NHSLA Risk Management Standards Pilot Level II

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NHSLA Risk Management Standards Pilot Level II
Risk Management

• Michelle Appleby- Associate Director of Risk
  Management and Patient Safety

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Risk Management
Feedback Outline

• Trust composition
• Timeline
• Collaboration/Key Players
• Strategy for evidence gathering
• Early work
• Key Documents
• Assessment process

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Risk Management
Trust Composition

• 2000 Staff
• Mental Health
• (CAMHS)
• NOT Forensics
• Growing community Focus
• 395 beds ( 38 Picu, 162 older people, 12
  adolescent and 183 adults)

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Risk Management
Trust Background

• Operates over 80 sites covering (1200 square
  miles)
• Single Electronic patient information system -
  Carebase
• Risk Management Department dealing with all
  aspects of Risk reports through Director of
  Nursing to the Board (9 members)
• Trust Pharmacist

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Risk Management

• Prior to assessment became a Foundation Trust
• Web based filing system not ready for us to use
• Evidence template to be used

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Risk Management
Timeline Journey

• Offered to be a pilot in Late 2006
• Initially not chosen
• End of May 2007 invited to be a pilot
• Decision in June Level II
• Action Plan agreed by Board In June
• Detailed Consideration by EMT highlighting the
  changes

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Risk Management
Collaboration

• Detailed Action Plan clear responsibilities for
  each element traffic lighted to alert EMT of
  areas of difficulty
• Identify Leads, publish new standards and agree
  action plan
• Specific meetings with each lead to go through
  their responsibilities to avoid misunderstandings

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Risk Management
Two Clear Messages to Senior Management

• Stress that these standards are different from
  previous assessment and cover both clinical and
  non clinical risks they need to read the small
  print!
• Written tangible evidence of the practical
  application of policies etc is crucial and needs
  to be embedded in all departments

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Risk Management
Key Players

• Senior buy - in to the process
• Human Resources including Medical Staffing and
  Training departments
• Infection Control, Medicines Management
• Child protection and Vulnerable adults
• Information Management and CPA
• Communications Department
• Complaints, PALs

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Risk Management
Early work

• Start to populate the evidence template or
  equivalent filing system.
• Identify any policies that will be out of date
  for the assessment
• Also any key policies that need to be reviewed to
  ensure they cover all the points at Level I and
  have appropriate Training needs analysis and
  monitoring/audit arrangements
• Avoid Policy overload

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Risk Management
Key Policies

• Risk Management Strategy
• Incident reporting
• Claims Management (used Template)
• Induction
• Policy On Policies

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Risk Management
Evidence

• Robust Training Needs assessment based on clear
  requirements in Policies
• Be realistic in training requirements
• Attendance records (helpful if electronic)
• Minutes of meetings easy to navigate to the
  issues particularly risk issues and connection
  with risk register maintenance

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Risk Management

• Terms of reference of meetings need to be up to
  date and reflect the structure of the
  organisation.
• Copies of risk assessments client, stress, lone
  working, fire, security and manual handling and
  general health and safety.
• Statistics e.g how much rapid Tranx and which
  units.

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Risk Management
Evidence Template Nightmare

• Totally underestimated the time it would take to
  populate the template
• Difficulties in using evidence more than once
• Only one thing can be hyperlinked to one box
  where multiple evidence exists
• Specific names and good filing arrangements
  cannot be stressed enough.
• Allow time if you need to scan documents into the
  system
• Person with IT skills

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Risk Management
Specific Areas of Difficulty

• 43/50 final score
• Standard 1 Governance 8
• Standard 2 Competent workforce 8
• Standard 3 Safe Environment 9
• Standard 4 Clinical Care 8
• Standard 5 Learning from Experience - 10

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Risk Management
Governance (St 1)

• Sub committee reporting to the risk committee
  needs to be clearly documented including
  frequency reflected in terms of reference and
  minutes
• No formal policy detailing how external visits,
  inspections and subsequent recommendations are
  managed and monitored. (Now standard template)

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Risk Management
Competent Workforce (St 2)Safe Environment(St 3)

• Induction policy too old, lack of evidence of
  local inductions including temporary staff
  checklists need to have all disciplines
  represented as evidence
• Security assessments these need to have a
  formal Trust wide action plan

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Risk Management
Clinical Care (St 4)

• Identification of Service users no one policy.
• Clinical record- keeping standards minimum
  standards /minimum content of the audit not
  explicit enough in policy. Arrangements for the
  development and review of action plans.

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Risk Management
Other messages

• Embed Risk Management training for Board Members
  - Foundation Trust
• Clear Observations after Rapid Tranx
• Follow up after training DNA need good evidence
  of the system and that it covers all training

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Risk Management
Summary

• Organisational commitment in time and resources
  crucial.
• Buy-in by senior staff
• Standardised evidence format and early deadlines
• Dedicated staff to gather evidence
• Taking our time to embed systems ready for Level
  III