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Monitoring Compliance Are we getting it right

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Title: Monitoring Compliance Are we getting it right


1
Monitoring ComplianceAre we getting it right?
  • Delegate workbook

Workshops 2008
2
Monitoring
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
3
What 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
  • _________________________________________________
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Monitoring the board
Notes
4
Levels 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
  • _________________________________________________
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Level 1
Level 3
Notes
5
Clarification 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
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Monitor/Monitoring?
Criteria 1.6 and 2.6
Notes
6
Criterion 3.8 - Level 1
Please record the documentary requirements for
monitoring the minimum requirements
Exercise 1a
  • a._______________________________________________
    __________________________________________________
    __________________________________________________
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    ______________b.__________________________________
    __________________________________________________
    __________________________________________________
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    _________________________

7
Criterion 3.8 - Level 1
Exercise 1a
Please record the documentary requirements for
monitoring the minimum requirements
c._______________________________________________
__________________________________________________
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________________________________d.________________
__________________________________________________
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_____________e.___________________________________
__________________________________________________
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8
Criterion 3.8 - Level 3
Please record the evidence you may present to
gain compliance at Level 3 for the bullet points
above
Exercise 1b
  • _________________________________________________
    __________________________________________________
    __________________________________________________
    __________________________________________________
    __________________________________________________
    __________________________________________________
    __________________________________________________
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    ________________________________________

9
Criterion 5.10 - Level 1
Please record the documentary requirements for
monitoring the minimum requirements
Exercise 2a
  • a._______________________________________________
    __________________________________________________
    __________________________________________________
    __________________________________________________
    ______________b.__________________________________
    __________________________________________________
    __________________________________________________
    __________________________________________________
    _________________________

10
Criterion 5.10 - Level 1
Exercise 2a
Please record the documentary requirements for
monitoring the minimum requirements
c._______________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
________________________________d.________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
_____________e.___________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
_____________________
11
Criterion 5.10 - Level 3
Please record the evidence you may present to
gain compliance at Level 3 for the bullet points
above
Exercise 2b
  • _________________________________________________
    __________________________________________________
    __________________________________________________
    __________________________________________________
    __________________________________________________
    __________________________________________________
    __________________________________________________
    __________________________________________________
    __________________________________________________
    __________________________________________________
    __________________________________________________
    __________________________________
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