Annual Report and Accounts 2012/13 - Royal Devon & Exeter Hospital

94 4. Our Governance
Royal Devon and Exeter NHS Foundation Trust
Annual Report and Accounts 2012/13
• The Trust’s self assessment process
for assessing compliance with Care
Quality Commission Regulations for
the period April 2012 to March 2013.
4.4 The Governance Committee is
chaired by a Non-Executive Director
and provides leadership to the
risk management process. The
Committee takes a comprehensive
oversight of the quality and safety
of care provided by the Trust and
provides assurance to the Board
of Directors. The work of the
Governance Committee is supported
by five key sub-committees:
• Integrated Safeguarding
Committee
• Clinical Effectiveness Committee
• Workforce and Diversity
Committee
• Safety and Risk Committee
• Engagement and Experience
Committee.
These five committees are
responsible for monitoring and
managing specific types of risk.
4.5 The Adverse Events Forum is
chaired by a consultant clinical lead
and reviews all adverse incidents,
Clinical Audits and Mortality and
Morbidity Reviews. The Incident
Review Group is chaired by the
Deputy Chief Nurse and Patient
Care and reviews all Serious
Incidents Requiring Investigation
(SIRI) and action plans.
Other specialist Groups led by a
Director or senior clinician include:
• Clinical Audit and Guidelines
Group
• Medical Devices Group
• Medicines Management Group
• Medical Gases Group
• Patient Safety Programme Group
• Radiation Safety Group
• Trust Infection Control and
Decontamination Assurance Group
• Drugs and Therapeutics
Committee.
5. Risk Identification
and evaluation
5.1 The Trust has a risk management
strategy which has been approved
by the Board of Directors and clearly
sets out the process for identifying
and managing risk. It incorporates
a standard methodology in which
risk is evaluated using a likelihoodconsequence
matrix. The roles
and responsibilities of staff in
managing risk are defined and key
posts highlighted. The strategy also
includes the governance reporting
structure and the terms of reference
of the Governance Committee and
all the committees reporting to the
Audit Committee and Governance
Committee.
5.2 The Board has developed a revised
Board Assurance Framework; it
focuses on risks, controls and
plans to address gaps in control
that might impact on the delivery
of the Trust's strategic objectives.
The highest strategic risk identified
is the failure to deliver the
recurrent annual £17 million Cost
Improvement Programme (CIP).
Controls and plans are in place but
the risk is not fully mitigated.
5.3 The Trust maintains a
comprehensive Corporate Risk
Register covering both clinical and
organisational risk. There are 33
current risks on the Corporate Risk
Register. All identified risks have
clear mitigation plans in place. Of
the Trust’s eight highest scoring
risks, four relate to a diagnostic test
ordering and result communication
system, one relates to storage of
medical records, one relates to
administrative staffing within one
area of the Trust, one relates to the
installation of a tracking system
for medical equipment and one
relates to the care of an individual
patient. These risks are assigned
to an appropriate executive lead
and manager who are responsible
for ensuring that the risk is
either eliminated or managed
appropriately. A robust system is in
place to monitor progress of action
plans. This is undertaken by both
the Head of Governance and the
Divisional Governance Groups to
ensure that risks are proactively
managed down to their end target
score. A detailed report is produced
by the Head of Governance to the
Safety and Risk and Governance
Committee each time they meet.
5.4 The Trust has Directorate-level
risk registers which feed into
the Corporate Risk Register. At
Directorate level, the risk registers
contain lower-level localised risks,
which can be managed by the
relevant Directorate. The Corporate