Nurses Day! - Birmingham Children's Hospital

SECTION FOUR
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Annual Governance Statement
Scope of responsibility
As Accounting Officer, I have responsibility for
maintaining a sound system of internal control that
supports the achievement of the NHS Foundation
Trust’s policies, aims and objectives, whilst
safeguarding the public funds and departmental
assets for which I am personally responsible, in
accordance with the responsibilities assigned to
me. I am also responsible for ensuring that the
NHS Foundation Trust is administered prudently
and economically and that resources are applied
efficiently and effectively. I also acknowledge my
responsibilities as set out in the NHS Foundation
Trust Accounting Officer Memorandum.
The purpose of the system of
internal control
The system of internal control is designed to
manage risk to a reasonable level rather than
to eliminate all risk of failure to achieve policies,
aims and objectives; it can therefore only provide
reasonable and not absolute assurance of
effectiveness. The system of internal control is
based on an ongoing process designed to identify
and prioritise the risks to the achievement of
the policies, aims and objectives of Birmingham
Children’s Hospital NHS Foundation Trust, to
evaluate the likelihood of those risks being
realised and the impact should they be realised,
and to manage them efficiently, effectively and
economically. The system of internal control has
been in place in Birmingham Children’s Hospital
NHS Foundation Trust for the year ended 31 March
2013 and up to the date of approval of the annual
report and accounts.
Capacity to handle risk
Leadership
The Board of Directors is responsible for the
management of key risks. Key risks are described
within the Board Assurance Framework which is
considered every month by the Board of Directors.
In addition, risks are clearly defined within the
reports presented to the Board by the Executive
Directors. This process is supplemented on a
quarterly basis when the self assessment of the
financial, activity and service risks is made for
submission to the independent regulator, Monitor.
The Trust’s Risk Management policies clearly set
out responsibilities for risk management within
the organisation. As Chief Executive Officer I
have overall responsibility and accountability
for risk management. This is shared with the
Executive Directors who are responsible for
ensuring that the risk management framework is
systematically implemented and developed across
the organisation. In addition they, through the Board
of Directors’ committee structure, are responsible
for providing assurance to the Board of Directors
that risk management continues to be an essential
element of all management systems and corporate
planning, as well as the setting of strategy and
objectives. The committees for 2012/13 included
the Quality Committee and the Finance and
Resources Committee, which are both chaired by
Independent Non-Executive Directors, with nonexecutive
and executive director membership.
The sub-committees which monitor risks to safety,
quality and workforce objectives include the Clinical
Risk and Quality Assurance Committee, the Non-
Clinical Risk Coordinating Committee, the Patient
Experience and Participation Committee and the
Strategic Workforce Committee.
Staff training and guidance
A range of risk management and information
governance training is provided to staff and there
are policies in place to describe their role and
responsibilities in relation to the identification
and management of risk. This includes an online
training resource for refresher training. This
ensures that risks are actively managed at all levels
of the organisation. The importance of feedback to
staff on incidents reported is stressed at all levels of
training.
changes have been made to mandatory training
related to medicines management, observation and
monitoring, and resuscitation.
Bespoke risk management training has also been
developed for Board members and directors to
enable them to fully understand their role and
responsibilities in relation to risk management.
The risk and control framework
The Trust’s risk management policies ensure that
risk management is embedded in the activities of the
organisation in a number of ways:
l Both Corporate and Directorate objectives are
risk assessed and inform the Board
Assurance Framework, which is reviewed
regularly by the Board of Directors and the
Audit Committee.
l The Trust has achieved level 3 compliance with
the NHS Litigation Authority (Clinical Negligence
Scheme for Trusts) Risk Management
Standards. This demonstrates not only that there
are clearly defined and embedded policies in
place to address risk but also that those policies
are monitored on an ongoing basis and that
action is taken when those policies are not
effective.
To ensure the quality of local management of
incidents, we deliver training (level 2) for all local
managers. This is an interactive session which
covers day-to-day management of risks at a
local level, investigation tips and techniques for
managing incidents and complaints and guidance
on how to carry out robust risk assessment and
how to use the risk register appropriately.
Level 3 ‘Risk Leaders’ training has been designed
for members of staff that need a high level of
expertise in risk management. The session is
focused on Root Cause Analysis techniques
and processes, includes some advanced risk
management techniques and introduces the role
and development of assurance frameworks.
Training implications are considered as part of
all Root Cause Analysis investigations. As a
direct result of learning from these investigations,
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l Risks to information are managed
through the use of the NHS Information
Governance Toolkit. The Trust’s policy provides
a documented mechanism for the immediate
reporting and investigation of actual or
suspected information security breaches/ losses
and potential ulnerabilities/weaknesses within
the Trust.
The Information Governance Toolkit
submissions and the annual plan to improve
compliance with the relevant standards is
approved and regularly reviewed by the
Regulatory Compliance Committee, which
reports to the Board via the Quality Committee.
Following a self-assessment and submission the
overall score against the Information
Governance Toolkit for 2012/13 was 82% and
graded Green (‘Satisfactory’).