Docstoc

Policy on clinical risk assessment tools

Document Sample
Policy on clinical risk assessment tools Powered By Docstoc
					                                                                                                                   Code No: CP5
                                                                                                                 Issue number: 2



           Policy on clinical risk assessment tools
    Lead Executive                                        Medical Director
                                                          Clinical Governance Manager / Risk Manager
    Author with contact details
                                                          01244 364198
    Responsible Committee/Sub
                                                          Clinical Standards Sub Committee
    Committee
    Document approved by & date:                          Clinical Standards Sub Committee - May 2009
                                                          Clinical Risk Assessment Trainer
    Document consultation:
                                                          NHSLA Compliance Team (Task and Finish Group)
    Patient and Public Involvement
    (outline any PPI input into policy and
                                                          PPI representation at Clinical Standards Sub Committee
    associated impact on service users
    and carers)
    What type of document is this (delete
                                                          Policy
    as appropriate)
    Document applicable to
     (Identify by location and staff                      All staff working in clinical areas within the Trust
    groups):
                                                          The policy has been written and updated to ensure that
    If new document, reason for
                                                          the Trust is compliant with the NHS Litigation Authority risk
    development:
                                                          management standards 2009.
                                                          This policy outlines which assessment tools have been
                                                          approved for use within the Trust, and the process for
                                                          approving new assessment tools. It links with the CPA
    Synopsis outlining document aims:
                                                          Policy, and documents the training requirements for those
                                                          inpatient clinical risk assessment tools that are routinely
                                                          used in the Trust.
    Implementation Date:                                  May 2009
    How will the implementation of this
    document be monitored and                             For NHSLA monitoring standards see page 2.
    reviewed
    Review Date (default 2 years1):                       May 2011
                                                          HR6 Trust-wide learning and development requirements
    Document to be read In conjunction                    including the training needs analysis (TNA)
    with:                                                 CPA Policy
                                                          Admission to and Transfer/Discharge from Hospital Policy
                                                          Some financial resources could be identified with regard to
    Financial resource implications of                    purchasing licenses for use of risk assessment tools within
    this document and how these are                       the Trust. Any resource issues will be reported from
    going to be addressed:                                Clinical Standards Sub Committee to Finance,
                                                          Performance and Planning Committee.
    Is this document carried out wholly
    or in part by contractors, or
    organisations with which the Trust                    N/A
    has a service level agreement, and if
    so state the relevant contractor

1
 Check with Clinical Governance/Risk Manager to ensure that there is not an external requirement that determines review date
________________________________________________________________________________________________________________
Clinical Governance Manager / Risk Manager                    Page 1 of 10                                               27 October 2009

O:\Policy Support Officer\Policy System\2. Current online\CP5 Clinical risk assessment tools Issue 2.doc
Document Change History (changes from previous issues of policy (if appropriate):

  Issue
                 Page             Changes made with rationale and impact on practice                                 Date
 Number
                            Change to Medical Director duties so that approval, review and
      2             5                                                                                            5 May 2009
                            monitoring processes are incorporated
                            Changes to Research & Effectiveness Manager duties as
      2             6                                                                                            5 May 2009
                            maintenance of the approved list role was previously absent
                            Appendix 1: hyperlink inserted so that potentially outdated tools
      2             7                                                                                            5 May 2009
                            are not included
                            Change to process for monitoring compliance with minimum
      3             5       requirements to reflect monitoring of all other risk assessment                      18 May 2009
                            tools
                            Changes to responsibility of Divisional Managers to reflect
      3             6                                                                                            18 May 2009
                            monitoring of all other risk assessment tools.
                            Appendix 2: Rows added to table for date of approval and
      3             8                                                                                            18 May 2009
                            monitoring/audit arrangements

NHSLA monitoring - Clinical Risk Assessment (1.2.7)

                                     Monitoring                    Monitoring                Frequency of
                                                                                                                    Lead
                                     Compliance                    Committee                    Review
     Minimum
                                          How                           Who                       When              Who
   Requirements
                                                                                           Minimum 2 yearly
                              Will be reviewed as
                                                                                           or when changes
                              part of the update of
                                                                                            to the policy are
                              the policy and will take
Duties                                                                 WOD                    made due to       Policy author
                              account of changing
                                                                                              guidance or
                              roles, organisational
                                                                                             organisational
                              structure and tasks.
                                                                                                changes.
Organisation’s
expectations in
relation to staff                                                                                               Learning and
                              Mandatory training
training as                                                            WOD                      6 monthly       Development
                              report.
identified in the                                                                                                 Manager
training needs
analysis
                                                                                                                Policy author /
                              Register – when new
                                                                                                                Research and
Tools/processes               tools become                             CSSC                       Annual
                                                                                                                Effectiveness
authorised for use            available
                                                                                                                    Team
within the
                                                                                                                   Clinical
organisation
                              Audit                                    CSSC                       Annual         Governance
                                                                                                                  Manager




________________________________________________________________________________________________________________
Clinical Governance Manager / Risk Manager          Page 2 of 10                                   27 October 2009

O:\Policy Support Officer\Policy System\2. Current online\CP5 Clinical risk assessment tools Issue 2.doc
CONTENTS

1.0       Introduction/background ............................................................................................................. 4
2.0       Tools/processes authorised for use within the organisation ....................................................... 4
2.1       Organisation’s expectations in relation to staff training as identified in the training needs
          analysis ....................................................................................................................................... 4
2.2       Process for monitoring compliance with minimum requirements ................................................ 5
3.0       Duties and responsibilities .......................................................................................................... 5
4.0       Training ....................................................................................................................................... 6

Appendix 1 - Tools/processes authorised for use within the organisation.............................................. 7
Appendix 2 - Risk Assessment/Outcome Tool Template for Approval Process ..................................... 8
Appendix 3 - Equality and diversity/Human Rights impact assessment ................................................. 9




________________________________________________________________________________________________________________
Clinical Governance Manager / Risk Manager          Page 3 of 10                                   27 October 2009

O:\Policy Support Officer\Policy System\2. Current online\CP5 Clinical risk assessment tools Issue 2.doc
1.0     Introduction/background
Clinical risk assessment is integral to patient safety within the Trust. In order to ensure that staff are
undertaking appropriate risks assessments, the Trust has developed a process for approval of risk
assessment tools for use within the Trust. The approval process is based on assessment of key
elements such as; what the tool is used for, whether the tool is valid and reliable, whether there are
any copyright issues for the Trust, if there are any training issues and how staff can access the tool.

The process was developed following a baseline assessment, undertaken in November 2006, across
the Trust of the number and types of risk assessment tools that were in use. This enabled the Trust to
review and approve a core set of tools for use in clinical practice, which was issued to staff in January
2007.

The Trust also monitors whether risk assessment tools identify risks, which are then used to inform
treatment/care plans and subsequent interventions.

2.0     Tools/processes authorised for use within the organisation
Staff should only use assessment tools that have been approved for use within the Trust. Appendix 1
directs staff to the Trust Intranet site where approved tools are located, so as additional tools are
developed/approved, the list will be updated. This updated list will be communicated to staff via Trust
communications bulletins issued via PN Brief.

For all new assessment tools
The following process must be undertaken to ensure approval:
         If an assessment tool is being considered for use within the Trust, the service must contact
           Research and Effectiveness Manager for advice and guidance with regard to utility, validity,
           reliability, training, copyright and access issues
         Individuals must complete the template in appendix 2 and submit to Clinical Standards Sub
           Committee to be included on the next meeting agenda
         The individual/service representative must attend the Clinical Standards Sub Committee
           meeting to present the tool and answer any queries from the Sub Committee members
         If the tool is approved, the list of assessment tools for use within the Trust is updated and
           staff informed via PN Briefing.

Staff must ensure that any identified risks as a result of clinical assessment tools are adequately
recorded and used to inform the treatment/care plan.

2.1     Organisation’s expectations in relation to staff training as identified in the training
needs analysis
The Trust provides clinical risk assessment training for specific staff groups, as part of its corporate
induction and mandatory training programme, which outlines the minimum training requirements for
staff. This provides the Trust with assurance that identified staff are competent in relation to clinical
risk assessment and the management of clinical risk.

When assessment tools are being considered for approval within the Trust, the Clinical Standards Sub
Committee reviews any additional training requirements for implementation of the assessment tool.
Where training is identified, Clinical Standards Sub Committee will liaise with Workforce and
Organisational Development Sub Committee to ensure that any training programme is included in the
Trust Training Needs Analysis, which informs the review of the corporate induction/mandatory training
programme.

If no training needs are identified, but guidance is available, this will be issued to staff via the intranet
and PN Brief.




________________________________________________________________________________________________________________
Clinical Governance Manager / Risk Manager          Page 4 of 10                                   27 October 2009

O:\Policy Support Officer\Policy System\2. Current online\CP5 Clinical risk assessment tools Issue 2.doc
2.2       Process for monitoring compliance with minimum requirements
           A register of all assessment tools (including risk assessments tools) approved within the
             Trust is maintained by the Research and Effectiveness Team.
           The Clinical Standards Sub Committee approves and reviews updates to tools as
             appropriate when required.
           Completion of risk assessment tools in use within inpatient areas are assessed within the
             Trust-wide annual inpatient ward audit by the Clinical Audit Team. The clinical governance
             manager will present an audit report to the clinical standards sub committee which will
             include analysis of compliance with the risk assessment tools, identifying areas for action,
             which will be taken forward by the sub committee.
           Services are responsible for monitoring the use of all other assessment tools. Support can
             be sought from the Research and Effectiveness Team.
           Assurance regarding any training in the use of clinical risk assessment, and its subsequent
             monitoring, is confirmed with Clinical Standards Sub Committee upon approval [who will
             liaise with Workforce & Organisational Sub Committee to ensure inclusion in the Trust
             Training Needs Analysis if appropriate] or identified in the Trust wide Policy on Learning
             and Development requirements.

3.0       Duties and responsibilities

Chief Executive
As accountable officer, the Chief Executive must ensure that responsibility for clinical standards,
including safe systems with regard to use and competence in clinical risk assessment is delegated to
an appropriate executive lead, as outlined in the executive portfolios.

Medical Director
The Medical Director has responsibility to ensure there is an appropriate and effective clinical
governance system in place with regard to clinical risk assessments tools and their use within the
Trust.
Also as chair of the Clinical Standards Sub Committee, specific duties for the Medical Director include:
        Ensuring that approval, review and monitoring of clinical risk assessment tools within the
           Trust is included on Clinical Standards Sub Committee annual work plan and reported to
           Governance & Risk Management Committee on a bi-monthly basis through sharing of the
           Sub Committee’s work plan
        Ensure that there is a process of approval of Clinical risk assessments tools to include
           scrutiny as per Appendix 2
        Ensure that there is a register of all assessment tools (including risk assessments tools)
           approved within the Trust and that this is maintained, monitored and reviewed by Clinical
           Standards Sub Committee members.

Divisional Managers
        Ensure appropriate representation at Clinical Standards Sub Committee meetings
        Ensure that staff are aware of which assessments tools have been approved for use within
           the Trust
        Ensure that any tools which have not been approved for use within the Trust are not
           utilised within their clinical area and are presented at Clinical Standards Sub Committee for
           approval, if appropriate
        Ensure that any assessment tools identified as having a cost or copyright implication for the
           Trust are appropriately resourced, if being used within the clinical service
        Ensure that staff are enabled to complete any training requirements to ensure that staff are
           competent in clinical risk assessment and management of clinical risk, including the use of
           approved clinical risk assessment tools;
        Provide in-house peer support/training to any staff members who inform them that they do
           not feel competent to use any of the approved assessment tools within the Trust


________________________________________________________________________________________________________________
Clinical Governance Manager / Risk Manager          Page 5 of 10                                   27 October 2009

O:\Policy Support Officer\Policy System\2. Current online\CP5 Clinical risk assessment tools Issue 2.doc
              Participate in relevant clinical audits with regard to clinical risk assessment and the
               management of clinical risk.
              Participate in relevant monitoring audits with regard to all other risk assessment tools.

Staff
              Staff must comply with this policy and only use approved clinical assessment tools
              If staff members do not feel competent to use any approved assessment tool they must
               inform their manager immediately.

Research and Effectiveness Manager
       Provides support to services with regard to researching the requirements for review, as
         outlined in Appendix 2.
       Maintain the register of approved clinical assessment tools within the Trust and present
         regularly to Clinical Standards Sub Committee
       Liaise with Communications Teams regarding dissemination of approved clinical
         assessment tools.

Clinical Governance Manager
Ensure that clinical audits are undertaken to monitor the implementation of this policy, as outlined in
the annual clinical audit plan

Communications Team
Ensure that divisional staff are enabled to access information with regard to approved/newly approved
clinical assessment tools.

4.0    Training
For all Trust training please refer to policy HR6 Trust wide policy on learning and development
requirements http://www.cwp.nhs.uk/GuidancePolicies/Policies/Humanresources/Pages/default.aspx




________________________________________________________________________________________________________________
Clinical Governance Manager / Risk Manager          Page 6 of 10                                   27 October 2009

O:\Policy Support Officer\Policy System\2. Current online\CP5 Clinical risk assessment tools Issue 2.doc
                                                                  Appendix 1

                          Tools/processes authorised for use within the organisation

Risk and Assessment Tools accepted for use by Clinical Standards Sub Committee – those
highlighted have to be paid for (contact pat.mottram@cwp.nhs.uk).

Staff must only use the Risk Assessment and Assessment Tools that have been approved by the
Trust. It is also necessary to have had the appropriate training for each individual tool. The up-to-date
list of approved tools can be found at:

http://nww.cwp.nhs.uk/academicunit/assessmenttools/Pages/AssessmentTools.aspx




________________________________________________________________________________________________________________
Clinical Governance Manager / Risk Manager          Page 7 of 10                                   27 October 2009

O:\Policy Support Officer\Policy System\2. Current online\CP5 Clinical risk assessment tools Issue 2.doc
                                                                  Appendix 2

                        Risk assessment / outcome tool template for approval process


Name of Risk Assessment/Outcome Tool
(Please indicate if risk or outcome tool): _________________________________________________

Division: ____________________________

Service area(s) where this tool is used with name of individual submitting and contact details




Rationale for use, including how this will be used to improve patient care




Please complete the following with as much detail as possible



 Utility (what the tool is used for?)




 Validity/Reliability (what is the evidence base that
 says this works in the clinical setting?)



 Copyright and cost (are there any copyright issues
 for the Trust or cost for use?)


 Training (are there any training issues for staff e.g.
 needs to be incorporated into mandatory training, if
 there is a training cost for the Trust or if there are
 individuals in-house able to provide peer support etc)


 Availability (how will staff access this i.e. paper
 copies/CareNotes)

 Date of Approval (to be filled in by Research and
 Effectiveness Team)
 Monitoring/Audit Arrangements (describe how the
 service will monitor the use of this tool)


________________________________________________________________________________________________________________
Clinical Governance Manager / Risk Manager          Page 8 of 10                                   27 October 2009

O:\Policy Support Officer\Policy System\2. Current online\CP5 Clinical risk assessment tools Issue 2.doc
                                                             Appendix 3

                            Equality and diversity/Human Rights impact assessment

                                       IS IT RELEVANT?                                      HOW RELEVANT IS IT?
                            Does the policy      Is there evidence                    How much        Is there public
                            include anything     to believe that                      evidence do you concern that the
                            that …               groups could be                      have            policy is
                            Eliminates           treated different-                                   discriminatory2
                            discrimination       if so, which
                            and/or               groups within
                            Promotes equal       each                                 1. None or a               (Answer yes, no
                            opportunities        category(e.g.                           little                  or N/A for each
                            (Answer yes, no or under 16 year                          2. Some                    category listed)
                            N/A for each         olds in age                          3. Substantial
                            category listed)     category)

    Race                    NO                            NO                          N/A                        N/A

    Gender                  NO                            NO                          N/A                        N/A

    Disability              NO                            NO                          N/A                        N/A

    Age                     NO                            NO                          N/A                        N/A

    Sexual                  NO                            NO                          N/A                        N/A
    orientation
    Religion or             NO                            NO                          N/A                        N/A
    beliefs

Now evaluate your answers by using the criteria provided and underline which describes your
policy

    Relevance                         Rationale                                               Monitoring3
    High relevance                    If there is substantial evidence that                   You need to start monitoring the
                                      indicates that groups could be treated                  impact of this policy within a
                                      differently because of the policy                       year of it being introduced

    Medium relevance                  If there is some evidence that                          You need to start monitoring the
                                      indicates that groups could be treated                  impact of this policy within 2
                                      differently because of the policy                       years of it being introduced:

    Low relevance                     If there is little/no evidence that                     Impact monitored at least every
                                      indicates that groups could be treated                  3 years
                                      differently because of the policy




2
  Could be gauged from surveys, audit data, complaints etc,
3
  Policy Reviews Group working with Equality & Diversity/Human Rights Group must monitor the impact of policies through the following
channels: results from the national service user survey, the national mental health and ethnicity census, complaints data, PALS feedback,
individual systems within clinical services through which ward and community staff liaise with service users and carers i.e. ward meetings,
modern matron meetings
4
   This assent will be reviewed by the Equality and Diversity/Human Rights group

________________________________________________________________________________________________________________
Clinical Governance Manager / Risk Manager          Page 9 of 10                                   27 October 2009

O:\Policy Support Officer\Policy System\2. Current online\CP5 Clinical risk assessment tools Issue 2.doc
Human Rights
When developing any policies, policy writers should ask themselves ‘does the policy engage/restrict
anyone’s Human Rights?’

 What is the                          There are 16 basic rights in the Human Rights Act, all taken from the
 Convention of Human                  European Convention on Human Rights. There are 3 types of rights
 Rights?                              detailed as follows:
                                       Absolute- cannot opt out of         Right to life
                                       these rights under any              Prohibition of torture
                                       circumstance- cannot be             Prohibition of slavery and forced
                                       balanced against any public           labour
                                       interest                            No punishment without law
                                                                           Right to free elections
                                                                           Right to marry
                                                                           Abolition of the death penalty
                                       Limited- these rights are           Right to liberty and security
                                       subject to predetermined            Right to a fair trial
                                       exceptions
                                       Qualified- these rights can be      Respect for private and family
                                       challenged in order to protect        life
                                       the rights of other people          Right to Freedom of thought,
                                                                             conscience and religion
                                                                           Freedom of expression
                                                                           Freedom of assembly and
                                                                             association
                                                                           Prohibition of discrimination
                                                                           Protection of property
                                                                           Right to education
 Where can I get more                 More details can be found at the Department of Constitutional Affairs
 information about                    (DCA)
 this?                                http://www.dca.gov.uk/peoples-rights/human-rights/publications.htm
                                      Publications
                                      DCA (Oct 2006) Human rights: human lives – a handbook for public
                                      authorities, crown copyright
                                      DCA (Oct 2006) Making sense of human rights – a short introduction,
                                      crown copyright
                                      DCA (Oct 2006) A Guide to the Human Rights Act 1998, crown copyright
 What should I do if I                You should forward for discussion at the Trustwide Equality and Diversity
 suspect my policy                    and Human Rights Group within the Trust- contact Andy Styring, Director
 affects anyone’s                     of Operations, executive lead for Equality & Diversity and Human Rights
 Human Rights?                        mailto: andy.styring@cwp.nhs.uk

Please tick one of the following

 The above has been considered and to the best of my knowledge my policy does not affect
                                                                                                              
 any of the human rights listed
 The above has been considered and my policy does affect a human right article(s) but this has
 been discussed and ‘qualified’ at Trust Equality and Diversity and Human Rights Group




________________________________________________________________________________________________________________
Clinical Governance Manager / Risk Manager         Page 10 of 10                                   27 October 2009

O:\Policy Support Officer\Policy System\2. Current online\CP5 Clinical risk assessment tools Issue 2.doc

				
DOCUMENT INFO