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					                                                                                              INTERNAL AUDIT ACTIONS UPDATE (AUGUST 2009)                                                            Agenda Item 16.3 - Appendix 1


Title of report     Grading   Recommendation                                                  Original Management Response                                 Responsible Officer        Due Date       Update as at 18 August 09



                                                                                          Agreed.
Financial Systems             User Accounts (Cedar)                                       HR will be reminded of the importance of notifying
                                                                                                                                                                                                     Payroll log identifying leavers is available on the shared Drive between HR
Healthcheck            1      HR should notify the finance department of any leavers, to Finance of all leavers. In addition the physical security             HR Manager             Complete
                                                                                                                                                                                                     and Finance.
(August 2008)                 ensure that access to Cedar is disabled in a timely manner. of the buildings and the IT system should ensure that
                                                                                          this remains a low risk.


                              Recharge for personal use of mobile phones                      Noted.
                              NHS QIS should consider changing existing practices and         At the current level of reclaim of income management
Financial Systems
                              ask staff to repay the VAT incurred for personal use of work    does not believe it is appropriate to change current
Healthcheck            2                                                                                                                                  Acting Head of Finance      Complete       Will be kept under review.
                              mobile phones. This would ensure that NHS QIS is in line        practice.                                 This will be
(August 2008)
                              with HMRC guidance and that HMRC received the correct           reviewed regularly. If the level becomes significant, the
                              levels of VAT payments.                                         policy will be reviewed and amended accordingly.

                              Payroll Monitoring
                              NHS QIS should continue to monitor the quality of the work /    Agreed
Financial Systems             information provided by NSS, informed by the review of          This will be regularly monitored as part of the SLA
Healthcheck            2      NSS Payroll Services. Once the Acting Head of Finance is        monitoring process, with particular attention being given   Acting Head of Finance       In place      The process continues to be monitored on an ongoing basis.
(August 2008)                 satisfied that the quality of the work has developed to a       to payroll.
                              consistent standard the frequency and scope of the reviews
                              could be reduced.
                                                                                                                                                                                                     At the Executive Team meeting on 22 October 2008 it was agreed that each
                              Operational risk registers                                                                                                                                             Directorate could make its own arrangements regarding the level of register
                              In our view, directorate risk registers or PIDs should be                                                                                                              required (i.e. Directorate and/or Unit level) but that DMTs would be required
                              capable of capturing the vast majority of significant                                                                                                                  to consider the Strategic (corporate) Risk Register on a quarterly basis and
                              operational risks.                                                                                                                                                     that any risks identified by DMTs with a potential organisation-wide impact
                              Management should therefore review the requirement to                                                                                                                  should be fed into the CGRM Implementation Team for consideration and
                              maintain operational risk registers.                           Executive Team will consider the revised risk register,                                                 onward discussion with the Audit Committee where appropriate. A quarterly
Risk Management
                       3      If operational risk registers are required, these should be    the level of registers required and the associated                    ET                  Oct-08        reporting cycle has also been introduced, demonstrating the stages at which
(August 2008)
                              developed in line with the Risk Management Strategy. They delegation.                                                                                                  the Risk Register is reviewed by DMTs, the CGRM Implementation Team, the
                              should then be subject to regular review at directorate team                                                                                                           Executive Team and the Audit Committee.
                              meetings and updated to ensure that the registers continue
                              to be effective in achieving operational objectives.
                              If operational risk registers are no longer required, the Risk
                              Management Strategy should be updated to reflect this.

                                                                                                                                                                                                     1. Awareness-raising in relation to Clinical Governance and Risk
                              Staff Awareness / Induction                                                                                                                                            Management has been identified as an action for the CGRM Implementation
                                                                                                                                                       1. Head of Finance and                        Team.
                              1. We recommend that NHS QIS establish risk awareness
                                                                                                                                                       Clinical Governance and                       2. Incorporated into new induction process
                              sessions to support the launch of the Risk Management
                                                                                                                                                           Risk Management                           3. This is being actioned as part of development of the new corporate /
                              Strategy.                                         2. HR should 1. Agreed.                                                                          1. March 2009
Risk Management                                                                                                                                         Implementation Team.                         governance section of the intranet.
                       3      ensure that sufficient instruction and guidance is provided to 2. Agreed. This will form part of the new induction                               2. March 2009 3.
(August 2008)                                                                                                                                               2. Learning and
                              staff in relation to risk management as part of the induction procedures.                                       3.Noted.                          December 2009
                                                                                                                                                        Development Manager.
                              process.                      3. The Risk Registers should be
                                                                                                                                                          3. Executive Office
                              made available to staff through the new Intranet site
                                                                                                                                                          Business Manager.
                              (MOLE).



                              Role and responsibilities of the Clinical Governance
                              and Risk Management Implementation Team
Risk Management
                       2      We recommend that the Risk Management Strategy is                Agreed. Being actioned.                                    Acting Head of Finance   Sept / Oct 2008   In place
(August 2008)
                              updated to include the role and responsibilities of the Clinical
                              Governance and Risk Management Implementation Team.



                              Risk Assessment Form
                              1. We recommend that the Risk Assessment Form is                1. Agreed.                                                    1.Head of Finance
                                                                                                                                                                                   1. August 2008
Risk Management               included in the Risk Management Strategy.                       2. Agreed. All documentation in relation to risk            2. Director of Patient
                       2                                                                                                                                                            2. November      In place
(August 2008)                 2. In addition, the Risk Assessment Form should be updated      management will be reviewed by the CGRM                     Safety & Performance
                                                                                                                                                                                        2008
                              so that risks may be escalated to directorate risk registers,   Implementation Team.                                             Assessment
                              rather than the corporate risk register, if appropriate.
Title of report   Grading   Recommendation                                                  Original Management Response                                Responsible Officer        Due Date      Update as at 18 August 09




                            Corporate Risk Register and Action Plan
Risk Management             As agreed, management should update the corporate risk                                                                     CGRM Implementation                       In place. A workshop to refresh the Risk Register has been scheduled for 15
                     4                                                                      Agreed.                                                                                 Sep-08
(August 2008)               register in the new format as proposed at the risk workshop                                                                      Team                                September 2009.
                            held on 8 August 2008.




                            Directorate Risk Registers
                            In line with NHS QIS risk management procedures,                Agreed. Executive Team will consider the revised risk
Risk Management
                     4      directorate risk registers should be in place for all           register, the level of registers required and the                 Directors            Nov-08        See item 4 above
(August 2008)
                            directorates. In addition, these should be laid out in the      associated delegation.
                            same format as the corporate risk register




                            Scottish Health Council (SHC) risk register
                            Once the SHC review has been concluded and its findings
Risk Management                                                                     Accepted, subject to outcome on independent review of
                     3      have been reported, the NHS QIS Board should consider                                                                               TBC                  TBC         Ongoing
(August 2008)                                                                       SHC
                            whether risk management monitoring arrangements for SHC
                            should form part of the future governance framework.


                            Risk Tolerance
                            NHS QIS should consider identifying its risk appetite for                                                                 Clinical Governance and
Risk Management                                                                             To be considered by the Clinical Governance and Risk
                     3      each risk on the risk register. This would allow the                                                                          Risk Management          Nov-08        This will be considered as part of the Risk Workshop on 15 September 2009.
(August 2008)                                                                               Management Implementation Team
                            organisation to prioritise its resources according to the level                                                            Implementation Team
                            of risk tolerated.
                            Lack of Clarity Regarding CommitteeResponsibilities
                            Quarterly meetings should be held between the Chair of the      Annual reports will be trialled for 2008/09 for each of
                            Clinical Governance & Quality Assurance Committee and           the committees. Deadline October 2009.
Corporate                                                                                                                                             Eleanor Lewis, Director of
                            the Chair of the Audit Committee. These meetings can be
Governance                                                                                                                                              Planning & Resource
                     2      used to discuss current and proposed work programmes of         Executive Teams view is that quarterly meetings are                                     Oct-09       In progress
Review (January                                                                                                                                             Management
                            both committees thus ensuring no duplication of work and        too frequent and suggest 6 monthly (in April and
2009)                                                                                                                                                       (coordinator)
                            enhanced understanding of roles and remits. Annual              October) would be more appropriate.
                            reports should be produced by each committee for the
                            Board.



Corporate                   Monitoring Committee Performance                                                                                                                                     The Board Development questionnaire (Board Effectiveness Tool) is currently
Governance                  NHS QIS should supplement its performance reporting             A Board Effectiveness tool is being completed in the                                                 being completed by Board membersand will be used to inform future
                     3                                                                                                                                     Anne Lumsden             Sep-09
Review (January             arrangements with regular appraisal of the effectiveness of     summer.                                                                                              development actions as part of the Board Development event in October
2009)                       the Board, committees and members                                                                                                                                    2009.



                            Engagement with the Scottish Health Council                                                                                                                          The draft action plan has been submitted to SGHD. In relation to
                            There exists further opportunities for NHS QIS to develop its                                                                                                        governance, it reflects discussion by the NHS QIS Board on 30 April where
                            working relationship with the Scottish Health Council and                                                                                                            greater integration was identified as its preferred option. The PSRB allows
                                                                                            Following discussion at the Board meeting on 26
                            ensure that opportunities for joint working are fully                                                                                                                for this post set up of HIS.
Corporate                                                                                   February 2009, two groups will be set up – a joint staff
                            developed.                                                                                                               Eleanor Lewis, Director of Action Plan to
Governance                                                                                  team to lead the development of the action plan, and in
                     2      We appreciate that the findings of the independent review of                                                               Planning & Resource     SGHD by 29 May
Review (January                                                                             parallel, joint discussions involving members of SHC
                            SHC may lead to changes in the relationship between NHS                                                                        Management                2009
2009)                                                                                       and NHS QIS Board members to consider governance
                            QIS and SHC. Governance arrangements should be
                                                                                            issues.
                            considered as part of any proposed changes to ensure
                            effective joint working.
Title of report   Grading   Recommendation                                                    Original Management Response                                  Responsible Officer     Due Date   Update as at 18 August 09



                            Remits and Job Descriptions for the Executive Team
Corporate                   NHS QIS should review and refresh the job descriptions and
Governance                  remits of its directors. Through a regular programme or    Job descriptions will need to be refreshed in advance                                                   The Executive Team has begun a process to review job discriptions and
                     3                                                                                                                                        Chief Executive        Mar-10
Review (January             review and refreshment NHS QIS will ensure that the duties of the set up of Healthcare Improvement Scotland                                                        corporate responsibilities (August 09).
2009)                       and responsibilities of the management team continue to
                            remain in line with the strategic objectives of the Board

Corporate                   Governance Framework
Governance                  NHS QIS must finalise, approve and embed this framework                                                                        Adrian Masson, Head of              Draft Framework approved by the Audit Committee in June 09 and copies
                     2                                                                Agreed                                                                                        Complete
Review (January             to ensure it can demonstrate compliance with the Scottish                                                                       Corporate Secretariat              provided to all Board members.
2009)                       Government’s guidance


                                                                                              Agreed. We have had a technical difficulty with our
                            Reflecting the True Costs of Projects
Strategic and                                                                                 time recording software that was not in our gift to
                            NHS QIS should ensure that project costing captures the full
Operational                                                                                   resolve. We are now making progress with this and            Director of Planning &              Refreshed commitment to time recording by Directors. 100% compliance
                     4      cost of all resources to be used. This will increase                                                                                                    Dec-09
Planning Review                                                                               hope to reinforce the need for robust data from units.       Resource Management                 expected by August.
                            understanding of the cost of project work to the Board and
(November 2008)                                                                               We will begin utilising this data during 2009 in order to
                            aid prioritisation and decision making.
                                                                                              cost up our activities more appropriately.



                                                                                              Agreed. We are currently reviewing our organisational
                            Staff Objectives
                                                                                              structure to ensure that it fits with our strategic
                            NHS QIS must clearly link strategic objectives to
                                                                                              direction. Once this is complete we will ensure that we
                            departmental plans, section plans and individual staff plans.
                                                                                              have clarity of fit and purpose at unit and individual
                            This helps staff to understand the key strategic objectives
                                                                                              level.                                  The results of the
Strategic and               and how their role delivers against these objectives.
                                                                                              latest staff survey were presented to Partnership                                                Work is currently progressing. For example, in the Guidance & Standards
Operational                 The Board should also consider how it can continue to
                     3                                                                        Forum on 12th February 2009 and will be presented to               Directors          Ongoing    Directorate each unit has identified its three key issues from the staff survey
Planning Review             promote and raise the profile of its strategic objectives
                                                                                              Staff Governance Committee on 4th March. The results                                             and developed an action plan.
(November 2008)             internally. The Board has recently published an internal
                                                                                              are also being discussed by Directorates. From this,
                            document, ‘The Way Ahead’, highlighting the strategy. It is
                                                                                              action plans will be developed and fulfilled to target
                            important that the Board follows up this work and continues
                                                                                              areas of weakness in the latest results.
                            to promote and raise the profile of its strategic aims at every
                                                                                              Agreed. We are progressing with our internal
                            opportunity.
                                                                                              communications strategy.



                            Detailed Reporting Arrangements
                            The Board must ensure that the proposals highlighted within
Strategic and
                            the August 2008 paper are implemented and monitored.
Operational                                                                             Agreed. More Planning capacity will enable us to
                     3      NHS QIS should seek to improve communication links                                                                                  Unit Heads          Ongoing    Work in progress
Planning Review                                                                         achieve this.
                            between areas within NHS QIS during the planning stages
(November 2008)
                            of projects. This will ensure that sufficient resources and
                            timeframes are reflected within project proposals.


                            Linking Existing Projects to NHS QIS Priorities
                            The Board must establish an effective project matrix
                            arrangement to enable it to identify the strategic priorities
                            within existing workloads. NHS QIS must be prepared to
                            take tough decisions regarding existing projects and planned      The outcome of the Programme Board deliberations
Strategic and               outputs. NHS QIS must review projects and proposed                will be reported to the full Board on the 26th February
Operational                 projects and prioritise these against objectives. Where a         2009. Subsequently, the role, remit and protocols            Director of Planning &
                     4                                                                                                                                                              Ongoing    Work in progress
Planning Review             project is found to not be a priority or not delivering against   around the work of the Programme Board will be               Resource Management
(November 2008)             strategic objectives the Board must be prepared to stop the       reviewed to ensure that it is effective and fit for
                            project.                        It is important that the Board    purpose.
                            clearly outlines the rationale for prioritising projects. By
                            doing so the decisions will be demonstrable to staff and it
                            will encourage a culture of working that is driven by the
                            strategic objectives.

Strategic and                                                                          The Theme Coordinators role if being reviewed as part
Operational                 Theme Co-ordinators                                        of the Organisational Structure discussions and the                                                     Role has been reviewed and will be picked up under Programme Working
                     2                                                                                                                                           Directors          Mar-09
Planning Review             NHS QIS should review the role of the theme co-ordinators. move towards Programme working and more effective                                                       and Knowledge Management.
(November 2008)                                                                        Knowledge Management support.
Title of report    Grading   Recommendation                                                    Original Management Response                                 Responsible Officer     Due Date   Update as at 18 August 09



                             Staff T&S Claims
                             The new electronic system due to be introduced in March           The introduction of eExpenses that commences on 1st
                             2009 should resolve most of these issues, as it will not be       March 2009 addresses four of the five points raised.
                             possible to submit electronic forms without completion of         Going forward they are therefore no longer an issue in                                          Managers are aware of their responsibilities with regard to expense claims, a
Travel and
                             mandatory fields and the authorisation system will be             respect of these items as they are dealt with in the                                            position that was reinforced with the introduction of eExpenses. This part of
Subsistence
                      2      inherent in the electronic process.                 The           system parameters.                  The second point        Acting Head of Finance   Complete   the process is now complete. In addition a review of the policy on Expenses
Claims (November
                             issue of claims processed without valid receipts / vouchers,      relating to receipts is similarly dealt with by eExpenses                                       will be carried out that should promote clarity in the manner in which
2008)
                             however, could still remain. Although this issue was noted        but it will still be possible to pass a claim not fully                                         expenses claims will be handled.
                             only for a very small proportion of claims tested,                supported by receipts where this is deemed acceptable
                             management should ensure that claims that do not have             in line with explanations provided.
                             valid receipts / vouchers are not processed.



Travel and                   Non-Staff T&S Claims
                                                                                               The second point of the five represents a potential
Subsistence                  Management should ensure that staff processing non-staff
                      2                                                                        control concern and is currently being investigated to      Acting Head of Finance    Mar-09    Work in progress
Claims (November             claims do not process those claims that do not fully comply
                                                                                               gain a better understanding of the cause.
2008)                        with procedures, in particular the authorisation signature.



                             Partnership Forum and Staff Governance
                             Recommendation at November 2007
                             Induction for Partnership Forum Members
                             1. An information pack should be produced for staff               Set up a small Partnership Forum subgroup to take
                                                                                                                                                                                               A pack has been developed for new members, a training session is held and
                             considering running as staff representatives;                     forward these actions. Follow Up as at Jan 09:
Follow Up Review                                                                                                                                                                               each new member has an induction meeting with Staff Side Chair. MOLE has
                   Medium    2. An induction pack should be provided to all new                Partially Complete. A small Partnership Forum                    Joint Chairs         Jun-09
(February 2009)                                                                                                                                                                                also been updated with job descriptions for the role of PF Representative and
                             members on election;                                              subgroup has been set up and work is underway to
                                                                                                                                                                                               an explaination of the work of Partnership Forum with FAQs.
                             3. A buddy/mentoring arrangement should be put in place           develop an information pack covering all aspects.
                             where, for example a staff representative might act as
                             buddy to a new representative from their directorate; and
                             4. Induction should occur on a timely basis.


                             Partnership Forum and Staff Governance
                             Recommendation at November 2007
                             Agreement for Staff Representatives                               The Partnership Forum Sub-Group will develop the
                             Staff representatives should circulate an agreement to the        staff representative agreement together with the                                                A pack has been developed for new members, a training session is held and
Follow Up Review             staff they represent at the beginning of their term recording     Induction Pack. This will be subject to ongoing                                                 each new member has an induction meeting with Staff Side Chair. MOLE has
                    Low                                                                                                                                      Partnership Forum       Jun-09
(February 2009)              what their role is and what staff can expect from them, for       monitoring. Follow Up as at Jan 09: Partially                                                   also been updated with job descriptions for the role of PF Representative and
                             example monthly update emails, and also what the                  Complete. This is under development for piloting with                                           an explaination of the work of Partnership Forum with FAQs.
                             representative expects from them in terms of issues raised.       the next Partnership Forum appointment.
                             An example should be provided in the induction pack and
                             tailored with the advice of the buddy/Employee Director.



                                                                                               NHS QIS will consider which commodities/ services
                             Procurement Review
                                                                                               would be appropriate to be on contract and will develop
                             Recommendation at June 2008
                                                                                               the processes to put this in place. Follow Up as at Jan                                         Use of contracts discussed with National Procurement in December 2008
                             Supplier Contracts
                                                                                               09: Partially Complete. NHS QIS is currently trying to                                          and more recently with the members of the Special Health Board's Working
                             A contract should be held with all regular suppliers and
                                                                                               seek advice from NHS National Procurement on the              Head of Corporate                 Group. The Head of Corporate Secretariat was seconded to the Scottish
Follow Up Review             contractors with whom NHS QIS place reliance for the
                   Medium                                                                      use of Terms and Conditions. There is a particular           Secretariat / Head of     TBC      Governement until April 09 but has now returned to QIS and is currently
(February 2009)              support of key business systems and material sources of
                                                                                               issue with universities and intellectual property rights.          Finance                      undertaking a review of NHS QIS' approach to procurement which will include
                             supply.
                                                                                               Once resolved, terms and conditions will need to be                                             consideration of the appropriate use of contracts, including terms and
                             NHS QIS should ensure that the terms and conditions
                                                                                               introduced as new contracts are negotiated. The                                                 conditions.
                             agreed with suppliers fully reflect their organisational needs,
                                                                                               greater use of contracts will be a progressive and long
                             as well as addressing relevant legal requirements.
                                                                                               term action.


                             Data Migration
                                                                                               Further data cleansing requirement already highlighted
                             Recommendation at September 2007
                                                                                               as being required and underway. Follow Up as at Jan
Follow Up Review             Standing Data
                   Medium                                                                      09: Partially Complete. There is a major exercise      Christine McLaughlan           Apr-09    Major exercise complete but will remain ongoing
(February 2009)              We would recommend that a detailed review is undertaken
                                                                                               currently underway to eliminate duplicate suppliers
                             of the shared pool of Standing Data on E Financials in order
                                                                                               shared by all Boards.
                             to remove any duplicate entries.
Title of report    Grading   Recommendation                                                    Original Management Response                              Responsible Officer   Due Date   Update as at 18 August 09



                                                                                               A process has now been agreed with the Clinical
                             Project Management Arrangements - Blood                           Governance and Quality Assurance Committee and is
                             Transfusion Standard                                              being rolled out across all Directorates. This is being
                             Recommendation at November 2006                                   implemented in 2008/09.The Clinical Governance and
Follow Up Review                                                                                                                                                                          First exception report to be presented to Clinical Governance and Quality
                      -      NHS QIS should introduce a method of internal quality             Quality Assurance Committee will receive exception          Executive Team       Jun-08
(February 2009)                                                                                                                                                                           Assurance Group in September 2009.
                             assurance across the whole organisation, which would help         reports. This will help to highlight areas where
                             to maintain the level of quality of the projects, and also help   improvements are required. Follow Up as at Jan 09:
                             to identify methods of improvement and good practice              Partially Complete. This is being implemented across
                                                                                               the organisation.

				
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