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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