Risk Management Annual Report

NHS Fife

Risk Management Annual Report

2014-2015

NHS FIFE RISK MANAGEMENT ANNUAL REPORT

1. PURPOSE OF THE REPORT

To provide the Audit & Risk Committee with an update report in relation to key Risk Management activities which have been undertaken during 2014- 15.

2. EXECUTIVE SUMMARY

The Chief Executive, as Accountable Officer, has responsibility for maintaining a sound system of Internal Control and reviewing the effectiveness of the system within the organisation culminating in the preparation of an annual Governance Statement.

As part of the minimum requirements an assessment of the effectiveness of risk management arrangements should be conducted and it is recommended that this is evidenced by an Annual Risk Management report confirming if adequate and effective risk management arrangements were in place throughout the year.

Within NHS Fife, the Audit & Risk Committee has delegated responsibility from Fife NHS Board for reviewing the organisation’s risk management arrangements, systems and processes.

The presentation of this report seeks to demonstrate adequate and effective arrangements for Risk Management are in place and the contribution, in governance terms, that the systems in place to manage risk make throughout NHS Fife.

3. CONTRIBUTION TO NHS FIFE’S STRATEGIC AIMS

The functions of Fife NHS Board include strategic leadership and direction and to ensureefficient, effective and accountable governance of NHS Fife; a robust set of riskmanagement arrangements will allow these to be achieved.

4. MEASURES FOR IMPROVEMENT

Risk Management Key Performance Indicators will be developed in the second quarter of 2015; these will allow us to measure performance and identify measures for improvement.

5. IMPACT ASSESSMENT & INFORMING, ENGAGING & CONSULTING

All risks influenced by any equality and diversity issue will have an impact assessmentundertaken.A number of individuals from Clinical Governance, Risk Management and members of the Strategic Management Team were consulted in relation to the content of

this report.

KEY RISK MANAGEMENT ACTIVITIES

Over the period 2014 - 15, a number of actions have been taken which are designed to enable NHS Fife to improve its level of risk maturity and to improve the day to day management of risk.These are summarised below:

1. NHS Fife Risk Management Framework

Risk management is everyone’s business and forms an essential and integral part of NHS Fife’s governance arrangements. For both users and providers, it is vital that robust mechanisms are in place to identify, mitigate and escalate risks associated with our services.

To this end, during 2014, NHS Fife’s risk management arrangements were revised. This culminated in the development of a Risk Management Framework.

The Framework builds on the valuable work that has been done in NHS Fife over many years, to develop and implement strategy, systems and processes to help us to manage risk effectively. It was produced through dialogue between members of the Audit & Risk Committee, Executive and Non- Executive Directors. The Framework was approved by Fife NHS Board in August 2014.

The Framework comprises the following pillars:

• Risk Philosophy
• Approach to Risk Management
• Board Assurance Framework
• Risk Policy & Procedure
• Audit & Risk Committee Terms of Reference
• Reporting Framework
• Risk Appetite and Tolerance
• Tools to Assess Ourselves Against

It brings these key elements together for the first time. This is to make it easier for staff to understand the Board’s approach to managing risk and to reinforce their role in its delivery. Some of the elements are familiar to staff, e.g. the Risk Register & Risk Assessment Policy; others, such as the Board Assurance Framework and Risk Appetite and Tolerance, are areas for development. Details of these will emerge in line with other initiatives such as the Strategic Framework and the Clinical Strategy.

Communications took place with each of the delivery units around the Framework via their Clinical Governance and Risk Management groups. The Framework was well received by all parties, with interest expressed in its continuing development over the coming year.

2. NHS Fife Risk Register and Risk Assessment Policy GP/R7

The policy was updated in June 2014. It will be subject to review and update during 2015.

3. Development of the NHS Fife Corporate Risk Register

An extraordinary session of SMT took place on 1 December 2014. This formed part of the ongoing development of risk management in NHS Fife and took place against the backdrop of the evolving NHS Fife Risk Management& Strategic Frameworks.

The session was the catalyst for a wholesale review of the Register which resulted in 11 risks being retained on the register and 4 risks being closed.

The process allowed the SMT to consider the scope of the register and to identify any gaps and take appropriate action. It also reinforced the fact that for the register to be truly meaningful, SMT must devote more time on a regular basis to considering its content and monitoring its efficacy. To this end, from April 2015, the NHS Fife Risk Manager will attend SMT on a bi monthly basis to:

• facilitate a regular focused review of the Corporate Risk Register and
• support the continuing improvement and development of the Register

A review ofall NHS Fife's risk registers will be undertaken inQ2 of 2015. This will inform our priorities and the development of appropriatekey performance indicators on which to report.

4. The Management of Adverse Events

In the wake of the publication of the report “The Management of Significant Adverse Events in NHS Ayrshire & Arran in June 2012”, HIS undertook a national programme of Board visits to review arrangements for managing adverse events. Following NHS Fife’s review in December 2012,an actionplan containing 36 actions was developed; this included themes such as stakeholder engagement, communications, education, development of the Datix system, and update of policy.

This built on work already underway to review and strengthen the system and processes to effectively manage adverse events and in doing so, to prevent harm and improve patient care and service delivery.We recognised that there was particular scope to increase the reliability of our arrangements for managing significant adverse events i.e. those graded major or extreme in terms of severity.

This work has continued to date.It has taken cognisance of and has been informed by national and international guidance on adverse events management.

All but one of the actions referred to above have been completed. This relates to the development of guidance for staff on providing a statement; this will be complete by the end of March 2015.

The Adverse Events Policy has undergone 2 cycles of review and update. The policy draws heavily on the National Framework for Learning from AdverseEvents (Healthcare Improvement Scotland (HIS), 2013).

Incident Reporting Levels:

Adverse event reporting is an indicator of the organisation’s culture of openness and willingness to learn when things go wrong. Analysis of aggregated data across NHS Fife indicates that the level of incident reporting is increasing. The reasons for the increase in the overall number of incidents reported are likely to be multi-factorial. These may be attributable to ongoing encouragement for staff to report incidents, a rise in staff confidence that there is value in reporting incidents and ease of reporting with DatixWEB.

Monitoring and Review:

Three weekly Adverse Event Group meetings have been in place since 2013 to oversee the implementation of the NHS Fife Adverse Event Policy and Process which were introduced in June 2013. The meetings focus particularly on the management of events graded major and extreme and the associated adverse event reviews.

Membership consists of Board level Executives, Clinical Governance, Risk Management and Patient Relations staff as well as Senior Managers from the delivery units.

As we approach Health and Social Care Integration, an invitation will be extended to the Director of Health and Social Care to identify an appropriate individual from the partnership to participate in the meetings.

Updates on progress with the management of adverse events are submitted to every meeting of the NHS Fife Clinical Governance Committee and the NHS Fife Quality, Safety and Governance Group.

Learning and Improvement:

Learning and actions from adverse event reviews are captured in the Reducing Harm Action Plan. The NHS Fife Quality, Safety and Governance Group monitor progress on this plan.

NHS Fife is striving to improve the overall management of adverse events, and a concerted effort is being made to drive learning and improvement from adverse events.To support this aim, the following are in place locally; these will continue to be developed and embedded throughout 2015 - 16:

•Systematic approach to adverse event review

•All Significant Adverse Events are subject to an Executive level review and decision on required level of review e.g. local or Significant Adverse Event Review

•Standardised tools and templates to assist reviews

•Ongoing development of DatixWEB to make reporting and feedback easier

•Second Victim Project - to improve support for staff following an adverse event

• Core training programmes & customised sessions

•LEARN PRO incident reporter & reviewer modules

•Sharing lessons from adverse event reviews

•Learning summaries and newsletters - DatixWEB, DISPATCH, Mortality

•Morbidity & Mortality meetings / Divisional / Strategic meetings

•Inter-specialty Clinical Governance events

•Directorate / Service Performance Reports

To ensure it reflects internal and external developments, a detailed Adverse Events Improvement Plan for 2015 will be submitted to the next meeting of the NHS Fife Clinical Governance Committee in April 2015.

Involvement in National Programmes

i) National Adverse Events Programme:The Associate Medical Director is a member of the HIS National Adverse Events Programme Board and the Risk Manager is a member of one of the underpinning work streams- Learning and Improvement and heavily involved in the development of an Adverse Events Community of Practice.

ii) Healthcare Improvement Scotland (HIS) & NHS Education Scotland (NES) Knowledge into Action (KIA) Project:NHS Fifeis a national KIA demonstrator site for the project. This involves librarians and clinical governance teams working together to show how knowledge into action support can positively impact on national strategic priorities. In this case, to define, test and evaluate the knowledge support to assist with local learning from adverse events. NHS Fife’s focus is in relation to local activity on pressure ulcers.

5. Learning from other Health Boards

Recently there have been significant publications from reviews on 3 Scottish Health Boards[1]. Fife Health Board is establishing an approach which ensures that there is a process in place so that lessons which need to be learned from such reviews and any emerging risks are identified, consulted upon, and shared widely. Such reviews will be used to reduce risk and support and drive local improvements in patient care and service delivery.

6. Risk Management Software System

Datix is the principal IT system in use across NHS Fife to administer its risk management portfolio.It is the single repository for all risk related information across NHS Fife; this includes all incidents, claims, complaints and risks.There has been considerable investment in this system in the past 2 years.

Around 13000 adverse events are now reported annually via the DatixWeb Incidents module in NHS Fife and about 1500 complaints, suggestions, queries and compliments are logged via the Complaints module.The system has over 900 registered users.

A key focus of the NHS Fife Risk Management Team in 2014-15 has been to upgrade the Datix system to enable greater functionality. In September 2014, we installed web based modules for the Complaints, Claims and Risks modules.This work was supported by the Datix company which provided training in the various modules for the Risk Management, Legal Services and Patient Relations Teams. A review of the modules is scheduled for March 2015.

Incidents Module:

There have been several modifications to the incident reporting and review process including: - improving the reporting options for Mental Health and Learning Disabilities re incidents involving restraint, improving reporting around tissue viability and violence/aggression related incidents.

Much work has also been done to improve the way that significant adverse events are recorded and managed.This has included re-coding a Datix database to record information from Mortality case note reviews, SPSO cases and others to assist in the identification of common themes related to adverse events.

A wide range of reports are regularly produced to support the organisation’s work to improve safety and reduce risks e.g. around Patient Falls, Violence & Aggression, Equipment, Medication and Tissue Viability and to inform FOI responses.

Risk Register Module:

In early 2014, an exercise was undertaken to transfer all 800+ active risks from the ‘Datix 2009 & Risks’ system. This was necessary to enable the system to be upgraded to the DatixWeb Risk Register module; this took place in January 2015.Training is currently underway with over 100 users of this module to enable the creation and maintenance of NHS Fife Risk Registers in the updated system.

Initial user feedback is very promising.

Other Datix Related Information:

LearnPro:

We have designed a new LearnPro module for Datix Incident Reviewers which is now available via the main content site and we are currently reviewing our Reporter LearnPro module. Two additional modules are in development - one for Risk Handlers and one for staff wishing to create reports via DatixWeb.

Newsletter:

The Risk Management Team publishes a weekly Datix newsletter. It contains information on system changes and improvements for users – we regularly receive and respond to feedback – over 90 issues have been published and we have now introduced an Intranet based Datix Discussion Forum which has registered over 1300 views in the last 12 months.

Appointment of Datix Administrator:

A Datix Administrator has recently been appointed to support the further development of the Datix system and to manage the large number of user accounts and data which have increased particularly since the rollout of DatixWeb. The post holder will provide more in depth technical knowledge and will assist us to further exploit the potential and expand the efficiency and functionality within the system to improve patient and staff safety.

Datix Work Plan:

The Risk Management Team has a detailed work plan for further development of the system extending into 2016; this contains more than 70 improvement actions.

7. Risk Management Training

During the period 2014-15, the Risk Management Team provided training input to a wide range of educational programmes including: All Datix modules, CHP Protected Learning events, In House Core Training, NurseInduction, Trainee Doctor Corporate Induction,Foundation Year 1 and 2, Leading Better Care, Mandatory ConsultantTraining and Adverse Event Reviews.

8. Health and Social Care Integration

The NHS Fife Risk Manager is working closely with Fife Council counterparts to develop the

risk management arrangements for the Integrated Joint Board. These include a risk

management strategy and a risk register for the Partnership as an Integration Authority.

A meeting was held on 2 March2015 with the Director of Health and Social Care to agree

the process and a furtherworkshop session isscheduled for 18th March 2015.

9. Risk andControl Evaluations (RACEs)

The RACEs tool was developed by Internal Audit to be a guide to support the assessment of controls which mitigate to an acceptable level, key risks and control weaknesses that result in risk exposure. It is a key part of the internal auditfieldwork process. The tool is based heavily on Public Sector Internal Audit Standards (2013), section 2010 - Risk Management.

It was agreed that NHS Fife would assess itself against this tool. Appendix 1presents an assessment of NHS Fife’s current compliance status. Areas of non compliance and outstanding issues and required actions are outlined and will be reflected in the risk managementwork plan for 2015-16.

10. RECOMMENDATIONS

The Audit & Risk Committee is asked to:

• review and approve the report
• recommendany further actions/ reports it considers necessary

Chris Bowring

(Interim) Executive Lead, Risk Management, NHS Fife

Pauline Cumming

Risk Manager, NHS Fife

13 March 2015

Appendix 1

[1] Aberdeen Royal Infirmary. Short-life Review of Quality and Safety. Healthcare Improvement Scotland. December 2014.

A rapid review of the Safety and Quality of care for Acute Adult patients in NHS Lanarkshire. Healthcare Improvement Scotland. December 2013.

The Vale of Leven Hospital Inquiry Report. Scottish Government. November 2014.