Compliance Programme Briefing Paper. Version 2.0 (Net) / July 2014

Transcription

1 Compliance Programme Briefing Paper Version 2.0 (Net) / July 2014

2 Contents The purpose of this document is to provide a briefing to stakeholders on the NARU compliance programme and its corresponding outputs. 1 The NARU Compliance Function Summary of the Compliance Function 3 2 Risk Management Strategy Risk Management Process NARU Business Plan Extract 4 3 Delivery Method Breakdown of Compliance Activity Compliance Function Costs 5 4 HART Specification 2015/ /16 HART Specification Outline HART Safe System Components HART Capital Replacement Programme 7 Christian Cooper MSc DipLaw NARU Compliance Officer July 2014 Version 2.0 (Net) Page 2 of 7

3 1. The NARU Compliance Function The NHS Ambulance Service owes a legal duty of care to both its staff and its patients. Over the last 15 years that duty has been extended into new high risk environments and has been distinguished in common law from the duty of other emergency services*. As the NHS continues to commission complex pre-hospital capabilities under its Emergency Preparedness Resilience and Response (EPRR) agenda, safe systems of work are essential to protect our staff and patients safe whilst also allowing hazardous area clinicians to take calculated risks to improve clinical outcomes or safe life. The compliance function within NARU develops mandatory minimum standards across a series of national capabilities and supports their ongoing maintenance. These standards ensure that service specifications remain legally compliant and that specialist capabilities can be efficiently maintained locally to an interoperable standard meeting NHS and Central Government expectations. 1.1 Summary of the NARU Compliance Function Update Risk Assessments Coordinate Change Process Update Safe Systems of Work Maintain Interoperability External Act Audit Safe Systems of Work Plan NARU Compliance Programme Check Assurance Process Risk Assessments National Interoperability Do Commissioning Interface Capability Profiling Develop Specifications Compliance Advice & Support * E.g. Kent v Griffiths [2001] QB 36 Version 2.0 (Net) Page 3 of 7

4 2. Risk Management Strategy NARU is responsible for supporting the delivery of several high-risk capabilities within the English NHS Ambulance Service. Under the contract with NHS England, NARU must also work with stakeholders to ensure the effective maintenance and national interoperability of these capabilities. A large-scale major incident will see the deployment of these capabilities utilising staff and equipment from a range of different local trusts. The effective management of risk, not only for HART but also for other nationally coordinated capabilities, at these incidents is predicated on compliance with interoperable specifications and external regulatory standards. The outputs of the NARU Compliance Programme create and maintain a safety critical system to support local delivery and reduce risk to staff and patients. 2.1 Risk Management Process 2.2 NARU Business Plan Extract NARU will take all reasonable steps to ensure that suitable and sufficient risk assessments are carried out. Such assessments will record the range of hazards associated with the activities of the Unit. It is worth noting that many of the operational capabilities supported by NARU require the application of safety critical systems. They have the potential to be high risk and NARU staff, particularly through our existing governance and compliance work programmes, provide a significant contribution to the effective management of risk for major incidents. Risk Management NARU Annual Business Plan 2014/15 S.9. p.30. Version 2.0 (Net) Page 4 of 7

5 3. Delivery Method 3.1 Breakdown of Compliance Activity The compliance functions within NARU are delivered through a full time seconded Compliance Officer with some contributory support from wider NARU departments, particularly Capabilities. The Compliance Officer works closely with external subject matter experts including; the Health & Safety Executive, legal advisors, commissioners and industry specialists to keep specifications and standards under continual review. They also work closely within the NHS family ensuring that various sectors are engaged with the compliance programme. SERVICE DEVELOPMENT - 40% Legal & regulatory research National risk assessments Capability review and analysis Development and drafting of service specifications Maintenance of interoperability standards Maintenance of safe systems of work for national capabilities Testing & evaluation Procedural reviews SUPPORT DELIVERY - 40% WIDER SUPPORT - 20% The Compliance Officer represents NARU and the NHS at a range of national meetings to provide expertise in legal compliance, risk management and national capability specifications. Commissioning support Compliance advice & guidance Stakeholder communications Audit Assurance process development National change process Operational reviews Wider policy and guidance development NARU internal governance Multi-agency procedure development Support to training & education NARU on-call Operational command support (national) 3.2 Compliance Function Costs Circa: 75,896 per annum Pay: Secondment (pay): 49,473 On Costs: 11,523 Non-Pay (forecast estimates): External advice (inc legal advice): 9000 Travel & Sustenance: 5000 IT provisions: 900 Version 2.0 (Net) Page 5 of 7

6 4. HART Specification 2015/16 The first capabilities to be subject to the NARU compliance programme were those of the Hazardous Area Response Teams (HART). A lack of safe system standards was identified in the 2013 Audit programme and weaknesses in procedures led to a request for support from the National HART Operations Group. Following a comprehensive analysis of HART operational practice and applicable external standards, a new safe system of work has been developed for the 2015/16 Service Specification. This system will set mandatory minimum standards creating transparency for commissioners and a safer working environment for staff and patients involved in NHS hazardous area operations. Based on the ISO9001 Quality Standard, the continual review process has been designed to conform to health and safety industry standards. National commissioners have also been involved in its development to incorporate NHS assurance and performance management into the new specification /16 HART Specification Outline Rescue Plans External National Interoperability HART SAFE SYSTEM OF WORK Standard Operating Procedures Risk Assessments PLAN DO CHECK ACT CONTINUAL REVIEW PROCESS External National Interoperability Risk Assessments Rescue Plans Standard Operating Procedures Capability Matrix Risk Management Training & Education Commissioning Key Performance Indicators Assurance Declarations Audit National Compliance Programme: Translate External Revise Operating Procedures Revise Interoperability Revise Risk Assessments Revise Rescue Plans Change Management Process Version 2.0 (Net) Page 6 of 7

7 4.2 HART Safe System Components Being developed by the NARU Compliance Programme throughout HART Capital Replacement Programme National Interoperability Risk Assessments Rescue Plans Standard Operating Procedures Capability Matrix Team Structure Competency Levels Equipment Specifications Estate Specifications State of Readiness Identifying Lessons and Safety Notification Local Operational Interface Generic Operational Activity Generic Training Activity Generic Equipment Specific Training Venue Joint Dynamic Hazards Assessment (JDHA) Dynamic Operational Activity Training Venues Activity Definition Method Statements Equipment Requirements Equipment Training Competency References Risk Assessment References External Standard References Another key output of the Compliance Programme for 2014 is coordination of the HART capital replacement programme. The HART fleet and incident technology represents 1.9 million of capital assets per unit ( 28.5 million nationally). These assets are depreciated locally but specified nationally to ensure interoperability standards and to achieve economies of scale. The replacement of the first sets of HART capital assets begins in The replacement programme comprises: User group workshops Confirmation of local user requirements Confirmation of national capability requirements User Requirements Fleet User Requirements - Technology Technical Specifications Fleet Technical Specifications Technology Tender Process Fleet Tender Process Technology Award of Contracts Incorporation into a National Buying Framework Incorporation into the 2015/16 Service Specification Commissioning Support The NARU Compliance Programme works closely with NHS Commissioners at a national level to maintain the mandatory minimum standards required for an interoperable safe system of work. Monthly meetings now take place with representatives from the National Ambulance Commissioning Group. The result will be a fleet of new vehicles and hazardous area coordination technology coming online across the country in This next generation equipment will enable NHS Paramedics to provide patient care inside hazardous areas more efficiently with higher safety standards. By combining this replacement project with the Stage 3 review and compliance project, significant cost efficiencies will also be realised in HART over the next seven years whilst enhancing the existing capabilities. Version 2.0 (Net) Page 7 of 7