Dudley & Walsall Mental Health Partnership NHS Trust Board

Transcription

1 Dudley & Walsall Mental Health Partnership NHS Trust Board Date of Board Meeting: 27 May 2009 Subject: Trust Board Lead: Presented by: Aim of the report: Risk Management Strategy Rosie Musson Head of Governance and Partnerships Gary Graham Chief Executive The aim of the Strategy is to provide Dudley and Walsall Mental Health Partnership Trust with robust risk management framework which enables effective risk management processes to be embedded in the organisation. The Strategy is underpinned by NHSLA standards Key points: Dudley and Walsall Mental Health Partnership Trust (DWMHT) has a statutory responsibility to patients, public and commissioners to ensure that it has effective processes, policies and people in place to deliver its objectives and to control any risks that it may face in achieving these objectives. The purpose of this Strategy is to define a framework, which enables effective risk management and promotes continuous improvement. The implementation of an effective Risk Management Strategy, supported by robust risk assessment processes will form a key tool to enable the Dudley and Walsall Mental Health Partnership Trust deliver this overarching Strategy and underpinning objectives. Recommendation: That the Trust Board endorses the Risk Management Strategy. Board action required (please tick) Information Approval Discussion Other (please state) Key Standard(s) for Better Health: Implications: Financial: HR/Personnel: Community/user: Equality & Diversity:

2 Risk Management Strategy Version 1 7 May 2009

3 Contents Page Section 1 Introduction 2 Section 2 Definitions 2 Section 3 Background Development Of Risk Management Strategy 2 Section 4 Assumptions Underpinning The Strategy 3 Section 5 Risk Management Vision 4 Section 6 Aims And Principles 5 Section 7 Roles And Responsibilities 7 Section 8 Delivery Of This Strategy 12 Section 9 Monitoring And Compliance 15 Section 10 Communication 15 Section 11 Review 16 Appendix 1 Table 1 Consequence Score 17 Table 2 Likelihood Score / Risk Matrix 20 Table 3 Strategy Implementation Plan 21 1

4 Section 1 Introduction Dudley and Walsall Mental Health Partnership Trust (DWMHT) has a statutory responsibility to patients, public and commissioners to ensure that it has effective processes, policies and people in place to deliver its objectives and to control any risks that it may face in achieving these objectives. The purpose of this Strategy is to define a framework, which enables effective risk management and promotes continuous improvement. The implementation of an effective Risk Management Strategy, supported by robust risk assessment processes will form a key tool to enable the Dudley and Walsall Mental Health Partnership Trust deliver this overarching Strategy and underpinning objectives. Section 2 Definitions For the purpose of this Strategy, the following definitions apply: (based on Risk Management Model HSG65) Risk Management: The systematic processes and procedures that an organisation puts in place to ensure that it identifies, assesses, prioritises and takes action to manage these risks to ensure it continues to deliver its objectives. Risk: Anything which prevents an organisation from achieving its declared aims and objectives. Risk Categories: Strategic Risks associated with a particular strategy, for example: overcapacity; competitor reactions; service line obsolescence. Financial Risks associated with the financial structure of the Trust; the financial transactions and the financial systems which are in place. Operational Risks associated with the operational and administrative procedures of a business, such as clinical activities; IT systems; recruitment. Regulatory Risks posed by potential changes in the regulatory and political and environment, such as tariff changes; policy changes; changes in political healthcare targets. Reputation Risks to the perceived quality or image, for example bad press resulting from service changes. Contingent Risks that will only come into existence if a certain contingent event takes place. Section 3 Background Development of Risk Management Strategy Since the publication in 1998 of First Class Service, the Department of Health has continued to define the risk management agenda for the NHS. The following publications have been instrumental in shaping this agenda. 2

5 Organisation with a Memory 1 : Sets out the requirement for the NHS to have a more focused approach to ensuring patient safety and minimising the occurrence of adverse clinical incidents. Building a Safer NHS 2 : Outlines proposals for a national adverse incident reporting procedure and the need for local NHS organisations to develop open learning cultures, understand the factors contributing to adverse clinical adverse incidents and provide systems of effective feedback to staff following these occurrences. Assurance: the Board Agenda: Emphasises how important it is for boards to be enabled to make well informed decisions regarding their confidence that the the systems, policies and people they have put in place are operating in a way that is effective, focused on key risks and driving the delivery of objectives. This is underpinned by a statutory statement on Internal Control: which forms part of the statutory accounts and annual report. Integrated Governance handbook: Outlined integrated governance as the umbrella for all NHS governance programmes. It combined the principles of corporate/financial accountability and the move towards a single risk sensitivity process covering all Trust objectives, supported by co-ordinated information collection and inspection. Further definition of the risk management agenda has come from national accreditation programmes such as the Clinical Negligence Schemes for Trusts (CNST), Risk Pooling Schemes for Trusts (RPST), and more recently the NHSLA Risk Management Standards and the Care Quality Commission Core Standards. All of these schemes have set explicit standards for NHS organisations in relation to systems and processes that should be implemented as part of risk management arrangements. In developing the Dudley and Walsall Mental Health Partnership Trust Risk Management strategy, the Trust has also considered other inter-related national and local strategies that impact or has the potential to impact on the convergent strategy. Section 4 Assumptions Underpinning the Strategy The development of this Strategy has been underpinned by a number of significant key assumptions: The requirements of the basic building blocks of Integrated Governance are further embedded as defined in Integrated Governance Handbook February 2006, and the Trusts Integrated Governance Strategy. The National Patient Safety Agency combined with other emerging national safety organisations will continue to be a key national driver for patient safety within the NHS. That Dudley and Walsall Mental Health Partnership Trust achieves in 2009 and maintains NHSLA Level 1 for NHSLA Risk Management Standards for Mental Health & Learning Disability Trusts, and aspires to achieve level 2. 1 (Organisation with a memory. Report of the Expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer Department of Health 2000) 2 Building a safer NHS for patients. Implementing an organisation with a memory, Department of Health

6 That key accreditation standards continue to have financial implications attached in both terms of rewards and penalties. That the Dudley and Walsall Mental Health Partnership Trust continue to achieve financial balance ensuring autonomy in its management structures. That the Dudley and Walsall Mental Health Partnership Trust Committee and Management Structures are continuously under review and that any changes may necessitate adjustments to the implementation reporting and monitoring systems of this Strategy. That the systems policies and processes, which underpin this Strategy, will be subject to frequent modification as the new Dudley and Walsall Mental Health Partnership evolves. This Strategy will be reviewed annually to take account of these changes. Section 5 Risk Management Vision Dudley and Walsall Mental Health Partnership Trust s risk management strategy aims to define a pragmatic and effective multi-disciplinary approach to Risk Management, underpinned by a clear accountability structure from Board to Ward level. The Trust recognises the need for robust principles, systems and processes to support continuous programmes of Risk Management. However, it also recognises that these processes need to be sufficiently flexible if staff are to effectively integrate Risk Management into their daily activities. Delivery of this strategy will support the development and measurement of continuous improvements in care and practice, recognising that these may only be incremental changes over a period. Implementation of this Strategy will enable the Dudley and Walsall Mental Health Partnership Trust to achieve and maintain high levels of accreditation against the NHSLA standards for clinical and non-clinical claims, risk management and complaints management. Dudley and Walsall Mental Health Partnership Trust will continue to involve its patient and public in a proactive approach, promoting user involvement where appropriate. Other key partners and stakeholders will be encouraged to participate in initiatives that foster a multi-professional, multidisciplinary and multi-agency approach. Staff will be encouraged and supported to share learning and best practice in a way, which creates a culture of open supportive learning with accountability, even when mistakes have been made. Information and knowledge will be seen as a cornerstone of building safer care in the future and Dudley and Walsall Mental Health Partnership Trust will work to adopt and provide a proactive information and knowledge management infrastructure. 4

7 Section 6 Aims and Principles The Strategy is designed to deliver a number of key aims and principles. These include: 6.1 Risk Identification and Management Dudley and Walsall Mental Health Partnership Trust will ensure that Risk Management principles, processes and systems are embedded through the Trust Board and within the organisation via a robust accountability framework with clear lines of responsibility from Board to ward level. The Trust Board will maintain its Assurance Framework in line with Department of Health guidance to ensure the effective management of Strategic risks and the appropriate preparation and sign off the Trusts annual Statement on Internal Control. Dudley and Walsall Mental Health Partnership Trust, through its operational and corporate governance infrastructure, will implement a rolling programme of risk management. These programmes will include activities which support effective risk management including Health and Safety management, incident reporting and management; risk assessment and management; risk management training and education; complaints and claims management. A risk register will be maintained and used to manage risk for all clinical and corporate directorates. Risks will be escalated and monitored as appropriate through the operational structure of Dudley and Walsall Mental Health Partnership Trust, taking into account risk severity, complexity and required resources, to ensure effective and timely risk mitigation can be achieved. The Trust Board will review the Assurance Framework/Strategic Risk Register on a quarterly basis. The Integrated Governance Committee will monitor its progress on behalf of the Trust Board The Audit Committee is responsible for ensuring that Dudley and Walsall Mental Health Partnership Trust has effective risk management systems including an effective system of internal control. Dudley and Walsall Mental Health Partnership Trust will develop systems for assessing risks for potential new activities i.e. through the business case process, business planning and the setting of individual staff objectives. 6.2 Risk Information Risk management information will be collected, collated and analysed to determine trends or areas of concern, ensuring that remedial action can be taken at the earliest possible stage. 5

8 The Dudley and Walsall Mental Health Partnership Trust will aggregate and analyse risk information to enable trends to be identified and appropriately managed. Risk information will be used as a mechanism to provide further understanding of the organisation risk profile. Risk Management reports will be used to maintain an appropriate focus on organisation risk, communicating risk issues and promoting a culture in which risks and their solutions are shared and learnt from. The Board will continually review progress against strategic and significant/serious operational risks to ensure that it is appropriately informed about both these types of risks. The Governance Department will produce regular reports for the Integrated Governance Committee and Trust Board to demonstrate the risk management system s continuing suitability and effectiveness. 6.3 Learning Lessons Dudley and Walsall Mental Health Partnership Trust continues to develop its capacity to learn from mistakes, principally through the application of Root Cause Analysis tools and the Trusts risk management processes. Dudley and Walsall Mental Health Partnership Trust will continue to strengthen its approach to learning lessons. Ensuring local and Trust wide action is taken where appropriate in response to individual events, trends in incidents or complaints and external recommendations. Through the joint forums the Trust will develop a shared approach to the development of risk management and learning lessons across the local health economy Staff will be encouraged to report incidents and supported to share learning and best practice in a way, which creates a culture of open supportive learning with accountability, even when mistakes have been made. 6.4 Compliance The strategy will facilitate compliance with risk management standards through the development and monitoring of process and outcome measures at corporate and specialty levels. Dudley and Walsall Mental Health Partnership Trust will achieve Level 1 accreditation for the NHSLA Risk Management Standards (Mental Health & Learning Disability Trusts) by 2010 and work towards Level 2. Dudley and Walsall Mental Health Partnership Trust will achieve compliance with the core Health Care Standards and work towards a Healthcare Commission rating of Excellent for quality of services. 6

9 The Trust Board will ensure that they receive assurance on risk management systems. This assurance will be provided by the Internal Audit function, through a process of periodic audits. Dudley and Walsall Mental Health Partnership Trust will ensure that all risk management related reviews carried out by external agencies are effectively co-ordinated and any recommendations are implemented. Assurance reports will be presented to the Integrated Governance and Audit Committees in line with their Terms of Reference. 6.5 Risk Management Education and Training Dudley and Walsall Mental Health Partnership Trust will undertake a regular training needs analysis for the organisation, ensuring that comprehensive training programmes are delivered at all levels. All Dudley and Walsall Mental Health Partnership Trust staff will be enabled to receive appropriate risk management training upon induction and at appropriate intervals in line with the Trusts Training Needs Analysis and Core Training Policy and processes. The risk management training programmes will be subjected to regular monitoring and an annual assessment of effectiveness and suitability, taking into account the developing national agendas. The Trust Board will be supported in its role by the Integrated Governance Committee and supporting sub Committees which will ensure that sufficient information and expert advice is obtained to understand and appropriately manage the organisations risk. Dudley and Walsall Mental Health Partnership Trust will ensure that all staff with specific responsibility for the co-ordination and advising on aspects of risk management are adequately trained and developed to fulfil their role. 6.6 Patient and Carer Engagement Dudley and Walsall Mental Health Partnership Trust will consider how risk management should incorporate consideration of stakeholders i.e. patients, partner organisations and other interests. This will include any risk assessments of integrated working arrangements. Dudley and Walsall Mental Health Partnership Trust will ensure that all relevant stakeholders, including staff, are informed and, where appropriate, consulted on the management of risks faced by the organisation. Dudley and Walsall Mental Health Partnership Trust will actively promote and encourage patient and user involvement across the organisation with risk issues, and learning lessons where appropriate. 7

10 Section 7 Roles and Responsibilities This section of the strategy identifies the roles and responsibilities of key individuals, highlighting accountability levels at each stage. It provides a brief synopsis of key roles. 7.1 Individual Responsibilities The Trust Board, the Executive Team, managers and staff are responsible for establishing, maintaining and supporting a holistic approach to risk management, in all areas of their responsibility. They should comply with this Strategy and the policies and procedures which support it to ensure effective risk management mechanisms are implemented in accordance with these. Some members of staff and Committees have particular specialist functions in relation to risk management as described below: Title Chief Executive (CEO) Head of Governance and Partnerships Executive Directors Roles and Responsibilities The Chief Executive has overall responsibility for the Trust s risk management programme and ensuring that this operates effectively. This will be achieved through the Risk Management framework and reporting structure As Accountable Officer, the Chief Executive is responsible for signing the Statutory Statement on Internal Control (SIC). The CE delegates operational responsibility for risk management to the Head of Governance and Partnerships The Head of Governance and Partnerships is the designated Board member with overall responsibility for the implementation of organisational and clinical risk management systems ensuring this strategy is executed and communicated. The development of the Assurance Framework and coordinating the annual review of the effectiveness of internal control. To ensure that systems are in place to ensure that all service users are assessed for the risk of harm to self and others and to make sure that appropriate risk management plans are in place All Executive Directors are responsible for overseeing a programme of risk management activities, in accordance with the Dudley and Walsall Mental Health Partnership Trust s risk management and related policies and procedures and advising the Director of Governance and Standards on risk issues in areas of their responsibility. Executive Director Leads have been identified for each of the Dudley & Walsall Mental Health Partnership Trust principal objectives and are responsible for ensuring that systems are in place to manage risks and provide assurance for all areas within their sphere of responsibility They also have specific responsibility for the overall management of serious risks which fall within their area of responsibility 8

11 Non Executive Directors The role of the non-executive directors is to provide a level of independent judgement in relation to the workings of the Trusts risk management programme and activities, as part of their Board duties and responsibilities. Director of Finance The Finance Director is responsible for : Establishing and maintaining sound systems for internal financial control and for ensuring the adequacy of all controls related to disclosure statements prior to endorsement by the Board. advising the Trust Board on all aspects of financial risk and, through Finance Committee and Trust Board, ensuring effective mechanisms are in place to manage these Ensuring the Dudley & Walsall Mental Health Partnership Trust actively supports counter fraud risk based elements of work through the Risk Register, and the risk related work of the Counter Fraud provision. Medical Director and Director of Operation and Nursing Director of Human Resources All Directors and Associate Directors Governance Manager Risk Manager The Medical Director and Director of Operation and Nursing have the joint responsibility for managing the strategic development and implementation of clinical risk management and clinical governance..development and maintenance of infrastructure to enable identification, delivery and monitoring of training. Responsible for the collation of information on risks and risk management. Responsible for the development, monitoring and review of Directorate Risk Registers. The implementation of national quality initiatives, ensuring there is regular clinical audit and monitoring trends in key clinical quality and clinical outcome measures. The development of policies and procedures that ensure the clinical safety of service users, integrating these with other clinical governance processes. Ensure the Dudley & Walsall Mental Health Partnership Trusts approach to risk management is compliant with national and regulatory legislation, national standards and good practice. Ensure that systems are maintained to manage risk effectively. This includes systems for reporting and learning from untoward incidents, maintenance of the Dudley & Walsall Mental Health Partnership Trust s risk register, Verify the implementation and effectiveness of actions taken to treat risk and leading on external assessments, e.g. NHS Litigation Authority Standards. Provide expert advice on Risk Management and health and safety. 9

12 Health & Safety Officer Head of Corporate Affairs Complaints Manager Senior Managers, Service Leads and Professional Leads Ensure health and safety, fire and security incidents are investigated appropriately and liaising with the Health and Safety Executive (HSE) and the Medicines and Healthcare products Regulatory Agency (MHRA) The Health and Safety Officer is responsible for undertaking health and safety audits and providing advice on remedial measures required to ensure an environment of safety for patients, staff, visitors and other stakeholders. The Health and Safety Officer will also provide training on health and safety to all levels of staff within the Trust. The Head of Corporate Affairs incorporates the role of Company Secretary. This will ensure that this strategy is embedded in the annual board cycle and provides full evidence for the signed of the Statement of Internal Control Advise on legal issues including actual and potential litigation. Advise on legal issues including actual and potential litigation. The Complaints Manager is responsible for the management and coordination of the investigation of formal complaints, ensuring that the Trust s Complaints Procedure is adhered to and investigations are completed by the Directorate in accordance with identified standards, and that required follow-up action is taken in order to prevent recurrence. All Managers and Heads of Service are responsible for ensuring: Staff are aware of their responsibilities for identifying, managing and recording risk and attend appropriate training. Risk assessments are undertaken, risk treatment plans produced and any problems in the management of risk are recorded. All adverse incidents or accidents and near misses are reported. Risk assessment is incorporated in all service and capital plans. Risk assessments are conducted on all activities undertaken in their areas, and suitable action plans are produced and implemented. Risk control measures are reviewed at least annually Recording risks on their local risk register. Risk treatment plans are monitored Review risk registers quarterly. All staff are aware of risks within their work environment and their personal responsibilities. Incidents are reported, managed and investigated according to Dudley & Walsall Mental Health Partnership Trust procedures. All staff receive appropriate risk management training. Workplace induction, which includes risk management, is in place for all staff, including bank and agency staff. 10

13 Team Leaders Local Security Management Specialist (LSMS) Fire Advisor. Staff including bank, agency and locum staff Local policies and procedures are developed to manage specific risk issues where required. Ensure all staff are clear on their roles and responsibilities in respect of Mandatory training concerning the management of risk Coordinating work-based inspections and completing work based risk assessments Ensure all staff within their team(s) meet the minimum requirements in respect of mandatory training Ensure all staff have equitable access to mandatory training The Local Security Management Specialist is responsible for ensuring that the Trust meets the requirements of the Secretary of State s Directions for Security Management and the requirements of the NHS Counter Fraud and Security Management Service. The Local Security Management Specialist will advise on actions required to meet current and new security guidance and act as a link to the Police in managing violent and abusive incidents. The Local Security Management Specialist will monitor violence and security incident trends and investigate incidents to ensure that the Trust is taking appropriate action with respect to such incidents. To advise the Trust of their responsibilities in respect of Regulatory Reform (fire safety) Order 2005 and NHS Firecode To provide specialist advice to the Trust on fire safety. Ensure the requirements of the Regulatory Reform (Fire Safety) Order 2005 and the Firecode/Health Technical Memorandum Standards for Fire Safety are met Familiarising themselves with this Strategy, and associated documents To be aware and comply with their statutory duties (Health & Safety at Work Act 1974 and Management of Health & Safety Regulations 1999). Report untoward incidents and near misses according to the Dudley & Walsall Mental Health Partnership Trust s policy. Be aware of known risks within their working environment. Be familiar with emergency procedures for their area of work e.g. fire and resuscitation. Comply with policies and procedures and not to interfere with or misuse any equipment, which is provided for health and safety purposes. Attend any relevant training provided by their employer. 11

14 7.2 The Trust Board Dudley and Walsall Mental Health Partnership Trust Board is responsible for assuring that appropriate risk management systems are in place to enable the organisation to deliver its objectives. It delegates overall responsibility for risk management to the Integrated Governance Committee. Dudley and Walsall Mental Health Partnership Trust Board is also responsible for identifying and controlling the organisations Strategic Risks and Assurance Framework. Section 8 Delivery of This Strategy All aspects of this strategy will be delivered through the supporting Risk Management Policies and Procedures and underpinned by the following key components: Risk Management Cycle Risk Register Assurance Framework Risk Information and Communication Risk management Education and Training 8.1 Risk Management Cycle Risk management is the process by which an organisation identifies, assesses and takes action to manage their risks. It is the responsibility of all staff throughout the organisation. Dudley and Walsall Mental Health Partnership Trust will employ a standardised approach to risk assessment across the entire organisation. This will involve use of a risk register tool to guide staff through the process. Full guidance on the Trust s risk assessment process, summarised below, can be found in the Trust s Risk Management policy. The standardised approach to risk assessment will use a structured approach to the identification, collation, prioritisation and management of risks at both an organisational and local level. Risk Identification: Risk may be identified through a variety of external and internal sources. The Dudley and Walsall Mental Health Partnership Trust will take the widest possible approach to identify all types of risk. Risks will be identified at all levels throughout the organisation, from Board to practitioner level. Identified risks will be collated and logged locally at both a Directorate level and an organisational level through a risk register framework. Risk Assessment: Risk will be prioritised using a risk assessment matrix (Appendix 3), which enables the organisation to assess the level of risk based upon measurement of the likelihood and consequence of the occurrence. This prioritisation tool will be based upon the Australian and New Zealand Risk Management Risk Management Standard (AS/NZ 4360:1999). This matrix will be used to determine a risk score for each risk identified. 12

15 Risk Treatment: For identified risks, the organisation will agree a programme of actions to manage and control the risks. The organisation will use the following approaches to risk control: Reduction: taking action to reduce the risk; Avoidance: undertaking the activity a different way to prevent the risk occurring; Transfer: movement of the risk to another individual/organisation; Acceptance: above options are not applicable and risk is accepted. Action plans will be developed to set out the steps required to manage each risk. Where additional resources are required to effectively manage a risk, this will be linked into Dudley and Walsall Mental Health Partnership Trust s business planning process. Risk Review: All parts of the organisation will regularly review identified risks and the controls put in place to manage those risk on a regular basis. This will occur on a quarterly basis as a minimum. Once appropriate action has been taken to manage the risk, the risks will be re-scored and, where appropriate, removed from the risk register. Where required, Dudley and Walsall Mental Health Partnership Trust Board and Committees with particular responsibility for Risk Management will review these risks Risk Register The principle tool that the organisation will use for managing its risk assessment systems and processes will be Dudley and Walsall Mental Health Partnership Trust risk register. The Trust risk register can be described as a log of all the risks that may threaten the success of the Trust in achieving its declared aims and objectives. It will operate at both a local Directorate and organisational level. The Governance Team will manage the overall infrastructure and ensure that all risks are centrally collated. Directorates will be responsible for managing individual Directorate risk registers through their on-going local risk assessment procedures and governance forums. Risk registers will include as a minimum: Location and source of risk; Details of risk issue; Details of controls in place to manage risk; Initial and Current risk scores; Details of the actions required to manage the risk; Individual responsible for overall management of the risk; Details of any resources required to manage the risk; Timescales for risk review. Dudley and Walsall Mental Health Partnership Trust risk register will be used to inform the Trust Board, and the Integrated Governance Committee of the risks held by the organisation and will be reviewed on a quarterly basis (as a minimum) by these Committees. Directorates will be responsible for reviewing their risk registers as part of their routine management and governance activities 13

16 8.3. Assurance Framework The Assurance Framework (AF) details the principle risks to delivering Dudley and Walsall Mental Health Partnership Trust s strategic objectives. Its purpose is to help the Trust Board and Executive Team focus on and manage the risks to meeting these. The AF maps the risks to the controls (i.e. actions that manage and mitigate the risks) and to the assurances (i.e. systems, which inform the Board on how effective the controls are). The Head of Governance and Partnerships is responsible for facilitating the management of the Trust Board Strategic Risk Register / Assurance Framework and management of significant/serious risks with Trust Board 8.4 Risk Information and Communication The principle tools that the Trust uses to encourage learning and facilitate the communication of risk management information at a local and corporate level are: Directorate Locality Meetings: All clinical directorates have a forum at which governance and risk information is discussed and debated. A part of the role of this multidisciplinary group is to identify, manage, communicate and learn from risks associated with individual and trends in incidents, complaints, claims and other relevant data. These groups also form the mechanism by which unresolved or wide reaching risks are identified and escalated to the Integrated Governance Committee. Integrated Governance Report: The integrated governance report provides statistical information on incidents, complaints and claims as well as more qualitative information on how the Trust is responding to any risks posed by the most frequently occurring incidents. The purpose of this report is enable analysis and interrogation of trends in the frequency, location, severity or category of incidents, complaints and claims. It is used by the integrated governance committee to identify and take action in relation to key trends considered important to the safety or service provided by the Trust. 8.5 Risk Training To ensure that Dudley and Walsall Mental Health Partnership Trust has sufficient capability to implement effective risk management systems and processes, staff need to be skilled and supported in the application of the principles and practice of Risk Management. The Trust will adopt a structured and pragmatic approach to risk management training and will provide a comprehensive programme of risk management training to staff which will feature: Corporate and local induction programmes to provide relevant aspects of risk management training to new starters; Mandatory risk management training and in line with Dudley and Walsall Mental Health Partnership Trust Core Training Policy and Training Needs Analysis; 14

17 Where required, tailored training / education / awareness resources will be developed to reflect individual staff needs and their involvement in undertaking risk management activities; The ongoing provision of support and advice provided through the Governance team structure and working arrangements with the directorates; Provision on ongoing support and advice, via the Head of Governance and Partnerships and the Integrated Governance Committee, to the Trust Board to enable them to receive and act upon appropriate risk management information in line with their corporate responsibilities Dudley and Walsall Mental Health Partnership Trust will ensure that training programmes are accessible to all staff across the organisation and will implement systems to record and monitor attendance on risk management courses. The Trust will assess the effectiveness of its risk management training programmes through the setting of clear objectives for each course and seeking staff feedback. Training programmes will be reviewed on an annual basis. Section 9 Monitoring and Compliance The Trust Board will evaluate the effectiveness of the risk management programme on an annual basis. The Trust will utilise the following tools to support performance review: Internal tools: Quarterly reports to Integrated Governance Committee Regular reports to Operational Committees Use of risk management tools by departments; Compliance with mandatory induction and training standards; Incident investigations Complaints; Patient and staff surveys; Internal standards; Benchmarking activity; Annual report; Statement on Internal Control Annual internal audit governance work programme External tools: Healthcare Standards; Business Planning; NHSLA Risk Management Standards; The Trust Board may develop and use additional indicators to monitor risk management performance, as considered necessary. The Dudley and Walsall Mental Health Partnership Trust will also provide information on a regular basis to local healthcare partners in line with the performance management requirements of Primary Care Trusts. Information will also be provided as required to ensure that patients and the public are confident in the efforts of the Dudley and Walsall Mental Health Partnership Trust to provide the safest possible level of care. 15

18 Section 10 Communication Successful delivery of the strategy will be dependent on continuous strong and effective communication mechanisms which will be developed and improved as part of the delivery of this Strategy. Changes to systems, policies and procedures which support implementation of this Strategy will also be communicated appropriately in line with the Dudley and Walsall Mental Health Partnership Trusts Policy Framework to ensure all staff are aware of their roles and responsibilities. This Strategy and supporting Policies and Procedures will be available to all staff via the Policy document management system. The Governance Team will ensure that these documents remain current and up to date. Section 11 Review This strategy will be subject to consideration and formal review by Dudley and Walsall Mental Health Partnership Trust Board on an annual basis. 16

19 Appendix 1 Table 1 Consequence Score (C) Choose the most appropriate descriptor for the risk issue you have identified from the left hand side of the table. Working along the row, what could happen if this risk were to materialise? The consequence score is the number at the top of the column. A single risk area may have multiple potential consequences Descriptor Insignificant Minor Moderate Major Catastrophic Objectives / Projects Reputation/Publicity Insignificant cost increase / schedule slippage. Barely noticeable reduction in scope or quality No adverse publicity or loss of confidence in Dudley and Walsall Mental Health Partnership Trust < 1% over budget / schedule slippage. Minor reduction in quality / scope Local Media short term minor loss of confidence and effect on staff morale 1-5% over budget / schedule slippage. Reduction in scope or quality requiring client approval Local Media. - long term Relations with public affected, Moderate loss of confidence in Dudley and Walsall Mental Health Partnership Trust and significant effect on staff morale 5-25% over budget / > 25% over budget / schedule slippage. schedule slippage. Doesn't meet secondary Doesn't meet primary objectives objectives Widespread adverse National media > 3 publicity. National Media days. MP concern- < 3 days Major loss of questions in House confidence in the Dudley Major loss of confidence and Walsall Mental Health Partnership Trust Viability of Dudley and Walsall Mental Health Partnership Trust threatened Service / Business Interruption Minimal impact. No service disruption Inefficient short-term operation of one part of the Dudley and Walsall Mental Health Partnership Trust Loss >8 hours. Dissatisfaction in more than one area. Inefficient medium-term operational management Temporary Service closure. Permanent loss of service or facility Impact felt in other areas. 17

20 Injury Patient Experience Complaint / Claim Potential National Standards / best practice Staffing and Competence Minor injury or illness, Minor injury not requiring first aid treatment first aid needed Unsatisfactory patient experience not directly related to patient care Locally resolved complaint Unsatisfactory patient experience - readily resolvable Justified complaint peripheral to clinical care Minor non-compliance Non-compliance with with standards. standards. Minor recommendations Recommendations given Short term low staffing level temporarily reduces service quality (< 1 day) Financial Small loss(< 500) Inspection / Audit Ongoing low staffing level reduces service quality Moderate Loss (> 500) Minor recommendations. Recommendations Minor non-compliance given. Non-compliance with standards with minor standards RIDDOR reportable or equivalent. Increased LOS Mismanagement of patient care short term consequences (1 week or less) Claim < Justified complaint involving lack of appropriate care Reduced rating, Challenging recommendations. Non compliance with core standards, legislation Unsafe staffing level or competence (< 1day). Loss > 0.005% of budget(> 5,000) Reduced rating. Challenging recommendations. Noncompliance with core standards Major injuries, or long term incapacity / disability (loss of limb) Death or major permanent incapacity Mismanagement of Totally unsatisfactory patient care Long term patient outcome or consequences experience (More than 1 week) Claim > Multiple justified complaints Low rating Enforcement action HSE intervention. Critical report. Major non compliance with core standards, legislation Unsafe staffing level or competence (< 1 week) Loss > 0.05% of budget(> 50,000) Enforcement Action. Critical report. Multiple challenging recommendations. Major non-compliance with core standards Multiple claims or single major claim (e.g. Obstetrics) Zero Rating Prosecution. Severely critical report. Loss of contract Ongoing or critical unsafe staffing level or competence Loss > 1% of budget(> 1,000,000) Prosecution. Zero Rating. Severely critical report 18

21 Adverse Publicity / Staff morale Fire Safety System Environmental Impact Rumours Minor short term (<1 day) shortfall in fire safety system Minor non-compliance with standards Minimal increase in environmental impact Local Media - short term Minor effect on staff morale Temporary (<1 month) shortfall in fire safety system / single detector etc (non patient area) Non-compliance with non-core standards Small increase in environmental impact Local Media - long term Significant effect on staff morale Fire code noncompliance / lack of critical component of fire Significant failure of single detector etc safety system (patient (patient area) area) Non-compliance with core standards Significant increase in environmental impact National Media > 3 Days National Media < 3 Days MP Concern (Questions in House) Enforcement Action. Critical report. Major non-compliance with core standards Unacceptable increase in environmental impact Failure of multiple critical components of fire safety system (high risk patient area) Prosecution Severely critical report Severe impact on environment 19

22 Table 2 Likelihood Score (L) What is the likelihood of the consequence Occurring? A frequency based score will be appropriate in most circumstances, except in the case of time-limited projects or objectives, where the probability based score should be used Almost Rare Unlikely Possible Likely Certain Descriptor Frequency Probability Not expected to occur for years Expected to occur at least annually Expected to occur at least monthly Expected to occur at least weekly < 0.1% 0.1-1% 1-10% 10 50% Will only occur in exceptional circumstances Unlikely to occur Reasonable chance of occurring Likely to occur Expected to occur at least daily > 50 More likely to occur than not Risk Matrix R (Risk) = C (Consequence) x L (Likelihood) Likelihood Consequence

23 Table 3 Strategy Implementation Plan Full implementation of the risk management strategy will be completed by November 2009 and will be achieved through: Action Responsibility for Action Timescale 1 Seek approval of Risk Management Strategy by Integrated Head of Governance and May 2009 Governance Committee Partnerships 2 Seek Approval of Risk Management Strategy by Trust Board Head of Governance and June 2009 Partnerships 3 Review and update Corporate Risk Register (Tier 1) Head of Governance and June 2009 Partnerships & Risk Manager 4 Develop and approve Risk Management Policy Risk Manager July Develop and approve Directorate Risk Registers (Tier 2) Directors, & Risk Manager July Under take risk assessments in all Directorates to identify, control Health & Safety Officer and July 2009 and minimise risks Service Managers 7 Provide Risk Management training and support designated Risk Manager August 2009 individuals including senior managers to enable them to manage risk as a part of normal line management responsibilities 8 Develop and approve Operational Risk Registers (Tier 3) Service Managers & Risk Manager September