NHSLA Risk Management Standards Pilot Level II - PowerPoint PPT Presentation

1 / 20
About This Presentation

NHSLA Risk Management Standards Pilot Level II


... I and have appropriate Training needs analysis and monitoring/audit arrangements ... Sub committee reporting to the risk committee needs to be clearly documented ... – PowerPoint PPT presentation

Number of Views:344
Avg rating:5.0/5.0
Slides: 21
Provided by: instal9


Transcript and Presenter's Notes

Title: NHSLA Risk Management Standards Pilot Level II

NHSLA Risk Management Standards Pilot Level II
Risk Management
  • Michelle Appleby- Associate Director of Risk
    Management and Patient Safety

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

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)

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

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

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

Risk Management
  • 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

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
  • Written tangible evidence of the practical
    application of policies etc is crucial and needs
    to be embedded in all departments

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

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

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

Risk Management
  • 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

Risk Management
  • Terms of reference of meetings need to be up to
    date and reflect the structure of the
  • 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

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
  • Person with IT skills

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

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
  • No formal policy detailing how external visits,
    inspections and subsequent recommendations are
    managed and monitored. (Now standard template)

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

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.

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

Risk Management
  • Organisational commitment in time and resources
  • 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
Write a Comment
User Comments (0)
About PowerShow.com