Annual Report and Accounts 2012/13 - Royal Bournemouth Hospital

Financial AccountsThe risk and control frameworkIn compliance with statutory controls,the Foundation Trust has developed astandard matrix for measuring risk anddetermining the level of risk that canbe accepted at the key managementlevels within the organisation. Detailedguidance and advice on assessing,quantifying and managing risk iscontained within the FoundationTrust’s Risk Management Strategy (andassociated Risk Assessment Policy andProcedures). Under the Strategy, GeneralManagers and Directors are responsiblefor maintaining Directorate Risk Registersand for bringing significant risks to theattention of the Clinical Governance &Risk Committee and/or appropriate subcommitteesof the Foundation Trust’sBoard of Directors. In turn the subcommitteeswill bring important mattersto the attention of the Board of Directors.The Foundation Trust continuouslymonitors risk control systems in placeand utilises the assurance frameworkprocess to monitor, develop, implement,demonstrate and promote continuousimprovement and learning. Theeffectiveness of the assurance frameworkand its application has been reviewed bythe Healthcare Assurance Committee andverified by Internal Audit and the AuditCommittee.There is a strategic co-ordinatedapproach to the Trust’s clinical auditactivities to ensure that the clinical auditcycle is complete and therefore leadsto improvement in patient care. Thereis a Consultant lead for Clinical Audit, aClinical Effectiveness Manager who ispart of the Clinical Governance Team, andClinical Audit leads in each directorate.An annual audit plan is developed withineach directorate with audits prioritised inrelation to national requirements, Trustobjectives, contractual and statutoryduties and local requirements. Toprovide focus on the audit priorities andcompletion of the plan the directorateshave identified a clinical audit leadconsultant, which has a role profile. Thisapproach has been approved by theTrust Management Board. The committeefor coordinating the Trust’s strategyfor clinical effectiveness and clinicalaudit is the Clinical Governance & RiskCommittee, which provides oversightthat systems are in place and used tosupport, monitor and disseminate auditwithin the Trust. The Clinical Governanceand Risk Committee formally reports tothe Healthcare Assurance Committeeand recommends approval of the ClinicalAudit Programme prior to submission tothe Trust Management Board and theBoard of Directors. Directorates reviewtheir progress against the audit plan ona quarterly basis and provide a reportfor the Clinical Governance and RiskCommittee. Progress against the annualaudit plan is reviewed quarterly and aclinical audit report presented to theHealthcare Assurance Committee andthe Trust’s Board as part of the ClinicalGovernance Quarterly report. A quarterlyreport is also provided to the AuditCommittee. The Trust has recognisedover the last year that the processes canbe further improved through securingmore senior clinical time within theleadership of clinical audit and is currentlyimplementing this new process.In line with statutory requirements, theBoard of Directors has reviewed theFoundation Trust’s principal corporateand strategic objectives and identifiedmitigating strategies for any risks tothe delivery of those objectives viathe Assurance Framework process.The development of the assuranceframework has involved considerationof all objectives (strategic, quality,financial, corporate, business, clinical,human resources etc.) and all risks. Inaddition, a comprehensive review hastaken place of the Trust’s committeestructure and its ability to provide thenecessary assurance to the Board insupport of the assurance framework. Theframework is specifically linked to theTrust’s strategic objectives and to theregulatory requirements of Monitor andthe Care Quality Commission. Within theAssurance Framework, principal risksare identified and key risk controls put inplace to provide necessary assurancesAnnual Report and Accounts 2012/13 7