NHSLA Risk Management Standards

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1 NHSLA Risk Management Standards for NHS Trusts providing Acute Services Brighton and Sussex University Hospitals NHS Trust Level 1 October 2012

2 Contents Executive Summary... 3 Assessment Outcome... 3 Key findings... 5 Overview of assessment outcome... 7 Assessment Results... 8 Standard 1: Governance... 8 Standard 2: Learning from Experience Standard 3: Competent & Capable Workforce Standard 4: Safe Environment Standard 5: Acute, Community and Non-NHS Providers of NHS Care Document Check Appendix Contacts The comments and findings of the assessment recorded in this report reflect the opinions of the assessor(s) based on the evidence provided by the organisation in relation to the requirements contained in the relevant standards manual. They should not be read as approval or comment in any other context. Page 2 of 22

3 Executive Summary Assessment Outcome Reference number Organisation assessed Services assessed T631 Brighton and Sussex University Hospitals NHS Trust All services Date of last assessment Thursday, 11 November and Friday, 12 November 2010 Assessment date Monday, 22 October 2012 Standards assessed NHSLA Risk Management Standards for NHS Trusts Providing Acute Services Level prior to assessment Level 1 Level applied for Level 1 Level achieved Level 1 Organisations providing acute services are assessed against Standards 1 to 5, each containing ten criteria giving a total of 50 criteria. In order to gain compliance at Level 1 the organisation was required to pass at least 40 of these criteria, with a minimum of seven criteria being passed in each individual standard. The organisation scored as follows: Governance 10/10 Learning from Experience 10/10 Competent & Capable Workforce 10/10 Safe Environment 10/10 Acute Services 10/10 OVERALL COMPLIANCE 50/50 Detailed scores can be found in the organisation s evidence template which is a separate document that records the evidence reviewed and the compliance awarded at the assessment. An overview of the risk areas covered by the assessment is provided within this report. Those criteria highlighted in green indicate the areas where compliance was awarded during the assessment. Those criteria highlighted in orange indicate the areas of non-compliance and those criteria that were not reviewed are highlighted in yellow. Page 3 of 22

4 Prior to formal assessment the organisation was encouraged to conduct a self-assessment. The organisation s self-assessment results are depicted below and plotted against the actual assessment results. Level 1 Summary Chart Compliance / Self-Assessment Assessment Self-Assessment Assessment Self-Assessment Assessment Self-Assessment Assessment Self-Assessment Assessment Self-Assessment Assessment Standard 1 Standard 2 Standard 3 Standard 4 Standard 5 and 6 TOTAL Non- Not Reviewed TOTAL Chart 1: Comparison of the organisation s self-assessment to actual assessment outcome Page 4 of 22

5 Key findings Brighton and Sussex University Hospitals NHS Trust is congratulated on achieving compliance with the NHSLA Risk Management Standards at Level 1, with a score of 50 out of 50. Since the Level 1 assessment in November 2010, a considerable amount of work has clearly been undertaken to integrate and update systems, including revised training databases and programmes and risk management tools to ensure a solid foundation towards this Level 1 assessment. Efforts have been made to introduce monitoring tables to approved documents in a consistent manner, which when fully implemented will provide assurance of safe systems and help the service to identify improvements required on an on-going basis. A very well populated and hyperlinked evidence template was provided, and the approved documents and associated proformas presented therein had been carefully revised and were easy to navigate. The organisation had prepared for pilot minimum requirements and evidence was provided for these where not mentioned elsewhere in the body of the report. A spot check was undertaken at the start of the assessment, whereby ten documents were chosen at random and reviewed to ensure that they had been ratified in line with the organisation s stated process and that the versions presented were current and accessible to staff. All documents reviewed for this exercise were compliant with the service s stated process and available. More general themes arising include the need to ensure the addition of the accountability of the Chief Executive to the duties section of each approved document to drive leadership, and to ensure simple reference to training in line with the Mandatory Training Policy incorporating Risk Management Training and Training Needs Analysis, Version 3 (October 2012), rather than duplicating training statements for each type of training within relevant approved documents, which risks discrepancies between the approved documents and the organisational training needs analysis. The organisation should devise processes and monitoring statements which reflect the need to collate assessments across the organisation, for example within the approved documents Policy on Management of Physical Security, Version 2.2 (September 2012), Policy for the Prevention and Management of Stress at Work, Version 4 (October 2012) Manual Handling of Patients and Other Loads Policy, Version 3 (June 2012), detailing the annual collation and review of risk assessments for all sites by way of an appropriate individual, addition of outstanding actions to the organisational risk register and oversight of this process and associated actions by a designated committee, forum or group. In terms of description of process, flowcharts are useful to this end. The organisation would also benefit from more practical monitoring methods, since those described within the approved documents appear quite complex and difficult to implement. For example, in the case of the Policy for the dissemination and implementation of National Institute for Health and Clinical Excellence (NICE), Version 3 (April 2012) and the Policy for participating in and implementing outcomes of National Confidential Enquiries into Patient Outcome and Death (NCEPOD) and National Confidential Inquiry into Suicide and Homicide, Version 3 (May 2012), monitoring should include an audit of a random selection of NICE guidelines and National Confidential Enquiries and Inquiries to check that documented process has been followed to meet the NHSLA minimum requirements of receipt, dissemination, gap analysis and action planning. Similarly, the organisation should expand upon the monitoring statement within the Policy for undertaking and learning from Clinical Audit, Version 3.1 (May 2012), to ensure that it involves audit of a random selection of clinical audits undertaken to check that the policy has been followed, the Policy and Procedures for the Internal Page 5 of 22

6 and External Reporting of Incidents and Managing Serious Incidents, Version 3.1 (April 2012), to ensure that it involves audit of a random selection of incidents reported to check that the policy has been followed, and the Dignity at Work Policy and Procedure, Version 7.1 (August 2012), to ensure that it involves audit of a random selection of concerns raised to check that the policy has been followed, in all instances to meet the NHSLA minimum requirements. Also, the monitoring statements within approved documents for clinical care such as the Minimum standard for patient observations policy, Version 3 (May 2012), Discharge Policy for Adults and Children, Version 1.3 (May 2012) and Administration of Blood and Blood Components, Version 2 (May 2012) should involve audits of health record proformas to check that policy has been followed, in all instances to meet the NHSLA minimum requirements. Lastly, the monitoring statements within the approved documents Policy and Procedures for the Management of Medical Devices Training, Version 1.2 (July 2012) and Managing Medical Devices Policy and Procedures, Version 2 (November 2011) should involve audits of training logs against medical device inventories, audits to check that medical devices on the wards are logged upon inventories and are maintained in line with policy, in all instances to meet the NHSLA minimum requirements. The main body of this exception report contains some specific recommendations that will require action prior to any subsequent assessment. The NHSLA do not plan to carry out a full schedule of assessments in the assessment year, however should the organisation wish to come forward for a higher level assessment in this year please inform the NHSLA or your assessor by the 31 May The assessors would like to thank everyone involved for their time and hospitality throughout the assessment. Page 6 of 22

7 Overview of assessment outcome Non-compliant Not reviewed Not applicable Standard Criterion Governance Learning from Experience Competent & Capable Workforce Safe Environment Acute & Community 1 Risk Management Strategy Clinical Audit Corporate Induction Secure Environment Supervision of Medical Staff in Training 2 Policy on Procedural Documents Incident Reporting Local Induction of Permanent Staff Violence & Aggression Patient Information & Consent 3 High Level Risk Committee(s) Concerns & Complaints Local Induction of Temporary Staff Slips, Trips & Falls (Staff & Others) Consent Training 4 Risk Management Process Claims Management Risk Management Training Slips, Trips & Falls (Patients) Maintenance of Medical Devices & Equipment 5 Risk Register Investigations Training Needs Analysis Moving & Handling Medical Devices Training 6 Dealing with External Recommendations Analysis & Improvement Risk Awareness Training for Senior Management Hand Hygiene Training Screening Procedures 7 Health Records Management Learning Lessons from Claims Moving & Handling Training Inoculation Incidents Diagnostic Testing Procedures 8 Health Record-Keeping Standards Best Practice - NICE Harassment & Bullying The Deteriorating Patient Transfusion 9 Professional Clinical Registration Best Practice - National Confidential Enquiries & Inquiries Supporting Staff Involved in an Incident, Complaint or Claim Clinical Handover of Care Venous Thromboembolism 10 Employment Checks Being Open Stress Discharge Medicines Management Page 7 of 22

8 Assessment Results Standard 1: Governance Overview Effective functioning of the board, managerial leadership and accountability, and the organisation s systems and working practices will ensure that quality assurance, quality improvement and patient safety are central to the activities of the healthcare organisation. Organisations should apply the principles of sound corporate governance. Board level responsibility for risk management should be clearly defined and there should also be clear lines of individual accountability for managing risk throughout the organisation leading to the board. Organisations should undertake systematic risk assessment and risk management. Risk management should be fully embedded in the organisation s management and operational processes. Information governance principles will support the management of risk associated with health records and clinical record keeping. All relevant employees, whether permanent or temporary, should be registered with the appropriate professional body and have undergone the required employment checks relevant to the area of practice prior to working within the organisation. A score of ten out of ten was awarded in this standard. Findings and recommendations Criterion Outcome Findings and recommendations 1.3 High Level Risk Committee(s) All organisations must have approved documented terms of reference for the high level committee(s) with overarching responsibility for risk. 1.6 Dealing with External Recommendations Specific to the Organisation All organisations must have an approved documented process for dealing with external d) requirements for a quorum The organisation should consider increasing the quorum of the Operational Risk Management Group from four, since it operates at such high level that representation of a good selection of departments is required in decisions taken. c) how action plans are developed as a result of external recommendations Within the Policy on the Management of External Agency Visits, Inspections and Accreditations, Version 4 (October 2012), the organisation should annotate the table at page 15 External agency/organisation visits, inspections and Page 8 of 22

9 Criterion Outcome Findings and recommendations recommendations specific to the organisation. accreditations requiring Action Plans Year Template with the term Appendix 4, as it is referred to within the text, so that it is clear to staff. Page 9 of 22

10 Standard 2: Learning from Experience Overview All organisations should have in place robust systems for the reporting, management and investigation of adverse events, including those that result in no harm, to help facilitate organisational learning. Organisations should apologise and explain what happened to patients who have been harmed as a result of their healthcare. When all reported adverse events, concerns, complaints and claims are examined in conjunction, trends may be identified at both a local and strategic level and changes implemented to reduce the risk of recurrence. The sharing of lessons learned between organisational service areas and the wider healthcare community helps to ensure that system failures are addressed by the organisation as a whole and good practice is shared. Organisations should consider and implement appropriate external guidance to operate as safely as possible. A score of ten out of ten was awarded in this standard. Key findings and recommendations Criterion Outcome Findings and recommendations 2.1 Clinical Audit All organisations must have an approved documented process for making sure that all clinical audits are undertaken, completed and reported on in a systematic manner. d) how audit reports are shared The Policy for undertaking and learning from Clinical Audit, Version 3.1 (May 2012) could state that the recommendations of clinical audits are shared via the organisational newsletter, as this happens in practice. 2.9 Best Practice - National Confidential Enquiries & Inquiries All organisations must have an approved documented process for taking into account agreed best practice, as defined in National Confidential Enquiries and Inquiries, in the context of the clinical services provided by the organisation. a) duties The organisation should widen the scope of the Policy for participating in and implementing outcomes of National Confidential Enquiries into Patient Outcome and Death (NCEPOD) and National Confidential Inquiry into Suicide and Homicide, Version 3 (May 2012) so that it is relevant to all National Confidential Enquiries and Inquiries published, for review to ensure that lessons learned by other organisations are addressed locally. b) how the organisation responds to requests for data Page 10 of 22

11 Criterion Outcome Findings and recommendations The policy should clarify the arrangements for the identification and review of all published National Confidential Enquiries and Inquiries and how requests for associated information come into organisation. e) how action plans are developed to address any shortfalls, including recording decisions not to implement National Confidential Enquiry/Inquiry recommendations The policy should describe the local database of National Confidential Enquiries and Inquiries, their oversight and review to close off actions, perhaps in line with that descriptions within the Policy for the dissemination and implementation of National Institute for Health and Clinical Excellence (NICE), Version 3 (April 2012). Page 11 of 22

12 Standard 3: Competent & Capable Workforce Overview The organisation has a responsibility to deliver a safe service to patients by ensuring all staff are appropriately skilled. To ensure that both temporary and permanent staff are adequately equipped to work in a healthcare environment and provide care to patients they must receive training and support, both on initial appointment and on an ongoing basis. By ensuring effective, ongoing training and support, the organisation is promoting the delivery of high quality focused care as well as facilitating staff safety and wellbeing. A score of ten out of ten was awarded in this standard. Key findings and recommendations Criterion Outcome Findings and recommendations 3.2 Local Induction of Permanent Staff All organisations must have an approved documented local induction process for all new permanent staff. 3.3 Local Induction of Temporary Staff All organisations must have an approved documented local induction process for all temporary staff. 3.6 Risk Awareness Training for Senior Management b) minimum content of local induction The organisation should consider simplifying the Induction Policy and Procedure, Version 2.1 (August 2012) by merging Appendix 3 (Template for Local Induction Pack for Substantive Staff) and 4 (Departmental Induction review Checklist - Confirmation) and associated lists and checklists, to streamline the approach, including expected day one essentials, so that it is more easily implemented. b) minimum content of local induction The Template for Departmental Local Induction Pack for Temporary Staff at Appendix 6 of the Induction Policy and Procedure, Version 2.1 (August 2012) would benefit from the addition of a form to be signed on completion of induction on arrival at work, to be returned to a central point for collation, enabling oversight of uptake of local induction of temporary staff against uptake of temporary staff starting work within the organisation. a) how risk management awareness training is delivered to board members and senior managers, in line with the training needs analysis Page 12 of 22

13 Criterion Outcome Findings and recommendations All organisations must have an approved documented process for delivering risk management awareness training to all board members and senior managers. The organisation should ensure that records of Risk Awareness Training for Senior Management are forwarded for recording on OLM and associated organisational oversight, in line with all other training described within the Mandatory Training Policy incorporating Risk Management Training and Training Needs Analysis, Version 3 (October 2012). Page 13 of 22

14 Standard 4: Safe Environment Overview It is essential to provide a safe and secure environment in order to facilitate high quality clinical care. The environment should be safe for staff, patients and their visitors in order to prevent accidents, injury and disease. Accurate information must be shared between all professionals in all care environments, both internally and externally, to ensure that there is a safe and seamless transition of an individual s care. A score of ten out of ten was awarded in this standard. Key findings and recommendations Criterion Outcome Findings and recommendations 4.2 Violence & Aggression All organisations must have an approved documented process for the prevention and management of violence and aggression. b) how the organisation carries out risk assessments for the prevention and management of violence and aggression The Prevention & Management of Violence Policy, Version 5 (May 2012) should make clear reference to Appendix 3 Corporate Risk Assessment Form Violence and Appendix 4 Divisional RAG Summary for violence risk assessments, stating when these should be used and by whom. c) timescales for review of risk assessments This is a pilot minimum requirement for and as such a positive score has been awarded. Whilst Appendix 4 Divisional RAG Summary for violence risk assessments includes review dates, Appendix 3 Corporate Risk Assessment Form Violence would also benefit from the addition of these. d) how action plans are developed as a result of risk assessments This is a pilot minimum requirement for and as such a positive score has been awarded. Whilst action plans are clearly included within the risk assessments, the policy Page 14 of 22

15 Criterion Outcome Findings and recommendations would benefit from a description of how assessments are collated across the organisation. A flowchart of the process and expectations, for example, upon divisional managers/matrons, and overseeing security specialists would assist to this end. h) how the organisation monitors compliance with all of the above The monitoring arrangements described should also be reflected clearly within the policy as process, for example, a flowchart of the process and expectations upon divisional managers/matrons and overseeing security specialists could be included. 4.4 Slips, Trips & Falls (Patients) All organisations must have an approved documented process for managing the risk of slips, trips and falls involving patients. d) how the organisation raises awareness about preventing and reducing the number of slips, trips and falls involving patients The Prevention and Management of Inpatient Falls Policy, Version 4 (May 2012) should make reference to the Falls Alerts used by the organisation to raise awareness of issues arising from slips, trips and falls involving patients. 4.5 Moving & Handling All organisations must have an approved documented process for managing the risks associated with moving and handling. b) techniques to be used in the moving and handling of patients and objects, including the use of appropriate equipment The handbook of techniques associated with the Manual Handling of Patients and Other Loads Policy, Version 3 (June 2012) would benefit from re-formatting, as an appendix to the policy, to facilitate regular review and update. 4.9 Clinical Handover of Care All organisations must have an approved documented process for the handover of care of patients. a) handover requirements between all care settings, to include both giving and receiving of information For clarity, the Clinical Handover Policy, Version 3 (May 2012) should specify all documentation requirements, for each Level of Care 0-3 defined at section 5.2.3, within the flowchart at Appendix 1, Summary of inter hospital transfer of the patients between BSUH hospital sites, covering both inter-hospital transfers (including sites other than those of Brighton and Sussex University Hospitals NHS Trust) and intra-hospital transfers. Page 15 of 22

16 Criterion Outcome Findings and recommendations b) how handover is recorded This is a pilot minimum requirement for and as such a positive score has been awarded. See above. c) out of hours handover process Whilst a statement of the risks associated with out of hours transfer is included within the policy, if the out of hours handover process is no different to that at other times of day this should be stated, so that the position is clear to staff Discharge All organisations must have an approved documented process for the discharge of patients. b) information to be given to the receiving healthcare professional c) information to be given to the patient when they are discharged In respect of both of the above minimum requirements, the organisation would benefit from using the table at section of the Discharge Policy for Adults and Children, Version 1.3 (May 2012) as the basis on which to develop a single, simple, step by step discharge proforma, flowchart or checklist, integrating all of the proformas within the appendices of the policy to encourage their use. Page 16 of 22

17 Standard 5: Acute, Community and Non-NHS Providers of NHS Care Overview The care provided to patients across all care environments should be of the highest quality and delivered in such a way as to minimise the risk to patients. It is particularly important to ensure patients have clear information to prepare them for treatment and that accurate information is shared between all professionals in all care environments. To underpin these principles, a systematic approach must be in place to ensure there are clear lines of responsibility, appropriately trained staff, safe systems of work and effective communication across the organisation and between staff, patients and others. The organisation must be able to define and demonstrate the achievement of quality and safety through high standards of record-keeping that are consistent across the organisation. A score of ten out of ten was awarded in this standard. Key findings and recommendations Criterion Outcome Findings and recommendations 5.6 Screening Procedures Organisations providing acute and community services and non-nhs providers must have a documented process for managing the risks associated with screening procedures. b) how the organisation risk assesses screening procedures This is a pilot minimum requirement for and as such a positive score has been awarded. Whilst compliance was awarded for this criterion, the Management of Screening and Diagnostic Testing Procedures Policy, Version 3 (October 2012) would benefit from a clear risk assessment process, aside from the overarching organisational process described, to assign a risk level to each screening procedure carried out, for example in terms of numbers of patients screened, and the risk to patients if the procedure does not go as planned. This risk assessment should be applied to all procedures to gage their relative risk and inform their management organisationally. c) how the screening procedure is requested This is a pilot minimum requirement for and as such a positive score has Page 17 of 22

18 Criterion Outcome Findings and recommendations been awarded. Whilst an overarching statement is set out within the policy, processes for requesting each screening procedure should be set out within each associated procedural document. f) how the patient is followed-up or referred, including timescales This is a pilot minimum requirement for and as such a positive score has been awarded. Whilst the policy describes the overarching process for follow up of the patient, it would benefit from the added stipulation that any such communication with the patient should also be documented within the health record. g) how minimum requirements c) to f) are recorded Aside from within the overarching policy, each associated specific test protocol should detail how the test is requested, for example, outlining the request form to be used and where copies of this should be stored, along with specific timescales for delivering results to the relevant clinician and patient, and where all such communication should be recorded, perhaps by way of a simple flowchart for clarity. 5.7 Diagnostic Testing Procedures Organisations providing acute and community services and non-nhs providers must have an approved documented process for managing the risks associated with diagnostic testing procedures. b) how the organisation risk assesses diagnostic testing procedures This is a pilot minimum requirement for and as such a positive score has been awarded. Whilst compliance was awarded for this criterion, the Management of Screening and Diagnostic Testing Procedures Policy, Version 3 (October 2012) would benefit from a clear risk assessment process, aside from the overarching organisational process described, to assign a risk level to each diagnostic testing procedure carried out, for example in terms of numbers of patients screened, and the risk to patients if the procedure does not go as planned. This risk assessment should be Page 18 of 22

19 Criterion Outcome Findings and recommendations applied to all procedures to gage their relative risk and inform their management organisationally. c) how the diagnostic test is requested Whilst an overarching statement is set out within the policy, processes for requesting each diagnostic testing procedure should be set out within each associated procedural document. f) actions to be taken by the clinician, including timescales This is a pilot minimum requirement for and as such a positive score has been awarded. Whilst the policy describes the overarching process for follow up of the patient, it would benefit from the added stipulation that any such communication with the patient should also be documented within the health record. g) how minimum requirements c) to f) are recorded Aside from within the overarching policy, each associated specific test protocol should detail how the test is requested, for example, outlining the request form to be used and where copies of this should be stored, along with specific timescales for delivering results to the relevant clinician and patient, and where all such communication should be recorded, perhaps by way of a simple flowchart for clarity Medicines Management Organisations providing acute and community services and non-nhs providers must have an approved documented process for learning from medication errors. b) how the organisation makes sure that all prescription charts are accurate Whilst the Policy for the Safe and Secure Handling of Medicines, Version 3 (May 2012) describes the commitment to monitor prescription charts, the document should also describe more clearly the process for checking these details, for example by way of daily ward round prescription chart checks using green pen annotation. d) how the organisation learns from medication errors This is a pilot minimum requirement for and as such a positive score has Page 19 of 22

20 Criterion Outcome Findings and recommendations been awarded. Whilst the policy describes the process for reporting and sharing medication errors, it could also state that the recommendations of clinical audits are shared via the organisational newsletter, as this happens in practice. e) how a patient s medicines are managed on handover between care settings This is a pilot minimum requirement for and as such a positive score has been awarded. Although the policy states how medicines are managed on handover, crossreference to the Clinical Handover Policy, Version 3 (May 2012) and associated transfer forms would assist staff in understanding their implementation in terms of medicines management. Page 20 of 22

21 Document Check At all levels the evidence presented at assessment must be in use and reflective of day to day practice within the organisation. To test this, the assessor(s) randomly selected ten documents from the organisation s evidence portfolio and asked to see evidence of their approval. Additionally, the assessor(s) reviewed the organisation s intranet and/or policy folders to ensure that the ten documents are readily available for use by staff. If the organisation was unable to evidence that a document has been approved and is in use, compliance was not given for the criterion that it relates to. Name of approved document Criterion Format Approval Availability 1 An organisation-wide policy for managing the quality of health records 1.8 Elec Apr-12 Extranet Yes 2 Employment Checks Policy 1.10 Elec May-12 Extranet Yes 3 Policy for undertaking and learning from clinical audit 2.1 Elec May-12 Extranet Yes 4 Being Open Policy 2.10 Elec Mar-12 Extranet Yes 5 Mandatory Training Policy Incorporating Risk Management Training and Training Needs Analysis 6 Policy for the Prevention and Management of Stress at Work 7 Prevention and Management of Violence Policy 3.4 Elec Oct-12 Extranet Yes 3.10 Elec Oct-12 Extranet Yes 4.2 Elec May-12 Extranet Yes 8 Patient Observations Policy 4.8 Elec May-12 Extranet Yes 9 Consent to Examination or Treatment Policy 5.3 Elec May-12 Extranet Yes 10 Prevention and Management of VTE Policy 5.9 Elec May-12 Extranet Yes TOTAL compliant 10 Page 21 of 22

22 Appendix Contacts Assessment/Report enquiries This report was prepared by Det Norske Veritas on behalf of the NHS Litigation Authority. Any queries regarding this report should be directed to: General enquiries: Address for correspondence: Det Norske Veritas Highbank House Exchange Street Stockport Cheshire SK3 0ET NHSLA general enquiries General enquiries: Risk management enquiries: Address for correspondence: The NHS Litigation Authority 151 Buckingham Palace Road Westminster London SW1W 9SZ Website: Page 22 of 22

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