Numeracy in Healthcare Managing Risk 19 November 2004 Hazel Borland Head of Clinical Governance

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Numeracy in Healthcare Managing Risk19
November 2004Hazel BorlandHead of Clinical
Governance Patient SafetyNHS Quality
Improvement Scotland
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Overview of session

• What do we mean by Risk Management?
• Patient safety
• Blame culture in the NHS
• NHS QIS Clinical Governance Patient Safety

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Risk Management

• Risk management is about having the structures
  and processes in place to achieve an appropriate
  balance between realising opportunities for gains
  while minimising losses.
• To be most effective, risk management should
  become an integral part of an organisations
  culture. When this is achieved, everyone in the
  organisation becomes involved in the management
  of risk.
• AS/NZS 43602004

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Patient Safety

• NPSA 7 steps
• Building a patient safety culture international
  healthcare lessons

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Blame culture in the NHS

• Barrier to open and honest reporting systems
• Recent NHS Grampian study (Gault)

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Numeracy and risk management

• Professional and organisational accountability
• Openness and learning from experience

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NHS QIS (1)

• established in January 2003
• integration of
• Clinical Resource and Audit Group (CRAG)
• Clinical Standards Board for Scotland (CSBS)
• Health Technology Board for Scotland (HTBS)
• Nursing and Midwifery Practice Development Unit
  (NMPDU)
• Scottish Health Advisory Service (SHAS)
• and supporting
• Scottish Intercollegiate Guidelines Network
  (SIGN)
• Scottish Medicines Consortium (SMC)

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NHS QIS (2)

• and later
• Scottish Clinical Audit Quality Assurance Group
  (SCAQAG)
• Clinical Negligence and Other Risk Indemnity
  Scheme (CNORIS)
• Scottish Health Council and its 15 local offices

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NHS QIS - Clinical Governance Patient Safety
(1)

• 2003
• Scottish Executive Health Department tasked NHS
  QIS with supporting the implementation of
  clinical governance across NHSScotland.
• NHS QIS was given responsibility for the standard
  setting and accreditation of risk management
  within NHSScotland.
• CNORIS level 1 accreditation of Trusts almost
  universal

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NHS QIS - Clinical Governance Patient Safety
(2)

• 2004 - 05
• draft healthcare governance standards issued for
  consultation
• establishment of NHS QIS Clinical Governance and
  Patient Safety Support Unit
• interim review of clinical governance and risk
  management
• healthcare governance standards and national
  governance framework to be finalised

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Clinical Governance Patient Safety Support
Unit (CGPSSU)

• So far
• review of risk management practice report
  published
• clinical governance scoping exercise report Nov
  2004
• clinical governance development day for
  Non-Executive Directors report Nov 2004

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Risk Management Report

• Some key messages
• Provided a clear understanding of current risk
  management practices in NHSScotland.
• Require to develop and agree common risk
  management definitions, processes and an
  overarching framework.
• Need to develop a toolbox for use across
  NHSScotland

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Clinical Governance Scoping Report

• Some recommendations
• Short Term Build on the Liaison Co-ordinator
  network Dec 2004
• Medium Term Training and education needs
  analysis for clinical governance leads and
  support staff
• Long term Aim to improve links between clinical
  governance and performance management

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Clinical GovernanceDevelopment Day

• Examples of the needs identified
• More effective induction on clinical governance
  for Non-Executive Directors
• Development of a Non-Executive network for
  clinical governance
• Training for Non-Executive Directors in chairing
  skills, interview skills and knowing the
  correct questions to ask.
• Developing a series of toolkits for best practice

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Future CGPSSU Work programme

• Detailed action plans from reports
• Development of clinical governance framework
• Exploring joint working with other national
  bodies, for example, NPSA.
• Mapping of alerts currently sent to NHSScotland
  and partner agencies

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Numeracy in Healthcare Managing Risk19
November 2004Hazel BorlandHead of Clinical
Governance Patient SafetyNHS Quality
Improvement Scotland