NHSLA Risk Management Standards

1
NHSLA Risk Management Standards

• Pilot Assessment

2
Contents

• Overview of UHB and CNST position
• Pre-assessment preparation
• The spreadsheets
• Day 1
• Day 2
• Specific standards
• General comments

3
University Hospital Birmingham NHS Foundation
Trust

• Large acute teaching trust
• Across two sites, but new PFI build
• Board of Directors in state of change
• December 2005 successful reaccredidation at
  CNST level 2
• February 2006 pre-pilot scoping exercise
• November 2006 pilot assessment at level 2

4
Pre-assessment Preparation

• Principles of assessment
• Spreadsheets complete level 1 and level 2
• Communication with the assessor
• Re-organised spreadsheet
• Upload CD spreadsheet and supporting
  documentation
• Sent via courier

5
(No Transcript)
6
(No Transcript)
7
(No Transcript)
8
Day 1 off site

• Not long enough to review all the evidence,
  especially level 1 and 2
• Must provide a glossary, e.g. PAS, PICS, Lorenzo

9
Day 2 on site

• Not long enough to cover all areas
• Stand down staff not enough notice
• 2 assessors is very important
• Feedback to limited number of people

10
Standard 1

• Assurance framework internal and external audit
  assess this
• Split out clinical and non-clinical record
  keeping
• Finance records assessed by internal audit

11
Standard 2

• Training need minimum standards so a level
  playing field
• Medical staff in training
• Ensure links between training policy and
  individual training standards

12
Standard 3

• Vulnerable people standard needs to be
  rewritten to provide clarity
• Decontamination external quality marks, what
  assurance is taken from these?
• Long-term sick

13
Standard 4

• Validation of results

14
Standard 5

• Cross-reference incident, complaints and claims
  policies
• aggregated incident, claims and complaints
  reports one single point, not a joint report

15
Looking forward to level 3

• What is effectiveness?

16
General comments

• Cannot do anything not in policy
• But inflexible, e.g. SABS process at UHB
• Board minutes certified extracts, especially in
  committee
• Clarify links between S4BH and NHSLA who
  provides assurance to who?
• Explanatory notes provide credit to standards
• Interim visits

17
Finally

• Overall a better process
• Focused us on policy development, implementation
  and monitoring
• Discuss and debate not just a tick box