Risk Management Strategy

Transcription

1 Authors Name & Title: Joan Matthews Risk Manager, Hazel Holmes Director of Nursing Scope: Trust Wide Classification: Non Clinical Strategy Replaces:, v3.1 To be read in conjunction with the following documents: Board Assurance Framework, BAF Policy, Incident Reporting Policy, Whistle Blowing Policy, Liverpool PCT Policy for SUI Reporting, Essential Standards for Quality and Safety Policy, Terms of Reference for the Assurance Committees, Terms of Reference for The Directorate Governance Committees Document for public display? Yes Unique Identifier: TT02 (08) Review Date: 26 th April 2014 Issue Status: APPROVED Issue No: 3.2 Issue Date: 27/04/2011 Authorised by: Board of Directors Authorisation Date: 26/04/2011 After this document is withdrawn from use it must be kept in an archive for 10 years Archive: Document Control Date added to Archive: 10 th July 2013 Officer responsible for archive: Document Control Administrator For office use only: Has document been Equality Impact Assessed? Has Endorsement been completed? Yes Yes Page 1 of 23

2 1.0 Purpose Liverpool Heart and Chest Hospital NHS Foundation Trust is committed to achieving Excellent, Compassionate and Safe care for every patient every day in an environment and with a culture that promotes the safety, wellbeing and a positive experience for our patients, staff and visitors whilst safeguarding the continuity of services, assets and reputation of the Trust. The Board of Directors recognise that to achieve this level of excellence, effective risk management arrangements are essential and that risk must be managed in an holistic and proactive manner so that all types of risk: clinical, financial, environmental and organisational, are addressed when planning, decision-making and in day-to-day management. The aim, therefore, of this strategy is to enhance and reinforce a culture of openness and safety whilst encouraging creativity and innovation, in which risks are proactively identified and managed. The strategy describes the process for risk identification, management and escalation; as well as the responsibilities of staff groups and individuals. This strategy should be read in conjunction with other policies (named on the front page); however the Incident Reporting Policy is of significant relevance, as many risks are identified this way; and although many will be rated a green low harm; their identification and management supports an open and safe culture within an organisation. This strategy also describes our ambition to be an organisation that consistently learns from incidents and risks in order to prevent reoccurrence and minimise impact. The strategy must ensure the Trust complies with relevant statutory, mandatory and professional requirements including: NHSLA Risk Management Assessment scheme and can demonstrate embedded and sound risk management practices; Properties Expenses Scheme/Liabilities to Third Parties Scheme Standards; Health & Safety Regulations; Care Quality Commission Regulatory Standards The Health Act 2006 The Health and Social Care Act 2008 Professional Codes of Conduct (e.g. NMC, GMC) Page 2 of 23

3 2.0 Risk Management Definitions Risk Management is a process of identifying, assessing, controlling and reducing risk across the whole organisation. Risk is defined as a hazard / exposure to danger which may lead to harm. The consequence of risk can be damaging and consequently steps must be taken to eliminate or minimise risks and / or limit the impact of occurrence. The term incident is used to denote any untoward or unexpected event that leads to actual or potential harm or loss. The term does not imply blame on the part of the individuals involved. 3.0 Risk Management Duties of Individuals and Committees 3.1 Board of Directors The Board Assurance Framework (BAF) is determined by the Board of Directors. It identifies the principal risks that would prevent achievement of the Trust s strategic goals; or threaten a safe self declaration to Monitor in respect of delivering the annual plan. It also supports the Annual Governance Statement. The BAF documents the control systems in place to mitigate these risks and the assurances that the Board wishes to receive directly to evidence the effective operation of these controls. Principal risks are purposely not scored or prioritised and the BAF sits separately from the operational risk register which operates in accordance with this. The standing assurance committees of the Board of Directors: Corporate Readiness Committee Clinical Quality Committee Patient and Family Experience Committee Workforce Committee Finance Committee Via the authority delegated to them by the Board of Directors, the assurance committees have responsibility for monitoring the management of major risks from across the organisation, in addition to relevant risks that may arise through the committee work plan and terms of reference; thus ensuring there is continuous and measurable improvement in the quality of the services provided. It is not the policy of LHCH to present Executive or Directorate Risk Registers to the Board. However, escalation of risks identified as major will be communicated to the Executive Lead for Risk Management (Director of Nursing) and then to the Board of Directors directly or Page 3 of 23

4 through hot topic reporting from the assurance committees. A decision will be taken by the Board of Directors to add this to or alter the Board Assurance Framework (BAF); thereby ensuring the controls is as robust as they can be. 3.2 The Audit Committee Is responsible for reviewing the adequacy of underlying assurance processes that indicate the degree of achievement of corporate objectives and the effectiveness of the management of principal risk. And To maintain and oversight of the foundation Trust s risk management strategy, including the production and issue of any risk and control-related disclosure statements. 3.3 The Corporate Readiness Committee Is responsible for the monitoring the effective implementation of the in accordance with its terms of reference. 3.4 The Executive Team Are responsible for moderating/reviewing risks assessed as major. The Executive Team will ensure that the risk is added to the Executive Risk Register and an appropriate assurance committee is identified to review and monitor the action plans developed to mitigate the risk until the level of risk is reduced. The Executive risk register will be reviewed monthly. 3.5 Non Executive Directors Non-Executive Directors have the duty to review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the organisation s activities (both clinical and non-clinical), that support the achievement of the organisations strategic objectives. As members of the Audit Committee, Non-Executive Directors have a duty to review the adequacy of the, and request at any time information regarding the implementation/effectiveness of the. 3.6 Director of Nursing (DoN) The DoN is accountable to the Board of Directors and Chief Executive and has executive responsibility for risk management. This incorporates Health and Safety, Emergency Planning, Customer Care and Safeguarding. Page 4 of 23

5 The DoN will ensure any major concern identified is reported to the Executive Team for moderation and review and if necessary adding to the Executive risk register. 3.7 Director of Finance and Information Is accountable to the Board of Directors and Chief Executive for financial risk management and control. The Director of Finance has a duty to seek the Chief Internal Auditor s opinion on the effectiveness of internal financial control. 3.8 The Trust Secretary The Trust Secretary will work with the Chairman and Chief Executive to populate and maintain a Board work plan for the year ahead. This will include receipt of all assurances detailed within the BAF. The post holder will make available the BAF for each Board of Director s meeting this process will ensure existing controls are reviewed on a regular basis and where necessary strengthened when newly identified risks are presented. 3.9 Deputy Director of Nursing and Governance Is responsible to the Director of Nursing and has the following duties in relation to risk management: Ensure the Risk Management Team is fit for purpose and have clearly defined roles Ensure robust operational risk management and complaints processes have been implemented across the Trust. All CQC Essential Standards of Quality and Safety (ESQS) assessments are completed and compliance from these assessments is reported to the appropriate standing committee General Managers, Associate Medical Directors and Assistant Directors of Nursing (Directorate Management Team) and Clinical Leads Have a duty to ensure that the Trust s risk management processes are fully implemented within their areas of responsibility, risk registers are maintained, and will ensure that the principal risks to the Trust s objectives are systematically identified, controlled or mitigated. In addition, they have a duty, on behalf of their Directorates, to provide information to the Executive Team on unacceptable and serious risks. Any risk identified as major will be reported to the Director of Nursing for presenting at the next Executive Team meeting. Page 5 of 23

6 The Directorate Management team and clinical leads have specific responsibilities to ensure that organisational learning occurs. They should do this by supporting an open and safe culture where staff understand and feel comfortable reporting incidents and identifying risks; sharing learning and seeking to always improve practice. The Directorate Management Team have a duty to ensure that effective risk management processes are in place within their Directorate, including ensuring staff are appropriately trained in risk management techniques. They will ensure risk registers are developed and discussed at Directorate Governance Committees at least twice a year. Any ward/departmental risk that are identified as minor will be reviewed through this reporting process. In the event that a risk has been identified as moderate it is added to the Directorate risk register and presented at the next Directorate Governance Committee for moderation. The GM and ADNS must ensure the assessments of the Essential Standards of Quality and Safety (ESQS) are performed at least on an annual basis in each ward and department and any risks identified are added to the relevant risk register Governance Leads (including the Risk Manager Role) Are responsible to the Deputy Director of Nursing. The post holders will ensure the Trust has established risk management processes. They are the lead contact with the National Patient Safety Agency (NPSA) and the Medicines and Healthcare Products Regulation Agency (MRHA). They have a duty to ensure that: Incident reporting trend data is reported to the Patient and Family Experience Committee twice yearly by the integrated Incident, Claims and Complaint report All relevant incidents are reported to Liverpool PCT in line with their protocol. All Safety Alerts and Notices received via the Central Alerting System (CAS) are appropriately disseminated, acknowledged and actioned within the defined timescales. There is an established process for the review of department risk registers by Directorate Governance Committees. Any major risks identified are discussed and possibly moderated before being reported to the Director of Nursing. Ensure the assessments of the Essential Standards of Quality and Safety (ESQS) are performed at least on an annual basis in each ward and department. Page 6 of 23

7 Ensure the outcomes from the ESQS assessments are reviewed at Directorate Governance and risks identified are placed on the appropriate risk register according to the level of concern. Take the operational lead for Emergency Planning and manage Health and Safety 3.12 The Health & Safety Advisor Has a duty to provide advice and facilitate the effective management of risk and health and safety issues within the Trust. The post holder has a duty to ensure that Health and Safety training is delivered via corporate induction, mandatory training and specific health and safety training needs are identified. The post holder has a duty to ensure that, in co-operation with the Governance Leads, all H&S concerns are addressed appropriately and that all RIDDORS are reported through the appropriate channels Fire Manager The post holder will ensure all fire regulations are adhered to within the Trust by the proactive management of risk assessments and specific fire training Legal Services Manager The post holder will support the Trust and staff in the management of claims, dealing with legal related issues. The Legal Services Manager has a duty to ensure the Trust manages claims within specified targets, and to monitor and report on the Trust s performance in respect of the procedure by the twice yearly Incident Complaints and Claims reports Customer Care Manager The post holder will be responsible to the Deputy Director of Nursing. They have a duty to ensure that the Trust handles complaints efficiently in line with complaints regulations and within specified targets. They have a duty to monitor and report on the Trust s performance in respect of these processes. The post holder has a duty to provide detailed reports and trend analysis, and identify changes in practice to reduce the incidence of complaints by the twice yearly Incident Complaints and Claims reports, and will identify complaint trends for investigation by appropriate managers and/or committees. Page 7 of 23

8 3.16 The Authority of All Managers with Regard To Managing Risks All Managers have a duty to: Implement risk assessment and management within their areas of responsibility ensuring the participation of staff. Act as designated Investigating Officer for complaints, untoward incidents and accidents. Ensure timely reporting of incidents / events in order to promptly react to risks. Ensure staff within their areas of responsibility attend mandatory training at the intervals agreed, including risk management awareness and any other necessary risk management training. Ensure risk assessments are undertaken as necessary within their areas of responsibility. Ensure at least a twice yearly review of departmental risk registers within their areas of responsibility. Ensure that risks categorised as minor are managed locally. Ensure risks categorised as moderate or major are escalated to the appropriate manager for consideration and inclusion in the Directorate / Executive team Risk Register All Staff All staff have a duty to: Practice in a safe and efficient manner, adhering to Trust Policies and Procedures, all of which are available on the Trust s intranet. Maintain and develop competence and safety through attendance at mandatory and training sessions at the agreed intervals, as per the LNA. Inform line managers of actual and potential risk situations within their working environment, through the use of the Trust s incident reporting system and/ or the Raising Concerns at Work Policy. Contribute to an open culture that allows and encourages learning from risks and incidents both in an informal and formal manner. Page 8 of 23

9 4.0 Guide to assessing Risks When assessing a level of risk, consideration must be given to the impact of and the likelihood of the risk actually happening Impact: Likelihood: Low Medium High Unlikely Minor Minor Moderate Possible Minor Moderate Major Almost certain Moderate Major Major Likelihood Unlikely Likelihood Definition Definition This will probably never happen or happen again as there are adequate controls measures in place Possible This may happen/will probably happen or will happen again, but is not an issue that occurs often Almost Certain This will happen on a frequent basis because the control measures are weak or there is no adequate process in place By identifying the likelihood and impact this will inform which level of concern should be identified for the risk. Once identified the decision to add the appropriate risk register must be made. Impact Definition Impact Low Medium High Definition None or low impact on people who use the service or on the service itself Some impact but no long term effect on people who use or work in the service or the service itself A significant or long term impact on people who use or work in the service or the service itself Page 9 of 23

10 4.1 Reporting Process once level of risk is identified The way in which risks are escalated and managed will be dependent on the level of risk identified. Minor Risk: will be managed by the department manager however, to ensure the appropriate actions have been identified and the risk is being appropriately managed the departmental risk register will be presented to the Directorate Governance Committee as part of the normal reporting schedule. The time period for reviewing minor risks will be made by the department manager unless the Directorate Governance Committee requests a different review time period. The risk register for the ward/department will be reviewed by Directorate Governance Committee at least twice per year. Moderate Risk: If a department manager identifies a moderate concern this will be escalated to the ADNS of the appropriate Directorate, and be discussed with the General Manager / Department Head. This moderate risk will be presented by the department manager and discussed at the next Directorate Governance Committee. Moderation of the risk should occur and collective decision made to either down grade the risk to minor and leave on the department risk register or agree with the assessment and place the moderate risk on to the Directorate risk register. The review period will be agreed at the Directorate Governance Committee and date for review added to the Directorate Governance schedule of reporting. Directorate risk registers will be reviewed at the Directorate Governance Meeting twice yearly. Major Risk: In the event that a major risk is identified from either the review of department risk registers or the business of the Trust then escalation of the risk will be to the Director of Nursing. This level of risk will be reported to the next Executive Team. The risk should be presented with an action plan by the General Manager or Governance Lead. Moderation of the risk should occur and a collective decision made to either down grade the risk to moderate and leave on the Directorate risk register or agree with the assessment made. This risk should then be added to the Executive Risk Register, be assigned to the appropriate assurance committee and reported to the Board of Directors either directly or via hot topics (depending on timing). Page 10 of 23

11 4.2 Risk Management Framework The following framework represents the risk management approach at LHCH. Page 11 of 23

12 5.0 Cost of Clinical Negligence The Legal Services Department of the Liverpool Heart & Chest Hospital handles Clinical Negligence claims against the Trust; it also handles all other claims including Public and, Employer Liability and Property expenses claims. The NHS Litigation Authority (NHSLA) Clinical Negligence Scheme for Trusts (CNST) provides a means for the Trust to fund the cost of clinical negligence claims. A separate scheme, Existing Liabilities Scheme (ELS), also administered by the NHSLA, funds clinical negligence claims arising from incidents occurring before 1 st April A Clinical Negligence claim is a claim that refers to any event arising or resulting from the clinical management of a patient, which may, or has caused harm to that patient. An event that has caused Injury to a staff member may result in a non clinical claim being made against the Trust. NHSLA will be notified as per their standards when the Legal Services Department receive notification of a clinical or non clinical claim being made. NHSLA produce Risk Management Standards on an annual basis. Assessment against theses standards is mandatory for all scheme members of which LHCH is one. Successful accreditation at each level will mean a reduction of 10% - 30% for the premiums paid into the scheme. 6.0 Training In order to ensure that staff have sufficient awareness of risk management and are competent to identify, assess and manage risk within their working environment, risk management awareness and incident reporting training will be made available to staff on Corporate induction and there after as part of their mandatory training as detailed in the Induction and Mandatory Policy and Procedure Learning Needs Analysis (LNA). The Trust s will be made available to all staff via the intranet. It is available to patients and the public upon request. This strategy should be read in conjunction with the policies and procedures related to risk management as detailed on the front cover of this Strategy. Page 12 of 23

13 7.0 Strategy Review This strategy will be reviewed annually and in the event of any changes to statutory requirements re ratification will occur at least every three years. 8.0 Implementation plan All departments will be made aware of this strategy by their respective Head of Department following ratification. Corporate Readiness Committee will monitor implementation of the Strategy at least on an annual basis. 9.0 Monitoring of the Compliance with the requirements of this policy will be monitored against NHS Litigation Authority (NHSLA) minimum requirements. A monitoring report will be produced by the Risk Manager. Where the report identifies deficiencies, the Risk Manager will produce an action plan to address these. The monitoring report and the action plan will be presented to the Corporate Readiness Committee who will be responsible for reviewing the action plan on a quarterly basis until the actions are complete. Monitoring will include: The review process for all clinical/department risk registers The management process for identified minor, moderate and major concerns The review process of the Executive Risk Register Review of Governance Meetings agenda and minutes, demonstrating discussion and decision making on identified concern levels Page 13 of 23

14 Appendix 1 Corporate Readiness Committee terms of reference Author s Name & Title: Paul Rushton, Associate Director, Service Development Scope: Trust Wide Classification: Terms of Reference Replaces: Risk Management Committee Terms of Reference, v3.3 To be read in conjunction with the following documents: Governance Manual Annual Work Schedule Board Assurance Framework Document for public display? No Unique Identifier: TOR/TB/09(09) Review Date: 30 th April 2012 Issue Status: APPROVED Issue No: 1.0 Issue Date: 21/04/2011 Authorised by: Board of Directors Authorisation Date: 29/03/2011 After this document is withdrawn from use it must be kept in an archive for 10 years Archive: Document Control Date added to Archive: Officer responsible for archive: Document Control Administrator Page 14 of 23

15 1. Constitution and Remit This Committee is established as an Assurance Committee of the Board of Directors of Liverpool Heart and Chest Hospital NHS Foundation Trust in order to provide the Board with assurances that the Trust has in place all of the necessary systems and governance structures to ensure it is capable of delivering health care of the highest quality in a safe and effective manner. This includes the oversight of the Trust s Risk Management process, incorporating Health and Safety, Continuity and Emergency Planning and Information Management. This will incorporate measures of performance and compliance with national and local requirements. 2. Authority The committee is authorised by the Board of Directors to investigate any activity within its terms of reference. It is authorised to seek information it requires of any employee (or contractor acting on behalf of the Trust) and all employees (or contractors acting on behalf of the Trust) are directed to co-operate with any request made by the committee. The committee is authorised to obtain legal advice or other professional advice from internal or external sources. Where appropriate the Committee will consider the Broadgreen site in totality where this will have an impact on the way the Trust delivers its services. 3. Objectives The Committee will deliver the following objectives along with any others that are assigned by the Board of Directors during the course of the year: 3.1 Risk Management Risk Identification and mitigation Receive and monitor risks escalated from the directorates / departments that are designated major, with associated actions to reduce the risks in relation to Estates, Health & Safety, Emergency Planning and Information Management. Receive and monitor areas within the Quality & Risk Profile (CQC) that are rated red ( worse than expected or much worse than expected ) in relation to Estates, Health & Safety, Emergency Planning and Information Management. Ensure that processes, structures and responsibilities for identifying risks are in place. Ensure that processes, structures and responsibilities for appropriately managing identified risks are in place. Ensure the quality and effectiveness of Directorate risk management processes through a programme of periodic and risk based reviews Receive the findings and recommendations from relevant SUIs and red incidents. Review appropriate reports received from Audit Committee, assess risks and performance manage action plans Develop a culture of risk awareness across the Trust Strategy, policy and procedures Ensure that the trust has an up to date risk management strategy and associated policies that comply with relevant regulatory, legal and code of conduct requirements. Page 15 of 23

16 Approve policies and procedures required for effective risk management and practice Monitor the Trust s compliance with NHSLA standards Policy on procedural Documents Risk Management Committees Risk Awareness Training for Senior Management Risk Management Process Risk Registers Responding to External Recommendations Health Records Management Secure environment Slips Trips and Falls staff Moving and Handling Violence and Aggression Incident Reporting Claims Handling Being Open Learning and spreading best practice Advise the Trust on risk management training requirements for all staff, contractors and volunteers in accordance with NHSLA and CQC standards and requirements identified through needs analysis. Advise the workforce strategy committee of mandatory training requirements and the metrics that that committee needs to monitor to ensure appropriate compliance. Effectively communicate key risk management lessons through corporate communication channels and education events. Monitor and evaluate the effectiveness of the risk management performance and the reporting and assurance mechanisms. 3.2 Information Management Monitor the implementation of the information strategy, including the adherence to Information governance requirements and the provision of Data Quality standards Advise on the management of any key risks arising from the informatics function Ensure adherence to informatics best practice and ensure lessons learned are effectively disseminated and incorporated Trust wide 3.3 Health and Safety 3.4 Estates Approve the Trust s Health and safety Policy and monitor adherence to it and take assurance that the Trust operates in a way that meets all regulatory requirements Provide assurance that the Estate: Offers a safe and efficient place from which to operate; Is conducive to delivering excellent healthcare; Meets all recognised standards, including equality and diversity issues; by presenting external reviews and internal audit information that benchmarks the Estate operation against best practice Monitor Estates KPIs Page 16 of 23

17 3.5 Business Continuity and Emergency Planning Ensure that the Trust has a robust plan in place to ensure business continuity in the event of a major incident Ensure that the Trust has an effective Emergency Planning process that supports the preparedness for and reaction to such an event, to include a robust disaster Recovery plan. 3.6 Governance Determine level of compliance for CQC outcomes 10, 11, 21 and monitor progress against major concerns identified Approve the establishment, work plans, duration and effectiveness of sub-committees and working groups Respond to action plans referred by the Audit Committee. 4. Equality and Diversity The Committee will ensure that equality and diversity, and due consideration to the Human Rights Act, are regarded in all aspects of its work. This will include ensuring that all Estates maintenance and site development work makes due regard of the E&D guidance, and that in developing our plans for emergencies and business continuity we consider all elements of the E&D agenda. In determining the Information Governance policies and strategies the committee will ensure that E&D legislation is adhered to at all times. In addition the Committee will have regard for the NHS constitution in delivering its objectives. 5. Integration The committee will support the integration of clinical, organisational and financial risk management systems across the Trust with that of the business planning process. It will promote a holistic approach to management and encourage all staff to provide safe, effective, timely and efficient care and treatment to patients, within a safe, open and learning environment. The committee chair will work with the executive team and Board to integrate clinical, financial and organisational governance and risk management processes and systems. 6. Membership Chair: Associate Director of Service Development Deputy Chair: Associate Director of Quality Improvement Nominated Non-Executive Director Chief Executive Director of Nursing (Nominated Deputy ADNS) Medical Director (Nominated Deputy Associate Medical Director) Director of Finance (Nominated Deputy Deputy Director of Finance) Associate Director of Quality Improvement (Nominated Deputy Research, Audit & Effectiveness Manager) Page 17 of 23

18 Associate Director of Human Resources and Organisational Development (Nominated Deputy Head of Workforce) General Manager, SACC General Manager, C&CM Business Manager, Support Services, Deputy Director of Nursing and Governance Head of Risk Management Estates Manager Head of Workforce Marketing and Communications Manager Head of Information Head of Procurement Head of IT 7. Attendance Members are expected to attend at least 3 of the 4 meetings held each year but should aim to attend all scheduled meetings. Where they are unable to attend, they should send their designated nominated deputy. All Non Executive Directors have the right to attend this meeting. 8. Quorum and Frequency The Chair or Deputy Chair and 1 Executive/Associate Director plus a minimum of 6 other members will constitute quorum. The Committee will meet quarterly. 9. Reporting The Committee will report to the Trust Board via hot topics, minutes and an annual report. The Committee will receive reports from the following sub-committees: Health and Safety (Chair Director of Nursing; bi-monthly) Information Governance Committee (Chair - Director of Finance ; bi-monthly) Emergency Planning Group (Chair Deputy Director of Nursing ; bi-monthly) 10. Conduct of Committee Meetings The chair of the committee will ensure that the appropriate processes are followed:- Minutes are kept by the secretary to the committee The agenda includes the following standard items o Matters arising o Action log o Risk Management o Information Management o Health and Safety o Estates o Business Continuity & Emergency Planning o Governance Page 18 of 23

19 o Any other Business o Date of next meeting The agenda and supporting papers will be sent out to committee members 5 working days prior to the committee, unless authorised by the Chair for exceptional circumstances Authors of papers presented must use the required template and indicate whether the paper is for decision by the committee, for discussion, for information or for approval. Presenters of papers can expect all committee members to have read the papers and should keep to a summary that outlines the purpose of their paper/report and key issues. Committee members may question the presenter. Page 19 of 23

20 Appendix 2 Department / Ward Risk Register Date Risk Where was the risk identified and when? What can you do today to control the risk? Likelihood Impact Outcome Is the control sustainable Y /N Action/Control (Do we need to put in place a sustainable control? If not, why not? Timescales for implementation and resource implications Responsible Person Review Date Assurance Ward/Department Directorate Corporate Page 20 of 23

21 ssue x [date] Issue 2.0 August 2008 Risk Management Strategy Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Committee Structure Audit Committee Investment Committee Charitable Funds Nominations & Remuneration (Execs) Board of Directors Executive Team Service Improvement Board Council of Governors Nominations & Remuneration (Non-Execs) Finance - Fundraising Committee -Robert Owen House Committee - IT Programme Board - Capital Control Group -Service and Cost Improvement Group Clinical Quality - Drugs & Therapeutics - Clinical Effectiveness & Audit - Cancer Services - Diabetes Steering Group - Transfusion - Critical Care Delivery Group - Research - Public Health - Resuscitation - Infection Prevention Patient & Family Experience Workforce Corporate Readiness - Safeguarding - Equality & Diversity - Learning & Development - Staff Forum - Partnership Forum - LNC - Health and Safety -Information Governance - Emergency Planning March 2011 V4 Page 20 of 23

22 ssue x [date] Issue 2.0 August 2008 Risk Management Strategy Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Endorsed by: Name of Lead Clinician/Manager or Committee Chair Position of Endorser or Name of Endorsing Committee Date Raj Jain CEO/Risk Management Committee 4 th July Raj Jain CEO/Risk Management Committee 7 th July 2009 Neil Large (Chair) Board of Directors 26 th Page 20 of 23

23 ssue x [date] Issue 2.0 August 2008 Risk Management Strategy Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Record of Changes to Document - Issue number: 2.1 Changes approved in this document: Date: 12/09/08 Section Amendment (shown in bold Deletion Addition Reason Number italics) Appendix 2 Committee Structure Previous reporting structure. New reporting structure Structure corrected to Structure re-approved by reflect actual sub Board of Directors April 09 committees reporting rather than processed being discussed. Changes approved in this document Date 1/9/2009 Roles and New staff roles and Role of Head of Corporate Deputy Director of Nursing Change in staff Responsibilities responsibilities added Risk Appendix 1 New Terms of Reference of Previous Terms of Reference Annual review of Risk Management Committee archived on Z drive LHCH Terms of Reference Changes approved in this document Date 14/3/2010 Appendix 3 Learning needs for Risk Nil New appendix NHSLA requirement Management Awareness Section 7.2 Changes to the reporting of Nil New section LPCT requirement page 10 SUI Issue No 3.2 Page 23 of 23