Risk Management Strategy 2014/2016

Transcription

1 Enclsure L Risk Management Strategy 2014/2016 Trust Bard Item: th January 2014 Enclsure: L Purpse f the Reprt: T present the Trust Bard the updated Risk Management Strategy fr ratificatin. The Strategy has been reviewed by the Quality Assurance Cmmittee and was apprval by the Audit Cmmittee in December The key changes are shwn in red text in the Strategy. FOR: Infrmatin Assurance Discussin and input Decisin/apprval Spnsr (Executive Lead): Authrs: Debrah Lawrensn, Head f Crprate Affairs / Cmpany Secretary Debrah Lawrensn, Head f Crprate Affairs Jacky Bush, Head f Quality & Risk Assurance Tam Mrcrft, Crprate Risk Manager Authr Cntact Details: Risk Implicatins Link t Assurance Framewrk r Crprate Risk Register: Debrah Lawrensn, ext 2522 Jacky Bush, ext 3846 Tam Mrcrft, ext 2536 Legal / Regulatry / Reputatin Implicatins: Link t Relevant Crprate Objective: T deliver quality, patient centered healthcare services with an excellent reputatin Objectives cnsidered by RMC and Quality Assurance Cmmittee. Strategy apprved by Cmpliance and Risk Dcument Previusly Cnsidered By: Cmmittee fr submissin t Audit Cmmittee Recmmendatin& Actin required by the Bard : The Bard is asked t: a) Ratify the revised Risk Management Strategy; and b) Agree a mid-year review shuld take place 1

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3 Enclsure L Summary 1. The Risk Management Strategy prvides a framewrk fr risk management within Kingstn Hspital NHS Fundatin Trust. Its aim is t ensure the safety f patients, staff and the public and t deliver quality, patient-centered services that achieve excellent results and prmte the best pssible use f public resurces, thrugh an integrated apprach t managing risks frm all surces. The Risk Management Strategy is reviewed and updated every year. Apprval and Ratificatin prcess 2. The prcess f updating and apprval is: Revised bjectives were agreed by the Risk Management Cmmittee in Octber 2013, and the Quality Assurance Cmmittee in Nvember 2013, and amended by the Audit Cmmittee in December 2013 The updated strategy was signed ff by the Cmpliance & Risk Cmmittee in Nvember 2013 The strategy was apprved by the Audit Cmmittee in December 2013 The updated strategy is being presented t the Trust Bard tday fr ratificatin. Revisins t the Strategy 3. Versin 11 f the Strategy has been reviewed, by the Crprate Risk Manager, the Head f Quality and Risk Assurance and the Head f Crprate Affairs / Cmpany Secretary. This review has resulted in the fllwing changes (shwn in red in the main dcument); Inclusin f Health and Safety as a risk categry. This categry had been remved in versin 11 f the strategy; hwever, t ensure that the crrect risks are reviewed by the apprpriate cmmittees, and t reflect the new gvernance structure, this categry has been reinstated. Updated risk management bjectives, these were reduced t three by the Audit Cmmittee prir t apprval Updating f individual and cmmittee rles and respnsibilities fllwing the Octber 2013 gvernance re-structure and the mve t Service Line Management References t Divisins have been replaced with Service Lines, t reflect the recent changes Amendment t the prcess fr risk escalatin nt the Crprate Risk Register An amended chart shwing the lcal risk management and gvernance arrangements, as required by the NHSLA standards. It is imprtant t nte that as Service Line Management develps these structures will mature and be mdified. Review f the Strategy 4. The Risk Management strategy is rutinely subject t an annual review, with a half yearly review f prgress against the bjectives. 3

4 Enclsure L 5. As the recent gvernance changes becme embedded, sme minr prcess and structure changes may ccur. It is therefre recmmended that there is a mid-year review f the Strategy, t ensure that it remains accurate and reflective f the Trust s prcesses and Risk Management apprach. Recmmendatins 6. The Bard is asked t: a) Ratify the revised Risk Management Strategy; and b) Agree a mid-year review shuld take place 4

5 Enclsure L RISK MANAGEMENT STRATEGY Plicy Authr Jacky Bush, Head f Quality & Risk Assurance and Debrah Lawrensn, Head f Crprate Affairs Versin 12 Impact Assessment Date 1 st June 2009 Ratifying Cmmittee Trust Bard Date Apprved January 2014 Review date July 2014 (mid-year review due t intrductin f SLM) 5

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7 CONTENTS Enclsure L Sectin Page N 1. Intrductin Definitins Strategic Aims Individual Rles and Respnsibilities fr Risk Management Gvernance Structure fr Risk Management Key Principles f Risk Management at Kingstn Hspital NHS Fundatin Trust Recrding risk Implementatin Cmmunicatin / Disseminatin Mnitring Review Archive Arrangements References Versin Cntrl...23 Appendix A - Crprate Framewrk...25 Appendix B - Bard assurance and escalatin framewrk...26 Appendix C - Gvernance Cmmittee Structure...39 Appendix C1 Service Line Risk Management Structure...40 Appendix D - List f Trust Plicies and Guidelines Relevant t Risk Management

8 1. Intrductin Enclsure L Kingstn Hspital NHS Fundatin Trust is cmmitted t a Risk Management Strategy which minimises risk t all f its stakehlders thrugh a cmprehensive system f internal cntrls, whilst maintaining the ptential fr flexibility, innvatin and best practice in delivery f its strategic bjectives arund delivering high quality care. The Risk Management Strategy is reviewed annually. The Risk Management Strategy prvides a framewrk fr taking this frward thrugh internal cntrls and prcedures which encmpass strategic, financial, quality, reputatinal, cmpliance and health & safety risks. Its aim is t ensure the safety f patients, staff and the public and t deliver quality, patient-centred services that achieve excellent results and prmte the best pssible use f public resurces, thrugh an integrated apprach t managing risks frm all surces. It is supprted by the Risk Identificatin, Assessment and Risk Register Prcedure which includes the prcess t identify and manage lcal risks and the systematic means by which these lcal risks are escalated t Bard level attentin thrugh the Crprate Risk Register and hw risks are cntrlled and mnitred. Linked t the strategy are a number f peratinal prcedures fr risk and incident management which are referenced in the Crprate Framewrk attached at Appendix A. The Trust als has a Bard Assurance Escalatin Framewrk in place which demnstrates hw the Trust s plicies, systems and prcesses wrk tgether t prvide an effective and rbust gvernance structure enabling the identificatin f emerging issues and their mnitring, escalatin and management at apprpriate levels and in a timely way. This is attached at Appendix B In Octber 2013 a number f changes t the Divisinal and Bard gvernance structures were made. The new structures are attached at Appendix C. These recent gvernance changes will need time t becme embedded. T ensure that the Strategy remains accurate and reflective f the Trust s prcesses and Risk Management apprach a mid-year review f the strategy will take place. The Trust has identified three key risks t the achievement f its strategic bjectives ver the next five years which are utlined in the Trust s 5 year Integrated Business Plan (IBP). These risks are reflected in the Crprate Risk Register and Bard Assurance Framewrk, and are: That financial and prductivity plans are nt delivered Fluidity in the external envirnment Insufficient rganisatinal capacity and delivery f cultural change t deliver ur visin The fllwing dcument therefre sets the aims and bjectives fr risk management and the assurance mechanisms fr measuring prgress. Trust Plicy Equality Statement This Strategy frms part f Kingstn Hspital NHS Fundatin Trust s cmmitment t create a psitive culture f respect fr all individuals including staff, patients, their families and carers as well as cmmunity partners. The intentin is t identify, remve r minimise discriminatry practice in the areas f race, disability, gender, sexual rientatin, age and religin, belief, faith and spirituality as well as t prmte psitive practice and value the diversity f all individuals and cmmunities. 8

9 2. Definitins Enclsure L Risk is defined as the chance f smething happening, r a hazard being realised that will have an impact upn bjectives (NPSA). It is measured in terms f cnsequence and likelihd. Risk can mean different things in different cntexts. Fr the purpses f this Strategy and the assciated peratinal prcedures, the risks faced by the Trust have been refined int 3 categries, which are reflected in the Risk Registers. Bundaries between the categries are nt always clear and sme risks may fall int mre than ne categry:- Quality These relate t risks which wuld impact n; Patient safety and experience, Clinical utcmes Cmpliance issues, fr example, meeting statutry and nn statutry standards set by the care quality cmmissin, NICE, the NHS litigatin authrity and ther regulatry r enfrcement bdies. Reputatinal risks fr example events which may damage the credibility r gd name f the Trust Health & Safety Infrastructure, Emplyee safety, The safety f visitrs t the trust s premises Cmpliance issues, fr example, meeting statutry and nn statutry standards set by health and safety executive and ther regulatry r enfrcement bdies such as the infrmatin cmmissiner and lcal fire authrity Strategic These relate risks which wuld impact n; the lng term strategic bjectives f the Trust, which may be affected by legal and regulatry changes and changes in the business envirnment Financial These relate risks which wuld impact n;: Incme, Expenditure, Fulfillment f cntracts The crrect applicatin f standing rders, standing financial instructins and the scheme f delegatin 3. Strategic Aims The Trust s key aims are t manage risks where they ccur as part f nrmal line management respnsibilities, and apprpriately priritise resurces t address risk issues thrugh the peratinal management and business planning prcesses. Strategic aims fr the Risk Management Strategy are; Cmpliance with relevant statutry, mandatry and prfessinal requirements and maintenance f the Trust s registratin with the Care Quality Cmmissin (CQC) Cnsistent and effective risk management prcesses at all levels f the rganisatin Open culture where peple feel encuraged t take respnsibility fr minimising risks The develpment f a learning culture t supprt imprvements t the safety f services Integratin f risk management int business prcesses, such as ensuring service develpments d nt adversely impact n safety 9

10 Enclsure L Specific measurable bjectives fr 2013 t 2016 are set ut belw. These bjectives will be reviewed annually by the Quality Assurance Cmmittee and Audit Cmmittee and prgress against them will be assessed six mnthly by the Cmpliance and Risk Cmmittee; T maintain cmpliance with regulatry requirements T ensure rbust gvernance arrangements as we change management structures T strengthen the incident and SI investigatin prcess s that investigatins and actins are mre rbust 4. Individual Rles and Respnsibilities fr Risk Management The Chief Executive The Chief Executive, as Accuntable Officer has verall respnsibility fr risk management and fr ensuring the Trust has a Risk Management Strategy and infrastructure in place t prvide a cmprehensive system f internal cntrl and systematic and cnsistent management f risk. S/He will delegate specific rles and respnsibilities t the appinted Executive Directrs/Senir Managers t ensure risk management is c-rdinated and implemented equitably t meet the Trust bjectives safely withut detriment t patient care. The Chief Executive line manages the Divisinal Directrs and chairs the Clinical Quality Imprvement Cmmittee. Deputy Chief Executive The Deputy Chief Executive is respnsible fr ensuring that risks related t the delivery f the quality, perfrmance and finances f the clinical directrates are identified and cntrlled thrugh the Perfrmance Management Review meetings between the Divisinal Directrs and the Service Line structures. S/he has specific respnsibility fr the leadership and delivery f the Health and Safety agenda and Estates Strategy. The Deputy Chief Executive chairs the Cmpliance and Risk Cmmittee. Head f Crprate Affairs/Cmpany Secretary The Head f Crprate Affairs/Cmpany Secretary has peratinal respnsibility fr the gvernance and risk management prcesses acrss the Trust and leads n the develpment f gvernance prcesses, the Bard Assurance Framewrk and the Crprate Risk Register. Directr f Nursing and Patient Experience The Directr f Nursing and Patient Experience has respnsibility fr ensuring risks related t quality are identified and cntrlled and fr Patient Experience and safeguarding agendas and is the Directr f Infectin Preventin and Cntrl. Medical Directr The Medical Directr has the verall respnsibility fr leading n, and the delivery f, the patient safety agenda and fr ensuring quality and the best pssible clinical utcmes, as well as enabling medical staff t achieve better utcmes and a safe service. As part f this s/he will ensure that there are prcesses in place fr sharing learning between departments. S/he is als the Caldictt Guardian and respnsible fr Medical Revalidatin. The Medical Directr has verall respnsibility fr the Serius Incident plicy and prcesses. Directr f Finance The Directr f Finance is respnsible fr ensuring that prper systems are in place and perated crrectly t minimise financial risk. In additin the Directr f Finance has a respnsibility fr ensuring that prper reprting exists and fr advising the Bard n financial 10

11 11 Enclsure L strategy. The Directr f Finance is the Senir Infrmatin Risk Officer (SIRO) and has a rle in minimising infrmatin gvernance risk. She/he Chairs the Cmpliance and Risk Wrking Grup which peratinally manages the prcesses arund the CRR and the BAF and ther peratinal wrk n behalf f the Cmpliance and Risk Cmmittee. Directr f Wrkfrce and Organisatinal Develpment The Directr f Wrkfrce and Organisatinal Develpment is respnsible fr delivery f the Wrkfrce Strategy and is the lead fr ensuring cmpliance with equality and diversity requirements. She/he is respnsible fr ensuring that risks related t the delivery f the strategy and f the learning and develpment agenda are identified and cntrlled. Directr f Estates and Facilities The Directr f Estates and Facilities is respnsible fr ensuring that; A cmprehensive prgramme f risk assessments exists in relatin t the estate. The estate cmplies with statutry standards and best practice guidance in infrastructure and maintenance including waste management. Adequate prvisin is made in terms f specialist advice and training including in relatin t fire. The Deputy Chief Executive is ntified if there are insufficient resurces t cntrl the risks r n risk treatment plan can be identified. All Executive Directrs Executive Directrs are accuntable fr the delivery f quality services in the areas within their remit whether clinical r peratinal, lead n the delivery f the Trust s Strategy and are respnsible fr ensuring risks are apprpriately identified and cntrlled. They will ensure the quality agenda is effectively c-rdinated, resurced and implemented acrss the Trust in an integrated way. They will ensure actins taken t imprve the quality f service delivery are cmpleted, measured and shared t prmte learning. Executive Directrs are accuntable fr ensuring that the ptential effect n the quality f service delivery is risk assessed prir t apprval f any new business prpsal. They will ensure that the infrastructure t enable staff t deliver high quality care within their areas f respnsibility is in place. Service Lines and Crprate Departments Each service line and crprate department has inclusive systems in place t ensure that all aspects f their wrk are subject t regular review acrss all specialties and teams. This will be identified within their dcumented gvernance structure and reflect the Trust requirement fr specified utcmes fr each aspect f service prvisin. Divisinal Directrs, Clinical Directrs, Assciate Directrs, Service Line Managers and ther Managers with an peratinal rle All Senir Managers are respnsible fr ensuring systems are in place t implement and mnitr prgrammes f quality imprvement within their areas f respnsibility in line with the Trust s pririties. Divisinal and Clinical Directrs, with supprt frm Assciate Directrs and Service Line Managers, are accuntable fr managing the strategic develpment and implementatin f integrated risk and gvernance within their Divisins and Service Lines. This includes ensuring: Systems are in place t identify, assess and manage risks thrugh implementatin and review f the Service Line Risk Register.

12 12 Enclsure L Effective systems are emplyed fr reprting, recrding and investigatin f all adverse events, such as serius incidents, incidents, near misses, cmplaints and claims. They will identify risks within the service line, will ensure apprpriate actins are taken t mitigate these risks, and will cmply with the reprting and gvernance requirements t ensure learning is shared acrss the rganisatin. They will mnitr their staff and service cmpliance against identified standards and safe systems f wrk whether set natinally r lcally and will facilitate and act upn regular user feedback. The Cmpany Secretary, Head f Crprate Affairs The Cmpany Secretary and Head f Crprate Affairs is respnsible fr the gvernance prcesses relating t managing risks and fr mnitring cmpliance with the plicy framewrk and fr c-crdinating the updating f the CRR fr reprting t Trust Bard. Crprate Risk Manager Reprting t the Head f Crprate Affairs, it is the respnsibility f the Crprate Risk Manager t ensure that: The Risk Management Strategy is being implemented at an peratinal level. The Risk Management Prgramme is crdinated and mnitred acrss the Trust. T maintain the Crprate Risk Register as an active dcument and mnitr treatment plans. T mnitr that the risk and safety requirements f external agencies, such as the NPSA, MHRA, NHSLA, Health and Safety Executive and Care Quality Cmmissin are being implemented. T implement the prcess t ensure that risks highlighted in external reviews and reprts are addressed by the Trust. C-rdinating the risk management training prgrammes Head f Clinical Audit and Effectiveness The Head f Clinical Audit and Effectiveness, reprting int the Medical Directr is respnsible fr ensuring that: Arrangements are in place t enable priritisatin f tpics related t risk, fr inclusin in the annual clinical audit prgramme. Guidance is prvided thrugh the Clinical Audit grup t ensure that actin plans are develped and their implementatin is mnitred. Head f Prcurement The Head f Prcurement, reprting int the Directr f Finance, is respnsible fr: Prviding advice and guidance n purchasing strategies, t enable the minimisatin f risk. Wrking with the Crprate Risk Manager t maintain an effective respnse t MHRA guidance. Divisinal Risk Managers Divisinal Risk Managers are respnsible fr: Prviding specialist clinical safety advice and supprt t managers within their divisins as required. T be a surce f expertise and training fr rt cause analysis techniques. Guidance fr thse undertaking risk assessments and ther lcal risk management functins. Develping and implement risk management training prgrams.

13 Enclsure L Analysing trends btained frm incidents, with the Head f Litigatin, Cmplaints and PALS triangulating the data with cmplaints and litigatin, prviding infrmatin and recmmendatins t relevant cmmittees and service line grups. Acting as the link between their divisins and the crprate functins n risk management issues. Crdinating the generatin f Service Line risk registers and assist in the develpment f risk mitigatin plans. Health and Safety Advisr The Health and Safety Advisr, reprting int the Head f Crprate Affairs and accuntable t the Deputy Chief Executive as Bard lead n health and safety, is respnsible fr: Acting as a Specialist Advisr (cmpetent persn) t the Trust n cmpliance with health and safety legislatin, standards, plicies and prcedures. Ensuring adequate investigatin and fllw up t health and safety incidents, prviding reprts, analysis and identifying trends. Identifying specific health and safety risks and ensuring that they are adequately assessed and recrded and mitigated. Respnding t health and safety issues identified thrugh cmplaints, legal claims, and medical device alerts. Prviding a cmprehensive training prgramme fr health and safety t staff. Head f Litigatin, Cmplaints and PALS The Head f Litigatin, Cmplaints and PALS, reprting int the Directr f Nursing and Patient Experience, is respnsible fr the fllwing areas in respect f risk: As the lead fr claims he/she is respnsible fr ensuring that any risk management issues r remedial actin identified during the curse f a claim, r during the review prcess n clsure, is referred apprpriately fr actin. As the lead fr cmplaints he/she is respnsible fr ensuring prper arrangements are in place fr: Managing and C-rdinating the investigatin f frmal cmplaints. Ensuring that the Trust Cmplaints Prcedure is adhered t. Ensuring that investigatins are cmpleted by Service Lines in accrdance with identified standards and that required fllw up actin is implemented in rder t prevent recurrence. Prviding infrmatin n a quarterly basis, in relatin t cmplaints fr inclusin in the aggregated risk management reprts. Infrmatin Gvernance Manager The Infrmatin Gvernance Manager, reprting int the Directr f Finance, is respnsible fr: Ensuring that the Trust meets statutry bligatins in relatin t infrmatin gvernance and freedm f infrmatin and that risks are identified and managed and where necessary drawn t the attentin f the SIRO. Ensuring that the Trust cmplies with the requirements f the Infrmatin Gvernance Tlkit. Analysing and identifying trends in infrmatin gvernance frm incidents, cmplaints r claims data. Prviding training in infrmatin gvernance issues fr staff. All staff, including medical, nursing, allied health prfessinals, administrative and supprt staff (clinical and nn-clinical) 13

14 Enclsure L All staff are accuntable fr the quality f services they deliver and cmplying with, and participating in, risk assessment prcesses as required. They will cmply with identified standards and safe systems f wrk specific t their rles, whether identified in natinal, prfessinal r Trust plicy, prcedures, and guidelines. They will reprt quality issues, hwever caused, thrugh identified channels t ensure prmpt actin can be taken using existing reprting systems within the Trust. As utlined abve, all managers and staff have respnsibility fr managing risks within the services within which they wrk. The Table belw utlines levels f specific respnsibility. 1. All staff Risk/hazards/cmplaints are reprted in line with the apprpriate plicy, cmply with plicies, standard perating prcedures and instructins t enable cntrl f risks 2. Risk Assessrs Perfrm risk assessment and reprt findings in accrdance with the prcess fr managing risk 3. Divisinal Risk Managers Ensure that risk assessments are included n the Service Line Risk Registers, ensure treatment plans are in place and mnitred. Analyse incident infrmatin supprting the Divisins in the identificatin f trends Supprt the investigatin f serius incidents and mnitring f changes arising frm investigatins. 4. Service Line Managers Review and prepare their Service Line Risk Register. Ensure treatment plans fr risks, incidents and cmplaints are in place. Ensure there are arrangements t mnitr the treatment plans. 5. Gvernance Structure fr Risk Management The Cmmittee structure set ut belw is designed t ensure that all risks are being effectively identified and managed. The current Service Line risk management structures and their inter-relatinship with the Trust-wide cmmittees are utlined in Appendix C1. These structures were intrduced in Octber 2013 and will develp further during 2013/14. Terms f reference fr all these Cmmittees and the Divisinal Risk r Gvernance Grups are available n the Trust intranet (Our Hspital/Structure/Cmmittee Structure). 5.1 High Level Cmmittees with Overarching Respnsibility fr Risk Management The high level cmmittees with verarching respnsibility fr risk management are: The Trust Bard is respnsible fr establishing principal strategic and crprate bjectives and fr driving the rganisatin frward t achieve these. It is als respnsible fr ensuring that there are effective systems in place t identify and manage the risks assciated with the achievement f these bjectives thrugh the Bard Assurance Framewrk and thrugh the Crprate Risk Register. The Audit Cmmittee, n behalf f the Bard, reviews the establishment and maintenance f an effective system f internal cntrl and risk management acrss the whle f the Trust s activities (bth clinical and nn-clinical), that supprts the 14

15 Enclsure L achievement f the Trust s bjectives and als ensures effective internal and external audit. The Quality Assurance Cmmittee (QAC) prvides assurance t the Trust Bard that there are adequate cntrls in place t ensure high quality care is prvided t the patients using the services prvided by Kingstn Hspital NHS Fundatin Trust. The Finance and Investment Cmmittee is respnsible fr scrutinising aspects f financial perfrmance as requested by the Bard. It will cnduct detailed scrutiny f majr business cases and prpsed investment decisins n behalf f the Bard and will regularly review cntracts with key partners. The Executive Management Cmmittee (EMC) is the cre leadership team fr the Trust, and is respnsible fr develping, maintaining and supprting apprpriate leadership behaviurs and visibility within the Trust. It is respnsible fr ensuring the fullest clinical cntributin t determining the strategic directin and its peratinal delivery. The Cmmittee mnitrs the delivery f the rganisatin s peratinal, quality, financial and perfrmance targets, ensuring crrective strategies are agreed where required. It The Cmpliance and Risk Cmmittee (CRC) ensures delivery f the rganisatin s risk management prcedures and practice Specifically it will; Develp, review and implement this strategy. Cnstantly review the Crprate Risk Register. Ensure systems are in place t supprt delivery f cmpliance with legislatin, mandatry NHS Standards, Mnitr, CQC, NHSLA and ther relevant bdies. Develp, review and implement the BAF fr apprval by the Bard. Mnitr delivery f BAF actin plans t ensure gaps in cntrls are clsed and t identify rbust assurance mechanisms. Lead annual reviews f the Trust s gvernance prcesses t take accunt f current best practice and relevant cdes f gvernance. Identify risks t cmpliance with the varius statutry bdies. Encurage and fster greater awareness f risk management thrughut the Trust Mnitr past and future external visits and any actin plans in place t respnd t any risks. Oversee implementatin f the Trust wide plicy management prcess and review and ratify risk and nn-clinical plicies in accrdance with the Plicy n Trust wide Prcedural Dcuments. The CRC is supprted by a number f subject-specific sub cmmittees, which are respnsible fr risks within a defined area and these are identified in Appendix B. The Clinical Quality Imprvement Cmmittee (CQIC) leads the Trust strategy fr the delivery f high quality clinical care ensuring that quality standards are maintained and cnstantly imprved.. Specifically it will: Develp and implement the Trust Quality Strategy. Develp the annual Quality Accunt Use infrmatin derived frm the analysis f adverse incidents, cmplaints and clinical data and audit t identify risks t quality and make imprvements. Ensure the Trust utilises natinal and internatinal best practice infrmatin t innvate and imprve. 15

16 Enclsure L Identify the key quality imprvement prjects fr the Trust annually and ensure they are successfully delivered. Oversee quality assurance (QEIA) elements f the prductivity prgramme. Infrm CRC f risks t quality and ensure risks are described in the CRR. Supprt QAC in the delivery f its rle. 5.2 Sub Cmmittees and Grups with Specific Respnsibility fr Risk The Sub Cmmittees and Grups with specific respnsibility fr risk are summarised belw. Terms f reference fr all these Cmmittees are available n the Trust intranet (Our Hspital/Structure/Cmmittee Structure). The Health & Safety Cmmittee is respnsible fr: Overseeing the Trust s health and safety prcesses and systems. Ensuring cmpliance with health and safety legislatin. Reviewing incidents and ther surces f infrmatin, e.g. staff surveys, t identify trends. The Patient Experience Cmmittee is respnsible fr: Overseeing the Trust Patient experience prcesses and systems. Ensuring delivery f the Patient Experience Strategy and annual wrk plan. Reviewing cmplaints perfrmance, identifying any trends and actin t be taken. The Infrmatin Gvernance Cmmittee is respnsible fr: Overseeing the Trust Infrmatin Gvernance prcesses and systems. Ensuring delivery f the Annual wrk plan. Mnitring cmpliance with the Infrmatin Gvernance Tlkit. Reviewing relevant incidents, cmplaints and litigatin, identifying any trends and actin t be taken. Leading and c-rdinating imprvements in data quality The Audit and Clinical Effectiveness Cmmittee is respnsible fr: Overseeing the Trust s clinical audit and effectiveness prcesses and systems. Ensuring delivery f the annual wrk plan. Mnitring the prgress f red flagged actins resulting frm clinical audits. Identifying any risk issues highlighted in audit reprts fr fllw up thrugh Perfrmance Review Meetings. The Equality and Diversity Cmmittee is respnsible fr: Overseeing the Trust s diversity prcesses and systems. Ensuring delivery f the annual wrk plan. The Cmpliance and Risk Wrking Grup is respnsible fr: Supprting the Cmpliance and Risk Cmmittee in ensuring the rganisatin cmplies with relevant legislatin and requirements t practice. Ensure that there are effective risk management systems in place. 16

17 The Quality Wrking Grup is respnsible fr: Enclsure L Supprting the Clinical Quality Imprvement Cmmittee with analysed data and trends. Ensure that quality standards are maintained and cnstantly imprved. Service Line Perfrmance Review Meetings are respnsible fr: Receiving and agreeing risk assessments frm service areas within the Service Line Ensuring that all risks relevant t the Service Line have been identified and assessed accurately That the Service Line Risk Register is cmprehensive Mnitring the implementatin f treatments plans Reviewing incidents, cmplaints and claims trends as surces f risk intelligence. Agreeing serius incident actin plans and mnitring implementatin f actins. The Serius Incident Review Grup is respnsible fr: Scrutinising and reviewing Serius Incident Rt Cause Analysis (RCA) reprts and Pst Infectin Reviews. Signing ff Serius Incident RCA reprts ahead f the submissin t Kingstn Clinical Cmmissining Grup Mnitring the SI Actin Plan Tracker Others There will be ccasins when specialist grups will be required t supprt the management f specific risk areas. Depending upn the risk issue either the Clinical Quality Imprvement Cmmittee r the Cmpliance and Risk Cmmittee will have verall respnsibility fr mnitring hw thse risks are cntrlled. 6. Key Principles f Risk Management at Kingstn Hspital NHS Fundatin Trust Healthcare prvisin and the activities assciated with caring fr patients, emplying staff, prviding premises and managing finances will always invlve an inherent degree f risk. In brad terms, grups r areas that may be affected are; Patients and visitrs Staff (including cntractrs and vlunteers) Finances The business f the Trust Cmpliance with statutry duties The Trust s reputatin The key surces f risks t thse grups are; Acts r missins by staff Infrmatin systems and the reprts they generate Trust estate and envirnmental impact Actins f cntractrs Business cntinuity i.e. the unexpected failure f a system, which may have a wide impact n delivery f services. 17

18 Enclsure L Changes in the external cmmissining envirnment 6.1 Identificatin f Risk The prcess diagram belw demnstrates the risk management identificatin, evaluatin and treatment cycle. 6.2 Identificatin f Hazards r Threats Pssible risks may be identified thrugh a variety f mechanisms, bth reactive and practive. Practive identificatin may arise frm lcal risk assessments, impact assessments and gap analyses f published reprts n healthcare subjects r inspectins f ther care prviders. Reactive identificatin can be flagged as a result f a serius incident, a trend in incidents r cmplaints r as a result f an audit, either internal r external. Mre descriptin f the risk identificatin prcess, and the triggers fr risk assessment, is prvided in the Risk Identificatin, Assessment and Risk Register Prcedure. 6.3 Risk Evaluatin Risks are analysed and scred accrding t the prcess utlined in the Risk Identificatin, Assessment and Risk Register Prcedure. As part f this prcess, current cntrls n the risks are evaluated. The aim f this prcess is t decide what further actin t cntrl the risk is required (treat the risk), r if the risk must be tlerated at its existing level (accept the risk). Risk Cntrls are the available systems and prcesses which help t minimize risk. The key cntrls used t manage risk are; Recruitment and training f cmpetent staff Clear accuntabilities and respnsibilities fr all levels f staff Effective Trust-wide plicies Standard perating prcedures fr service areas Gvernance and risk management systems, such as incident reprting Perfrmance framewrk Capital Investment prgramme 18

19 Enclsure L Wrking with cmmissiners and partner rganisatins 6.4 Assurance n cntrls; Assurances n cntrls are the methds by which the rganisatin measures the effectiveness f the cntrls in place. Assurance n the effectiveness f the cntrls is prvided at all levels f the rganisatin thrugh; Internal and external audit f cntrl mechanisms Key Perfrmance Indicatrs Benchmarking and Peer reviews Perfrmance review prcesses Self-assessment and internal challenge Cmprehensive risk identificatin, assessment, and cntrl are critical t being a high perfrming rganisatin and assuring the Bard, Cmmissiners and regulatrs that risk is well managed by the Trust. A separate prcedure fr the management f risk thrughut the rganisatin, setting ut the prcess fr assessing risks, is cntained in the Risk Identificatin, Assessment and Risk Register Prcedure and is available t all staff. 7. Recrding risk The tw key dcuments that the Trust uses t recrd risks and the actins in train t mitigate the identified risks are the Bard Assurance Framewrk and the Crprate Risk Register. 7.1 Bard Assurance Framewrk The Bard Assurance Framewrk (BAF) enables the Bard t review its principal bjectives t ensure there are sufficient cntrls in place t manage the risks t their delivery and t understand the assurance there is n the effectiveness f thse cntrls. The BAF maps ut the cntrls already in place and the assurance mechanisms available s that the Bard can be cnfident that they have sufficient assurances abut the effectiveness f the cntrls. The assessment f risk within the Bard Assurance Framewrk is reviewed at the Cmpliance & Risk Cmmittee and managed thrugh its wrking grup. Scrutiny f the Bard Assurance Framewrk is the principal respnsibility f the Audit Cmmittee with input frm the Quality Assurance Cmmittee in the areas f clinical quality and the Finance and Investment Cmmittee. It is als reviewed by the Bard at each meeting and at an Executive Level by the Executive Management Cmmittee, Clinical Quality Imprvement Cmmittee and Patient Experience Cmmittee. The Bard Assurance Framewrk is clsely linked with the Crprate Risk Register (CRR), which reflects significant risks identified at bth a crprate department and divisinal level. The Head f Crprate Affairs, thrugh the Crprate Risk Manager and Assistant Cmpany Secretary, will ensure that the link between the Crprate Risk Register and the Bard Assurance Framewrk is maintained, and that the Audit Cmmittee is satisfied that this is ccurring. The Head f Crprate Affairs is a member f the Quality Assurance and Cmpliance and Risk Cmmittees and attends the Audit Cmmittee. 7.2 Crprate Risk Register (CRR) The risk register is an active tl thrugh which the Trust manages its risks. Its purpse is t lg all risks identified in the high r extreme categries and the cntrls in place r planned t manage the risk t its lwest pssible level (residual risk). The Crprate Risk Register is built up frm the Service Line Registers and the rganisatin-wide and strategic risks 19

20 Enclsure L identified in the BAF and Integrated Business Plan and frm ther risks identified by crprate cmmittees and the Executive Team. Regular update and review f the CRR prvides assurance that risks are being managed and prgress in cntrlling risks is maintained. The Trust prcess fr ppulating a risk register is described in the Risk Identificatin, Assessment and Risk Register prcedure, which is available t all staff. The principles that underpin the apprach t the management f the risks identified n the CRR (and service line risk registers) are; Tlerate Transfer Terminate Treat Accept the risk at its current level Transfer the risk t anther party, i.e. by utsurcing, the cnsequences f this actin will require risk assessing Stp the activity that presents the risk, the cnsequences f this actin will require risk assessing Take actin t reduce r mitigate the risk, in terms f reducing the likelihd f its ccurrence r reducing the severity f impact if it des ccur The Crprate Risk Manager manages the CRR prcess. The CRR is reviewed by the Cmpliance and Risk Cmmittee (CRC) and Wrking Grup mnthly, wrking thrugh each risk in detail and thrugh reviewing service line risk registers, any prpsals fr escalatin and de-escalatin. The CRR is presented t the Audit Cmmittee wh, where required, will request that risks are either subject t further review by the CRC. The CRR is als presented t the Quality Assurance Cmmittee wh will review thse risks that relate t quality f care. The CRR is prvided t the Bard fr apprval n a quarterly basis. 7.3 Service Line and Departmental Risk Registers The purpse f these lcal risk registers, including thse within crprate departments, is t identify and mnitr risks t the achievement f lcal bjectives. All risks f whatever grading will be included s as t ensure cmprehensive and regular scrutiny f all levels f risk. Risks that scre 8 r abve will be cnsidered by the Cmpliance and Risk Cmmittee Wrking Grup fr inclusin in the CRR. Where it is agreed that the risk shuld sit n the CRR the risk will be cnsidered fr rescring t take int accunt the crprate impact f the risk. The CRR is mnitred by the CRC and the Bard in additin t the relevant Service Line Perfrmance Review Meeting. In additin the CRC reviews each Service Line Risk Register twice per year. Service Line Managers are respnsible fr the management f Service Line Risk Registers in cllabratin with their Clinical Directr and supprted by the Divisinal Risk Manager. 7.4 Bard Assurance and Escalatin Framewrk The Bard Assurance and Escalatin Framewrk attached at Appendix B demnstrates hw the Trust s plicies, systems and prcesses wrk tgether, prviding an effective and rbust gvernance structure enabling the Trust t identify, mnitr, escalate and manage emerging issues at the apprpriate levels and in a timely way. Assurance - describes the level f cnfidence that can be btained by the Bard, based n sufficient evidence that internal cntrls are in place, perating effectively and bjectives are being achieved. This dcument explains the key surces f assurance bth internal and external that infrm wrk f the Trust Bard. Escalatin is the prcess used within the Trust t ensure decisins are made at the right level t ensure cntinued quality f care, patient safety and delivery f crprate bjectives. 20

21 21 Enclsure L This prcess ensures risks ver delegated threshlds and decisins utside delegated authrity are escalated thrugh the Trust s gvernance prcesses, and that these decisins are systematically and prperly recrded. 8. Implementatin The implementatin f this Strategy will be achieved thrugh: Develpment f Service Line risk management framewrks t supprt the Trust Risk Management Strategy Prviding training and supprt t managers t enable them t manage risk as part f nrmal line management respnsibilities Effective use f the gvernance system and structures Risk assessments are undertaken systematically in all Service Lines and departments t identify risk, assess effectiveness f cntrls and implement treatment plans, where necessary. Delivery f actins plans at crprate, e.g. NHSLA and Organisatinal Develpment plans and at lcal level, e.g. individual risk treatment plans. Use f, and cmpliance with, plicies t strengthen the systems f cntrl Using infrmatin frm risk assessment, incidents, cmplaints, audit and claims and ther relevant external surces t imprve safety and supprt rganisatinal learning Internal and external audits and assessment t prvide assurance f the effectiveness f cntrls t minimise risk The crprate framewrk fr mnitring risk management is set ut in Appendix A. 8.1 Risk Management Training A prgramme f Risk Management Training, including Risk Assessment, Rt Cause Analysis, is in place and is delivered by the Risk and Safety Team. Risk Management is als included n the inductin prgramme fr new starters. In line with the Trust s Training Needs Analysis, cntained within the Mandatry Training Plicy and Prcedure, specific Risk Management Awareness sessins are held fr Bard members and Senir Managers n an annual basis. The Bard receives training n specific areas such as Risk Management, Infrmatin Gvernance, Health and Safety, Infectin Cntrl and Safeguarding at the start f the Trust Bard meetings. The recrding f attendance, fllw up f nn-attendance and mnitring the cmpliance with training requirements, is cvered in the Mandatry Training Plicy and Prcedure (including Training Needs Analysis). 8.2 Plicies and guidelines relevant t Risk Management The plicies and guidelines in place which are specifically relevant t Risk Management are listed in Appendix D. 9. Cmmunicatin / Disseminatin The Risk Management Strategy will be prvided t individuals with risk management respnsibilities and made available in the Plicy sectin f Trust Intranet fr all staff t access. When published, all staff will be infrmed f its publicatin via the Daily Bulletin. It is each individual Manager s respnsibility t cmmunicate the cntents within their departments. Cpies will be made available t all staff and Stakehlders, as apprpriate.

22 Enclsure L 10. Mnitring Element t be Mnitred Lead Tl Frequency Reprting Lead fr Actins Objectives Chief Review prgress in 6 mnthly Cmpliance & Crprate Risk Executive achieving bjectives Risk Cmmittee Manager Gvernance structure Risk Management Strategy: Head f Crprate The rganisatin s risk Affairs management structure, detailing al thse cmmittees and grups which have sme respnsibility fr risk Hw the bard r high level risk cmmittee(s) review the rganisatin-wide risk register Hw risk is managed lcally Duties f the key individuals fr risk management activities Review f cmmittee structure.. (CRC) Annual EMC and CRC Head f Crprate Affairs Gvernance structure - TORs fr the high level cmmittee(s) with verarching respnsibility fr risk: Duties Wh the members are, including nminated deputies where apprpriate Hw ften members must attend Requirements fr a qurum Hw ften meetings take place Reprting arrangements int the high level risk cmmittee(s) Reprting arrangements int the bard frm the high level risk cmmittee(s) Head f Crprate Affairs Terms f Reference f Bard Sub Cmmittees are reviewed at least annually (5.1) Annual reprts fr each subcmmittee f CRC (5.2) demnstrating cmpliance with terms f reference, reprting and attendance. TORs are reviewed at least annually as part f these reprts Annual Annual Bard CRC Head f Crprate Affairs Chairs f CRC sub Cmmittees Risk management prcess: Hw all risks are assessed Hw risk assessments are cnducted cnsistently Authrity levels fr managing different levels f risk within the rganisatin Hw risks are escalated thrugh the rganisatin Head f Crprate Affairs Review f risk management prcess /Audit Annual Cmpliance & Risk Cmmittee (CRC) Head f Quality and Risk Assurance Bard Assurance Framewrk Head f Crprate Affairs Review f BAF risks and actins prgress/ Audit Every Bard meeting Bard Assistant Cmpany Secretary 11. Review This Strategy will be reviewed by the Cmpliance & Risk Cmmittee, Audit Cmmittee at least n an annual basis t ensure its bjectives remain current and relevant. Prgress against the bjectives will be reprted t the Cmpliance and Risk Cmmittee, Quality Assurance Cmmittee and the Audit Cmmittee bi annually. 12. Archive Arrangements This strategy will be added t the Plicy Infrmatin Management System (PIMS) and will be archived in accrdance with the Plicy n Prcedural Dcuments. 13. References Natinal Framewrk fr Reprting and Learning frm Serius Incidents Requiring Investigatin (NPSA March 2010) 22

23 Enclsure L Care Quality Cmmissin Essential Standards (Dec 2010) Risk Management in the NHS (DH 1993) An Organisatin with a Memry (DH 2000) Mnitr Applying fr FT Status: Guide fr Applicants (Dec 2008) Kingstn Hspital NHS Trust Integrated Business Plan (IBP Octber 2012) SLM revised structures (Octber 2013) 14. Versin Cntrl Versin Cntrl Sheet Versin Date Authr Status Cmment V9 Jan 2011 Head f Risk & Safety V10 Dec 2011 Head f Risk & Safety Ratified Dcument is a merger f the previus Risk Management Strategy (V8) and Risk Management Plicy (V8) New Strategic aims and bjectives Additin f Key Cmmittee s Terms f Reference Updated cmmittee structure included Management & ppulatin f Risk Register infrmatin added Disseminatin sectin added Ratified Revised Strategic aims and bjectives Revised t reflect amended Bard gvernance structure and functining, including change f Strategic Risk Cmmittee name New mnitring table in line with NHSLA requirements Remval f prcedural guidance t create the Risk Identificatin, Assessment and Risk Register Prcedure V11 January 2013 Debrah Lawrensn, Head f Crprate Affairs Jacky Bush, Head f Quality & Risk Assurance 23 Ratified Revised Strategic aims and bjectives Refined the Risk Categries Amended structure charts Updated jb and cmmittee titles and rles and mved them in t the main dcument Synergised with the Trust s Integrated Business Plan Updated t ensure cmpliance with NHSLA Clarificatin f rles and respnsibilities Additin f the Bard Assurance and Escalatin Framewrk as an

24 Enclsure L appendix V12 January 2014 Tam Mrcrft, Crprate Risk Manager Jacky Bush, Head f Quality & Risk Assurance Debrah Lawrensn, Head f Crprate Affairs Revised bjectives Health & Safety added as a risk categry Individual and cmmittee rles and respnsibilities updated fllwing re-structure Reference t Divisins, replaced with Service Lines Amend the prcess fr risk escalatin nt the CRR 24

25 Enclsure L Appendix A - Crprate Framewrk Prcess Actin Respnsibility Timeframe Bard Assurance Review f BAF Bard Every meeting Framewrk Cmmittees with lead respnsibility fr a particular sectin f the BAF Every meeting Crprate Risk Register Review f register Audit Cmmittee Cmpliance & Risk Cmmittee Audit Cmmittee & Quality Assurance Cmmittee Bard Quarterly Mnthly Quarterly Every tw mnths Quarterly Service Line risk registers Annual Gvernance Statement Risk management training and educatin Risk management prcess Risk Management Strategy Review f Risk Registers Statement written as part f annual accunts Delivery f targeted training prgramme Review f Risk Management plicies and assciated prcedures and guidance Review and update Perfrmance Review Meetings Chief Executive Directr f Finance Head f Quality and Risk Assurance Head f Quality and Risk Assurance Head f Quality and Risk Assurance Mnthly Annual Mnthly inductin f new staff Annual prgramme fr all staff Annual Annual 25

26 Enclsure L Appendix B - Bard assurance and escalatin framewrk Bard assurance and escalatin framewrk Updated Nvember 2013 Versin Descriptin Date 0.1 Initial utline framewrk 2 April First draft dcument 26 April Fllwing EMT discussin 30 April JB cmments 29 May Review by Gvernance Planning Grup 20 June CM additins re Audit Cmmittee 27 July JP and DL amendments review by Gvernance Planning Grup 4 Octber DL amendments fllwing review by GPG 2 Nvember and 9 th Nvember 0.9 DL amendments fllwing review by EMT and GPG 10.0 DL amendments t fit with review f Risk Management Strategy th Nvember and 15 th Nvember 2012 GPG Nvember 12 th

27 Enclsure L Cntents Sectin Page 1 Intrductin 3 2 Definitins 3 3 Purpse 3 4 Culture 4 5 Staff invlvement 4 6 Patient and carer invlvement 4 7 Internal and external surces f assessment and 5 assurance 8 Cmmissiners (NHS Suth West Lndn, Clinical 6 Cmmissining Grups) 9 The Trust s perfrmance management prcesses 7 10 Mnitring cmpliance against the Care Quality 8 Cmmissin (CQC) Essential Standards f Quality and Safety 11 Risk management and risk registers 9 12 Bard assurance framewrk Standing rders, SFIs and scheme f delegatin Gvernance and Cmmittee structures Organisatinal Develpment and imprvement Assignment f mnitring functins t a cmmittee Organisatinal learning and cntinuus imprvement 11 Appendices available n request 27

28 Enclsure L 1. Intrductin 1.1. This framewrk demnstrates hw the Trust s plicies, systems and prcesses wrk tgether, prviding an effective and rbust gvernance structure enabling the Trust t identify, mnitr, escalate and manage emerging issues at the apprpriate levels and in a timely way. These systems are fundamental t supprt high quality and safe patient care, underpinning the Trust s visin fr lcal peple t chse Kingstn Hspital NHS Fundatin Trust because they recgnise it fr delivering cnsistent and excellent care services. 2. Definitins 2.1. Quality the Quality Strategy explains hw the Trust defines quality based upn the three dmains described in High Quality Care fr all (Darzi, 2007) patient safety, patient experience, and the effectiveness f care. The principles f that strategy are cnsistent with Mnitr s Quality Gvernance Framewrk, emphasising the imprtance f prcesses and structures t: Ensure required standards are met; Investigate and take actin n substandard perfrmance; Plan and drive cntinuus imprvement; Identify, share and ensure delivery f best practice; Identify and manage risks t the delivery f care Assurance - describes the level f cnfidence that can be btained by the Bard, based n sufficient evidence that internal cntrls are in place, perating effectively and bjectives are being achieved. This dcument explains the key surces f assurance bth internal and external that infrm wrk f the Trust Bard Escalatin is the prcess used within the Trust t ensure decisins are made at the right level t ensure cntinued quality f care, patient safety and delivery f crprate bjectives. This prcess ensures risks ver delegated threshlds and decisins utside delegated authrity are escalated thrugh the Trust s gvernance prcesses, and that these decisins are systematically and prperly recrded. 3. Purpse 3.1. This framewrk cvers quality, financial and ther aspects f gvernance. It explains the Trust s gvernance structure, as well as the systems and perfrmance indicatrs thrugh which the Trust Bard receives assurance. It describes the prcesses fr escalatin f emerging cncerns r risks that culd threaten delivery f crprate bjectives, service delivery r patient safety. 28