Risk Management Strategy A Summary for Patients & Visitors This leaflet has been designed to provide information on the Trust s Risk Management Strategy and how we involve patients and the public in reducing risk.
Introduction & Purpose As with any organisation the NHS carries a number of risks, which if not properly managed / controlled have the potential to cause harm to patients, staff and visitors and loss to its assets and reputation. It is accepted that given the nature of the service provided by the NHS, some risks may never be totally eliminated. However it is essential that NHS Trusts have in place good risk management systems and practices which eliminate risk wherever possible and reduce the impact of those risks which cannot be eliminated to an acceptable level. The Northern Lincolnshire & Goole NHS Foundation Trust takes a holistic approach to the management of risk, in accordance with the principles of Integrated Governance, and this document sets out the commitment of the Trust to managing risk (both clinical and non-clinical) and the Strategy for achieving this objective. In respect of patient safety, the Risk Management Strategy and indeed the Trust s risk management arrangements also reflect the NPSA s Seven Steps to Patient Safety principles. The Trust acknowledges that the provision of a strong system of governance and risk management can enhance the care and wellbeing of patients and those staff who look after them and is a key driver for change and modernisation. The Risk Management Strategy is an integral part of the Trust s approach to continuous quality improvement and is intended to support and assist the organisation in delivering the key objectives within the Trust s Quality Strategy as well as ensuring compliance with external standards, duties and legislative requirements including those relating to the Trust s Terms of Authorisation as a Foundation Trust. The Trust agrees annual risk management objectives, which are shared through the business planning and performance management frameworks. However, the overall objective of the Risk Management Strategy is to have an organisation which is fully risk aware where risk management is embedded within the organisation s culture, is integrated into the working practices of all grades and disciplines of staff and encourages and empowers those staff to identify and control risk which may affect the Trust s ability to achieve its objectives: encourages the open reporting of mistakes made, within a fair blame culture, and ensures that lessons are learnt from those mistakes and that measures to prevent recurrence are promptly applied accepts that Risk Management is everyone s responsibility. This in turn will assist in ensuring the achievement of the organisation s overall objective which is to provide quality healthcare for the local health community The Trust s Governance & Assurance Committee is responsible for overseeing the ongoing development and implementation of the Risk Management Strategy. The Trust Board will be responsible for the ratification and annual review of the Risk Management Strategy. Definitions Risk is defined as a hazard / exposure to danger / chance of loss or harm. As the consequences of taking risks can be damaging, steps must be taken to manage or minimise these risks. Risk Management is defined as the systematic process of risk identification,
analysis, evaluation and correction of potential and actual risks to which an organisation is exposed (whether affecting patients, visitors, staff or property). Clinical Risk Management concentrates on identifying and correcting risks associated with direct patient care, whilst Non-Clinical Risk Management is associated with all other Trust activities. Philosophy The Northern Lincolnshire & Goole NHS Foundation Trust is committed to the management of risk (both clinical and nonclinical) in order to: improve the quality of care provide a safe environment for the benefit of patients, staff and visitors by reducing and, where possible, eliminating the risk of loss, harm or damage protect its assets and reputation meet statutory and regulatory requirements (e.g. Monitor, CQC, HSE) This will be achieved through a process of identification, analysis, evaluation, control, elimination and transfer of risk. The Trust aims to be pro-active in its approach to the management of risk and will endeavor to identify, control and, where possible, eliminate the risk before incidents of actual loss, harm or damage have occurred. The Trust also aims to be open with patients and / or their relatives / carers when things go wrong. Risk Management Strategy Designated Responsibilities All staff within the Trust have responsibility for identifying and managing risk. The following sets out the duties and responsibilities of staff within the Trust s risk management arrangements including those key staff with specific responsibilities for leading and co-ordinating the Trust s governance and risk management arrangements (this is indicated by (*) after the job title and there are clear links between these members of staff): Trust Board The Trust Board is responsible for ensuring that the Trust has in place the necessary controls to manage its risk exposure. Chief Executive The Chief Executive carries ultimate responsibility for risk management including the implementation of Clinical and Corporate Governance Director of Performance Assurance (*) The Director of Performance Assurance carries delegated responsibility from the Chief Executive for all elements of Governance, Risk Management & Quality Assurance. The Director of Performance Assurance has delegated responsibility for developing an integrated Strategy for Governance incorporating issues of corporate and clinical governance, risk management (clinical and non-clinical) and quality improvement including audit. The Director of Performance Assurance is also responsible for the Trust s complaints and claims management arrangements.
Director of Finance The Director of Finance carries specific responsibility for financial risk management Director of Strategy & Planning The Director of Strategy & Planning carries specific responsibility for Information Governance risks. Director of Estates & Facilities The Director of Estates & Facilities has delegated responsibility for the management of the estate. Trust Risk Manager (*) The Head of Risk Management is the designated Trust Risk Manager and works closely with the Director of Performance Assurance in developing an integrated strategy for Governance with a specific focus on all aspects of clinical and non-clinical risk management and is specifically responsible for providing support / advice to Directorates in managing risk ensuring that this expertise is maximised by the organisation through structured training programmes and effective communication. The Head of Risk Management is also the operational lead for Information Governance. The Head of Risk Management is also responsible for raising awareness / profile of risk management and maintaining the Trust s overall Risk Register and the Incident Reporting System, in particular the analysis of incidents / risks reported and the identification of trends. Health & Safety Manager (*) The Health & Safety Manager is responsible for providing advice on requirements to comply with statutory obligations, use of best practice to further improve standards and a pro-active approach to ensure continuous improvement. The Health & Safety Manager acts as a resource to colleagues across the organisation in delivering the Trust s health & safety agenda and acts as the competent person for the management of health & safety risks. The Health & Safety Manager is also responsible for co-ordinating the provision of moving & handling training programmes which are designed to ensure that patients are handled safely whilst also promoting good back and neck care with a view to preventing the occurrence of moving & handling injuries within the Trust and is also responsible for the development and review of the Trust s Minimal Lift Policy and for recommending improvements and promoting better moving and handling practices and is the Trust s lead expert in this area of risk. Local Security Management Specialist (LSMS) (*) The LSMS is responsible for the development and co-ordination of the Trust s security management arrangements in line with National Security Management Service framework and Secretary of State Directions. The LSMS will lead on the day to day work to tackle violence against staff and act as the focal point for the provision of advice and support to staff within the organisation in respect of security management / violence & aggression. Fire Safety Advisor (*) The Fire Safety Advisor is responsible for providing advice on requirement to comply with fire legislation and co-ordinating the development and implementation of the organisation s fire safety policies. The Fire Safety Advisor is also responsible for implementing an effective training programme and for monitoring of the inspection and maintenance of fire safety systems.
Complaints Manager (*) The Complaints Manager is responsible for leading this service across the Trust s three sites and will provide the focal point for the investigation and response to complaints and concerns. Further, for ensuring that the relevant Trust policies are adhered to, investigations are completed by Directorates according to identified standards and that required follow-up action is taken in order to prevent recurrence. The Complaints Manager is also responsible for the analysis of complaints and concerns received in order to identify problems / trends. The Claims & Legal Services Manager (*) The Claims & Legal Services Manager is responsible for managing claims against the Trust, liaising with solicitors / insurers (where appropriate), to ensure timely and cost effective claims handling. Further, ensuring that any risk management issues / remedial action identified during the course of a claim, or during the review process on closure, is referred appropriately for action. The Claims and Legal Services Manager is also responsible for the analysis of claims in order to identify trends. Directors Directors are responsible for: the day to day management of risks of all types within their areas of responsibility including the allocation of resources as appropriate the implementation of effective governance and risk management arrangements within their areas of responsibility which are consistent with the principles outlined in the Trust-wide Risk Management Strategy including the implementation of relevant local policies as appropriate ensuring that risk assessment are undertaken on a pro-active basis, that details are included on Directorate Risk Registers (which in turn will inform the overall Trust Risk Register) and for ensuring that these risks are regularly reviewed and updated and that preventative action is taken as necessary escalating risks which cannot be dealt with within the Directorate for engaging all staff in the risk management process. Ward / Departmental Managers Ward / Departmental Managers are responsible for: the day to day management of risks of all types within their areas of responsibility and for escalating those which cannot be managed at that level ensuring that Trust-wide and Directorate risk management systems and processes are implemented within their wards / department and scope of responsibility and that these are known to and involve all staff ensuring that their staff receive the necessary level of risk management awareness / training in order to ensure that they are competent to identify, assess and manage risk within their working environment (see also the section on Training) Directorate Governance Leads or Directorate equivalent Responsible for leading the development and implementation of effective governance / risk management arrangements within Directorates.
Risk & Governance Facilitators (*) Responsible for supporting Directorates / Groups in the co-ordinating their governance / risk management activities. Staff Generally For risk management to be effective it must actively involve staff at all levels within the organisation (i.e. Board to Ward ), it must be seen as everyone s responsibility and not just that of any one individual or department. It is the responsibility of all staff, whatever their role, grade or status, to practice in a safe and efficient manner and to participate in the reporting, assessment and management of risk within their individual work area in accordance with relevant Trust policies. Risk awareness / assessment training will be provided to ensure that staff are conversant with the principles of risk management and the application of those principles to their particular work and area of responsibility. 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 and thus ensure that the Risk Management Strategy is effectively implemented and its objectives met, risk awareness / assessment training as well as other risk management its objectives met, risk awareness / assessment training as well as other risk management training is made available to all staff as part of the Trust s comprehensive Risk Management Training Programme. Managers (and ultimately Directors) with responsibility for the management of staff will be responsible for ensuring that an assessment of the risk management training needs of their staff, as part of individual personal development plans and training needs analysis, is undertaken and that staff are able to access and attend relevant training. In respect of new staff, information on risk management including information on incident reporting is included in the corporate and local induction arrangements for all healthcare staff. Strategy Dissemination This leaflet provides a summary only of the Trust s Risk Management Strategy. A full copy of the Strategy document can be obtained by contacting the Risk Management Department. Involvement of Patients and the Public: Comments and Suggestions that could help reduce risk The Northern Lincolnshire & Goole NHS Foundation Trust welcomes comments and suggestions from patients and visitors that could help reduce risk. Perhaps you have experienced something whilst in hospital, whilst attending as an out-patient, or as a visitor, and you felt at risk. Please tell a member of staff on the ward / department you are attending / visiting. Alternatively please contact the Risk Management Department on Direct Dial 01472 875449; Or by writing to: Head of Governance Northern Lincolnshire & Goole Hospitals NHS Foundation Trust West Arch Diana, Princess of Wales Hospital Scartho Road GRIMSBY DN33 2BA
Concerns About a Risk or Other Incident If you have any concerns / queries about any of the services offered by the Trust, in the first instance, please speak to the person providing your care. For Diana, Princess of Wales Hospital Alternatively you can contact the Patient Advice and Liaison Service (PALS) on (01472) 875403 or at the PALS office which is situated near the main entrance. For Scunthorpe General Hospital Alternatively you can contact the Patient Advice and Liaison Service (PALS) on (01724) 290132 or at the PALS office which situated on C Floor. Alternatively you can email: nlg-tr.pals@nhs.net Who will be able to advise on alternative ways of responding to your concern. Strategy Review The Trust s Risk Management Strategy will be reviewed in February 2015 or sooner should the need arise. Confidentiality Information on NHS patients is collected in a variety of ways and for a variety of reasons (e.g. providing care and treatment, managing and planning the NHS, training and educating staff, research etc.). Everyone working for the NHS has a legal duty to keep information about you confidential. Information will only ever be shared with people who have a genuine need for it (e.g. your GP or other professionals from whom you have been receiving care) or if the law requires it, for example, to notify a birth. Please be assured however that anyone who receives information from us is also under a legal duty to keep it confidential. Zero Tolerance - Violent, Threatening and Abusive Behaviour The Trust and its staff are committed to providing high quality care to patients within the department. However, we wish to advise all patients / visitors that the following inappropriate behaviour will not be tolerated: Swearing Threatening / abusive behaviour Verbal / physical abuse The Trust reserves the right to withdraw from treating patients whom are threatening / abusive / violent and ensuring the removal of those persons from the premises. All acts of criminal violence and aggression will be notified to the Police immediately. Risk Management Strategy The Trust welcomes comments and suggestions from patients and visitors that could help to reduce risk. Perhaps you have experienced something whilst in hospital, whilst attending as an outpatient or as a visitor and you felt at risk. Please tell a member of staff on the ward or in the department you are attending / visiting. Moving & Handling The Trust operates a Minimal Lifting Policy, which in essence means patients are only ever lifted by nursing staff in an emergency situation.
Patients are always encouraged to help themselves as much as possible when mobilising, and if unable to do so, equipment may be used to assist in their safe transfer. If you have any questions regarding moving and handling of patients within the Trust, please speak to a member of staff in the ward or department you are visiting. Northern Lincolnshire and Goole NHS Foundation Trust Diana Princess of Wales Hospital Scartho Road Grimsby 01472 874111 Scunthorpe General Hospital Cliff Gardens Scunthorpe 01724 282282 Goole & District Hospital Woodland Avenue Goole 01405 720720 www.nlg.nhs.uk Date of issue: April, 2015 Review Period: March, 2016 Author: Director of Performance Assurance IFP-624 v1.2 NLGFT 2015