Title: Monitoring Compliance Are we getting it right
1Monitoring ComplianceAre we getting it right?
Workshops 2008
2Monitoring
Aim
- The aim of this workshop session is
- To give you an understanding of monitoring
systems and processes and to be able to express
these clearly within your documentation at Level
1 - To discuss the concept of monitoring within the
organisation and develop suitable methods of
implementation and demonstration at Level 3 - Work within groups to consider and record the
systems and processes used within organisations
for monitoring - You will be given example policies based on two
of the criteria from the NHSLA Risk Management
Standards - Discuss and document a process for monitoring
each of the highlighted minimum requirements - List the evidence that could be provided for a
Level 3 assessment - Discuss your findings with the whole group
- Workbooks
- Policies
- Flipchart / blu tack / markers
Overview
Resources
3What is Monitoring?
Definition
- To check something at regular intervals in order
to find out how it is progressing or developing - The collection of information will help you to
answer questions about your systems and processes - How well are your systems and processes working?
- Are you doing the right things?
- Are all staff using systems and processes
appropriately? - What difference do these systems and processes
make? - Do you need to change things?
- Do your systems and processes reduce the risks
they were designed for?i.e. whats written in
your policies - Monitoring is a key means of providing assurance
to the board and stakeholders that the
organisations systems are working - Boards should be involved in the monitoring
process so that the information gained can be
linked effectively into the Assurance Framework
and corporate risk register - _________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
_________________________
Monitoring the board
Notes
4Levels 1 and 3 - Key points
- Monitoring arrangements will be assessed against
what the organisation has written in the approved
documentation (subject to 1st April 08) - Any document(s) with an approved date prior to
1st April 2008 should ideally contain this
information, however compliance will still be
awarded if all the other minimum requirements are
met. Any documents approved on or after this
date must contain the information to ensure
compliance. - Level 1 and Level 3 Evidence Templates must be
completed in relation to the two bullet points
that are assessed at the higher levels clearly
describing the monitoring arrangements -
- _________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
________________
Level 1
Level 3
Notes
5Clarification of terms
- Organisations should measure, monitor and
evaluate compliance with the minimum requirements
within the NHSLA Risk Management Standards. This
should include the use of audits and data related
to the minimum requirements. The organisation
should define the frequency and detail of the
measurement, monitoring and evaluation processes.
- Monitoring demonstrates whether or not the
process for managing risk, as described in the
approved documentation, is working across the
entire organisation. Where failings have been
identified, action plans must have been drawn up
and changes made to reduce the risks. Monitoring
is normally proactive - designed to highlight
issues before an incident occurs - and should
consider both positive and negative aspects of a
process. - Please be aware that criteria 1.6 Risk register
and 2.6 Training needs analysis are assessed
differently at the higher levels - _________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
_____________________________________
Monitor/Monitoring?
Criteria 1.6 and 2.6
Notes
6Criterion 3.8 - Level 1
Please record the documentary requirements for
monitoring the minimum requirements
Exercise 1a
- a._______________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
______________b.__________________________________
__________________________________________________
__________________________________________________
__________________________________________________
_________________________
7Criterion 3.8 - Level 1
Exercise 1a
Please record the documentary requirements for
monitoring the minimum requirements
c._______________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
________________________________d.________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
_____________e.___________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
_____________________
8Criterion 3.8 - Level 3
Please record the evidence you may present to
gain compliance at Level 3 for the bullet points
above
Exercise 1b
- _________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
________________________________________
9Criterion 5.10 - Level 1
Please record the documentary requirements for
monitoring the minimum requirements
Exercise 2a
- a._______________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
______________b.__________________________________
__________________________________________________
__________________________________________________
__________________________________________________
_________________________
10Criterion 5.10 - Level 1
Exercise 2a
Please record the documentary requirements for
monitoring the minimum requirements
c._______________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
________________________________d.________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
_____________e.___________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
_____________________
11Criterion 5.10 - Level 3
Please record the evidence you may present to
gain compliance at Level 3 for the bullet points
above
Exercise 2b
- _________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________