is at least three members. 5 AUTHORITY 5.1 The Committee is authorised by the Board of Directors to investigate/review any

activity within its Terms of Reference. 5.2 It is authorised to seek information from any employee and the employee is directed to

co-operate with the Committee. 5.3 The Committee is authorised by the Board of Directors to obtain any external advice it

requires to discharge its duties. 5.4 The Committee will receive minutes of the Trust Executive Committees for scrutiny. 6 REPORTING MECHANISM 6.1 Minutes of each meeting of the Committee will be formally recorded and submitted to

the Board of Directors. 6.2 The Chair of the Committee should draw to the attention of the Board of Directors any

issues that require disclosure or further action. 6.3 The Committee will report to the Board of Directors annually, reporting on Internal

Control and Assurance. 7 PROCESS 7.1 The Committee will review, in order to gain the necessary evidence of assurance:

i) The minutes of the Trust’s Executive Committees;

ii) The integrity of financial statements of the Trust and announcements relating to financial performance, reviewing significant financial judgements made within them;

iii) All risk and control related disclosure statements (in particular, the statement on

Internal Control and declarations of compliance with the Standards for Better Health) together with any accompanying head of Internal Audit statement, External Audit opinion or other appropriate independent assurances, prior to endorsement by the Board of Directors;

iv) The underlying Assurance processes that indicate the degree of the

achievement of corporate objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements;

v) The policies for ensuring compliance with relevant regulatory, legal and code of

conduct requirements; vi) The policies and procedures for all work related to fraud and corruption as set

out in the Secretary of State Directions and as required by the Counter Fraud and Security Management Service;

vii) Consideration of the provision of the Internal Audit service, the cost of the audit and any questions of resignation and dismissal;

viii) Review and approval of the Internal Audit strategy, operational plan and more

detailed programme of work, ensuring that this consistent with the audit needs of the organisation as identified in the Assurance Framework;

ix) Consideration of the major finds of Internal Audit work (and management’s

response) and ensure co-ordination between the Internal and External Auditors to optimise audit resources;

x) Ensuring that the Internal Audit function is adequately resourced and has

appropriate standing within the organisation; xi) Annual review of the effectiveness of Internal Audit; xii) Discussion and agreement with the External Auditor, before the audit

commences, of the nature and scope of the audit as set out in the Annual Plan, and ensure co-ordination as appropriate, with other External Auditors in the local health economy;

xiii) Discussion with the External Auditors of their local evaluation of audit risks and

assessment of the Trust associated impact of the audit fee; xiv) Review all External Audit reports, including agreement of the annual audit letter

before submission to the Board of Directors and any work carried outside the annual audit plan, together with the appropriateness of management responses;

xv) The wording in the statement on Internal Control and other disclosures relevant

to the Terms of Reference of the Committee; xvi) Changes in, and compliance with, accounting policies and practices; xvii) Unadjusted mis-statements in the financial statements; xviii) Major judgmental areas; xix) Significant adjustments resulting from the audit.

8 REVIEW 8.1 These Terms of Reference will be reviewed every five years or as requested by the

Committee Chairman. 8.2 The position of Chairman of the Committee will be reviewed at least every three years. Approved: TRUST BOARD Date: 17 December 2008 Review: December 2013

APPENDIX G

RISK REGISTER ASSESSMENT TOOLS

The following tools have been developed as part of the Risk Assessment process for prioritising identified risk, clinical / non-clinical incidents or near misses, for inclusion on the Trust Risk Register. The Incident/ Risk Grading Procedure is at Appendix 1.

Important Definitions:

HAZARD Anything that has the potential to cause harm

e.g. an unsheathed needle lying on the floor

RISK The likelihood that those harmful consequences occur and the severity of the outcome e.g. the likelihood of someone sustaining a needle-stick injury from the unsheathed needle

INCIDENT An actual occurrence e.g. if someone injures themselves on the unsheathed needle

NEAR MISS An actual occurrence that might have resulted in harm , e.g. the unsheathed needle is picked up and put in a sharps bin without causing injury

To ascertain the colour of the identified risk: 1. Likelihood Descriptor List to identify the likelihood of occurrence

(It is important that this is as accurate as possible)

2. Identify the consequence of non-action using the Risk Consequence Table (If possible use previous incidents to aid identification)

3. The Consequence and Likelihood can then be measured using the Risk Management Matrix, giving the risk a colour indicating its priority

Likelihood Descriptor List 1. RARE Could only occur in exceptional circumstances 2. UNLIKELY May occur in time, very infrequent 3. POSSIBLE May occur occasionally 4. LIKELY Likely to occur imminently or in the short-term 5. ALMOST

CERTAIN Will occur or does regularly

RISK CONSEQUENCE TABLE

Num

ber

Category Consequence

Quality

Finance

Agreed Targets

Safety (Staff, patients

& visitors)

Reputation

Litigation

1 Insignificant Minor non-compliance

<£5k

Minor cuts/bruises.

Within unit. Local press <1 day coverage

Minor out-of-court settlement

2 Minor Single failure to meet internal standards or follow protocol.

£5K - £50K Claim below excess

1% off planned. Fail to meet national target 1 quarter

Cuts/bruises. <3 days absence. <2 days extended hospital stay.

Regulator concern. Local press <7 days of coverage.

Civil action – no defence. Improvement notice.

3 Moderate Repeated failures to meet internal standards or follow protocols.

£50K -£500K

2% - 4% off planned. Fail to meet national target 2 quarters. Amber light.

>3 days absence. 3-8 days extended hospital stay. RIDDOR or MDA reportable. Semi-permanent harm.

National media <3 days coverage. Department executive action.

Class action. Criminal prosecution. Prohibition notice.

4 Major Failure to meet national standards.

£500K -£5M

5% - 10% off planned. Fail to meet national target >2 quarters. Red light.

>9 days extended hospital stay. Fatality. Permanent disability.

National media >3 days of coverage. Questions in the House.

Criminal prosecution – no defence. Executive officer fined or imprisoned.

5 Catastrophic Gross failure to meet professional standards

>£5M

>10% off planned. Fail to meet national target >2 quarters by >20%

Multiple fatalities. Multiple permanent injuries.

Full Public Enquiry.

Criminal prosecution – no defence. Executive officer fined or imprisoned.

Using information from the Risk Consequence Table and Likelihood descriptor List, plot the risk on the Risk Management Matrix.

CONSEQUENCE

1 2 3 4 5

Insignificant Minor Moderate Major Catastrophic

5 Almost Certain Low Low Moderate High High

4 Likely Low Low Moderate High High

3 Possible V.Low Low Moderate High High

2 Unlikely V.Low V.Low Low Moderate High

L I K E L I H O O D

1 Rare V.Low V.Low Low Moderate High

All Red and Amber risks must be accompanied by a risk assessment

Minimum Headings to be covered for risk assessments recorded on the risk register This could be a risk assessment, a report, a root cause analysis etc….

AIRS form - Bottom copy to Manager, top copy to Risk Management.

This process will be principally through the

CCG Risk Groups.

Risk graded by the Risk Manager using the Risk Register Assessment Tool. Red and Amber risk

duplications are filtered out.

Follow the Adverse Incident Reporting Procedure.

The CCG/Dir ADO reviews and confirms the grading using the

Risk Register Assessment Tool.

The CCG/Dir ADO must sign the risk assessment to authorise the risk to be added to the risk register. The CCG/Dir ADO

must regularly review the Risk Register, associated Action Plans and advise the Risk

Management Department of new, closed or amended risk.

On receipt of a Risk assessment, the Risk Management

Department records or amends risks on the Risk Register as

requested.

Risk Register Review Group clarifies new and significant

risks prior to the Risk Management & Safety

Committee Meeting.

The Manager grades the risk using the Risk Register

Assessment Tool and advises the CCG/Dir ADO of any Red

or Amber Risks.

New and significant risks are presented monthly to the Risk Management and Committees.

New Red & Amber risks are presented quarterly to the Audit and Governance Committee, HEC and then the Trust Board or sooner if required.

A risk will be closed where there are sufficient controls in place to negate the risk or to reduce the risk to a reasonably practicable level.

Risks may bypass the AIRS e.g. a change in S.L.A. with Harbour Hospital may generate a risk but an AIRS form would not be completed.

Incident / Risk Grading Procedure

The principle is that as a minimum, the following headings are covered:

AIRS reference number (If applicable) Title CCG Directorate Speciality Location (Ward/Dept) Manager Responsible Description of the risk Who is at risk? (Include out of hours) What controls are in place?

What is the residual risk?

Consequence Likelihood Rating R/A/Y/G Reference any other relevant documentation Standards compromised Record or attach action plan When is the risk being reviewed? Review date Print Name………………………….. Signature…………………………….. Title…………………………………. Date………………………………….. ADO Print ……………………….Signature ………………………… Date ……………..

APPENDIX H

EQUALITY IMPACT ASSESSMENT TOOL

To be completed by following the Trust Equality Impact Assessment Guidance Date of assessment:

1st May 2009

Care Group or Directorate:

Nursing and Patient Services

Author:

Mandy Rann

Position:

Assistant Director of Nursing ( Governance)

Assessment area: (i.e. procedure/service/function)

Risk Management Strategy

Purpose:

Provide strategic direction trust wide on the management of Risk.

Objectives:

Clarify roles and responsibilities in order to ensure effective, robust risk system in place.

Intended outcomes: Ensure trust remains compliant with risk management standards in continuing to provide a safe environment, care and treatment for patients staff and the public.

What is the overall impact on those affected?

Ethnic Groups Gender Groups Religious Groups

Disabled Persons

Other

High/Medium/ Low

High/Medium/ Low

High/Medium/ Low

High/Medium/ Low

High/Medium/ Low

Low

Low

Low

Low

Low

Available information: Equality monitoring data for staff in areas of - race, disability, and gender and for patient ethnic monitoring data. Assessment of overall impact: This Strategy contributes to the effective management of risk across the organisation. As such it therefore applies to all members of staff who have a role within it. Consultation: Members of the Risk Management and Safety Committee and Equality and Diversity Committee. Actions: None required

APPENDIX I POLICY INTENT

RISK MANAGEMENT AND SAFETY COMMITTEE

1. INTRODUCTION

The Risk Management and Safety Strategy was updated in May 2007 with minor amendments

made in October 2008 to take into account organisational changes. The formal review date for

this strategy is May 2009.

The Strategy aims to ensure that all elements of Clinical and Non-Clinical Risk are well

managed and reflect the trust commitment to taking all reasonable steps in providing a safe

risk-controlled environment for patients, staff, the general public and contractors.

2. SUPPORTING PATIENTS 2.1 To enable the effective delivery of the Risk Management Strategy the following key

policies have been developed.

Policy Responsible committee

Incident management Risk Management and safety Committee

Serious Untoward Incident Risk Management and safety Committee

Health and Safety Health and Safety Committee

External Agency Visits Risk Management and Safety Committee

Medical Devices Risk Management and Safety Committee

Vulnerable Adults Risk Management and Safety Committee

Sharps ( Inoculation incidents) Risk Management and Safety Committee

Stress Health and Safety Committee

Consent Risk Management and Safety Committee

Clinical Record Keeping Risk Management and Safety Committee

Blood Transfusion Risk Management and Safety Committee

Infection Control Risk Management and Safety Committee

Implementing National Guidelines Clinical Governance Committee

Patient Information Clinical Governance Committee

Resuscitation Clinical Governance Committee

Mandy Rann May 2009

APPENDIX J

CHECKLIST FOR THE DEVELOPMENT AND APPROVAL OF CONTROLLED DOCUMENT

To be completed and attached to any document when submitted to the appropriate committee for consideration and approval.

Title of document being reviewed:

Y/N/ Unsure Comments

1. Title/Cover Is the title clear and unambiguous? Y

Is it clear whether the controlled document is a guideline, policy, protocol or standard? N/A Document is a

strategy 2. Summary Points

Have the summary points of the document been included? Y

3. Document Details and History

Have all sections of the document detail/history been completed? Y

4. Table of Contents

Has the table of contents been completed and checked? Y

5. Relevance

Has the audience been identified and clearly stated? Y

6. Purpose

Are the reasons for the development of the document stated? Y

7. Definition

Is it clear whether the controlled document is a guideline, policy, protocol or standard? N/A Strategy

8. Development Process Is the development method described in brief? Y Are people involved in the development identified? Y

Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? Y

9. Associated Documents

Have all associated documents to the document been listed? Y

10. References

Have all references that support the document been listed in full? Y

11. Glossary

Has the need for a glossary been identified and included within the document? N/A

12. Consultation



Do you have evidence of who has been consulted? Y

13. Training

Have training needs been identified and documented? Y

14. Content Is the objective of the document clear? Y Is the target population clear and unambiguous? Y Are the intended outcomes described? Y Are the statements clear and unambiguous? Y 15. Approval

Does the document identify which committee/group will approve it? Y

If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document?

N/A

16. Dissemination and Implementation

Is there an outline/plan to identify how this will be done? N/A Revised document

Does the plan include the necessary training/support to ensure compliance? Y NHSLA monitoring

tool 17. Equality Impact Assessment

Has an Equality Impact Assessment been completed and included in the document? Y

18. Review and Revision Arrangements Including Version Control

Is the review date identified? Y

Is the frequency of review identified? If so, is it acceptable? Y

Are details of how the review will take place identified? Y

Does the document identify where it will be held and how version control will be addressed? Y

19. Archiving

Have archiving arrangements for superseded documents been addressed? Y

Has the process for retrieving archived versions of the document been identified and included within? Y

20. Process to Monitor Compliance and Effectiveness

Are there measurable standards or KPI's to support the monitoring of compliance with and effectiveness of the document?

Y NHSLA monitoring tool

Is there a plan to review or audit compliance within the document? Y Annual policy review



21. Format and Style

Does the document follow the correct style and format of the Document Control Procedure? Y

22. Overall Responsibility for the Document

Is it clear who will be responsible for co-ordinating the dissemination, implementation and review of the documentation?

Y

Individual Approval If you are happy to approve this document, please sign and date it and forward to the chair of the committee/group where it will receive final approval. Job Title Director of Nursing Date Print Name Martin Smits Signature Committee Approval If the committee is happy to approve this document, please sign and date it and forward copies for inclusion on the Intranet. Name of Committee

Board of Directors

Date February 2010

Print Name Peter Harvey Signature of Chair

APPENDIX K

STRATEGIC RISK REGISTER PROCESS

New Strategic risks

identified via the Clinical Care Group

Risk Register process

New risks identified via Board of Directors as

per the Assurance Framework review or

Business Planning process

Risk Assessment and Action Plan completed

risk vetting applied and forwarded to the

Risk Department

Risk Assessment and Action Plan reviewed

by Next High level Risk Register Review

Group

New risks to Risk Management & Safety

Committee monthly and Audit & Governance

Committee - 6 monthly

New risks and action plan placed on Risk

Register

Risk Assessment and Action Plan completed by Ian Triplow – add new title only here!!

Risk monitored via Care

Group/Directorate Quarterly performance

reviews

New risks to Risk

Management & Safety Committee monthly

and Audit & Governance

Committee - 6 monthly

OR