Preparation Process for Risk Management Level Assessment

While risk management level increases do offer benefits to trusts, the consensus of the various interviews was that obtaining such an increase takes considerable time and effort on behalf of many staff to be realised. The process adopted by these trusts differed slightly in each case but generally included the following steps:

(i) Process Mapping

Some trusts took the approach of process mapping across the whole organisation to see not just how they would make a risk management level increase at their next assessment, but also to see how they would move from level one to level two and on to level three in time. In the view of Joe Mallabone of the

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Central Manchester University Trust, a one-off approach for each assessment is ‘absurd as the three

levels are inextricably linked and the way you progress from one level to the next is more effectively done if you process map it all out’. Process mapping involved issues such as getting the performance

management systems in place, and writing documents where you identified how you disseminated and implemented policies and how you would measure compliance and subsequently monitor compliance. Regular meetings were then held over several months to map out how evidence would be presented and how a trust would demonstrate evidence of compliance.

Process mapping was also discussed by Joanne Sims of the Royal Bournemouth and Christchurch Trust – this initiated by a service development team from the NHS Centre for Innovation and Improvement, but is now ‘central to people’s consciousness in the trust’ – the trust now has a ‘team based approach to

embracing change’. In short, for the two trusts who spoke of process mapping, it was clear that they

viewed the rise to risk management level two as just a step on the way to ultimately achieving level three status.

(ii) Lead Person(s) with Responsibility for the NHSLA Assessment

All trusts which achieved risk management level increases put a specific person in charge of the NHSLA risk management level assessment, and this person was the chief coordinator of all of the various pieces of information which had to be prepared and collated for an assessment submission. The lead person chosen for each of the nine trusts was the interviewee for this research (apart from the Camden and Islington trust where Alison Martin jointly led the assessment with her colleague Ian Diley), and it was clear from the discussions that this role was a very necessary but onerous part of obtaining the risk management level increase. Aspects which were managed by this lead person included:

• Coordinate a range of meetings with staff over a period of typically twelve months in advance of the assessment;

• Coordinate interim meetings with NHSLA assessors which typically take place some months in advance of the assessment;

• Understanding what the NHSLA handbook asked for and preparing the evidence to a high standard – this involved providing support to people writing policies;

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• Determine where clinical engagement is needed and what administrative support is needed for the data collection;

• Identify gaps in the organisational plans to achieve a target risk management level and taking appropriate action to remedy these gaps;

• Report to a member of the board of directors (typically the medical director) on a regular basis on progress made;

• Coordinate the NHSLA assessment – this involves having someone accountable for each of the 50 standards, having staff on call for interview to explain parts of the documentation, and being preparing to provide extra evidence if needed on the day.

In short, it was clear to the interviewer that the lead person role required very good leadership and communication skills to mobilise a wide range of people in each trust to achieve this overall goal – in the words of Joe Mallabone of the Central Manchester trust, ‘it was not his assessment, it was the staff’s

assessment and he just facilitated the process of getting from A to B as a lot of the individuals were healthcare professionals who didn’t have much of a handle on governance systems’. This lead person

role was explicitly acknowledged by Alison Bartholomew of the NHSLA who felt that a barrier preventing many other trusts from achieving higher risk management levels was the absence of such a risk management champion. Looking to the future when funding will be restricted because of the economic situation, she felt the role of such champions will be crucial as these organisations will be more likely to conclude that risk management can help it in the current times whereas other organisations may be tempted to think that they can do without it.

(iii) Engagement with Clinical Staff and the Board of Directors

An additional enabler in the process of successfully securing a risk management level increase was engagement with clinical staff in the trust – many of whom initially viewed the document preparation as an unnecessary paperwork exercise. Joanne Sims of the Royal Bournemouth and Christchurch trust felt that the real key to ‘get success is to have change being driven by the clinical staff - this is also the way

in which you involve all aspects including the financial and efficiency side as well as the quality and safety side’. Neil Gibson of the Northumbria trust also spoke of the successful engagement of clinical

staff with risk issues, and cited it as a key factor in it obtaining a risk management level increase. However, obtaining such clinical involvement is not easy – Janet Waring of the Alder Hey Children’s

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trust felt that it was only when her trust went for level three that a ‘more positive viewpoint of the

relevance of standards was realised especially among clinicians and clinical staff – prior to this, it was seen as a huge bureaucratic exercise’.

The interview with Alison Bartholomew of the NHSLA also confirmed the importance of successfully engaging with clinical staff to secure risk management level increases. Initially, she acknowledged that completing the risk management level one assessment can largely be done by a good risk manager (with help from just a small number of additional people); but when one tries to move beyond level one, ‘you

have to get engagement from a lot of other people and it becomes much more difficult’. She elaborated to

say that the big progress block seemed to be from level one to level two – ‘it is not to say it is easier to

get from level two to three (as it was from level one to two) but it is more part of a natural journey at that stage’. This implies that an inability to foster clinician involvement in the risk assessment process

may be a strong barrier to trusts achieving risk management level increases. Obtaining such clinical involvement is difficult as this group of staff ‘often don’t see the benefit of the NHSLA risk management

levels and if they have a very strong influence in the trust, it can reduce the chances of risk management level increases’.

In addition to successfully engaging with clinical staff, trusts which secured a risk management level extended this engagement through to the top levels of management in the trust – the interviewees alluded to board members wanting to be regularly informed as to how preparations were faring for the NHSLA assessment. This involvement initially consisted of selecting an appropriate lead person and providing that person with the necessary support to perform his/her role; however, it became more actively involved in the lead up to an assessment visit when the need to have everyone communicating the same message became more important.

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(iv) Heavy Workload in Advance of NHSLA Assessment

A common theme for each of the successful trusts which secured risk management level increases was the thorough preparation in advance of the NHSLA assessment – the key to getting a successful result was ‘preparation, preparation, preparation’ according to Joe Mallabone of the Central Manchester University Trust. This preparation commenced up to eighteen months in advance of an assessment, and typically increased considerably in the weeks leading up to the assessment. Most interviewees spoke of the fact that the assessment became a prioritised part of their normal work during these weeks and the workload involved reached 70 to 80 hour weeks as the assessment approached. The additional workload did put considerable pressure on each of the lead people over this period - all felt that the volume of work put into the assessment added to the fact that it was a key strategy of the trust to get an increase made the assessment visit a very stressful and nerve wracking experience. However, Alison Bartholomew of the NHSLA, while being aware that the assessment required extensive effort, was surprised to hear of the ‘level of pressure which trusts feel at the time of an NHSLA assessment’.