V04.1 Update May 18 GDPR Update

Transcription

1 Document Title Reference Number Lead Officer Litigation and Claims Management Policy NTW(O)06 Executive Director of Nursing and Chief Operating Officer Author(s) (name and designation) Tony Gray Head of Safety, Security and Resilience Vicky Clark Incident Complaints and Claims Manager Ratified by Business Delivery Group Date ratified Jan 2018 Implementation date Date of full implementation Jan 2018 Jan 2018 Review Date Jan 2021 Version Number V04.1 Review and Amendment Log Version Type of change Date V04 Review Jan 18 Description of change Reviewed policy documentation V04.1 Update May 18 GDPR Update This supersedes the following document: Reference Number NTW(O)06 V04 Title Litigation and Claims Management Policy

2 Claims Management Policy NTW (O)06 Section Contents Page No: 1 Introduction 1 2 Purpose 1 3 Duties 2 4 Indemnity 4 5 Reporting 5 6 Media Interest 5 7 Remedial Action 5 8 Solicitors Requests for Report 6 9 Preparation of Statements 6 10 Criminal injuries compensation authority (CICA) 7 11 Third party claims 7 12 Consultation and communication with 7 stakeholders 13 Approval and Review of document 8 14 Policy administrative process 8 15 Definition of terms used 8 16 Equality impact assessment 9 17 Training Implementation Review updating and archiving of policy Monitoring and compliance Standard/Key performance indicators Fair Blame Fraud and Corruption Associated documentation References 12 Appendix A Appendix B Appendix C Appendix D Standard Appendices attached to policy Equality and Diversity Impact Assessment Training Checklist and Needs Analysis Audit and Monitoring tool Policy notification record sheet click here Appendices listed separate to policy Number Description Issue Date Review No: Issued date Appendix 1 What to do when a potential 1 May 18 Jan 21 claim is received Appendix 2 List of contact details 1 May 18 Jan 21 Appendix 3 Corporate reporting structure 1 May 18 Jan 21 Appendix 4 Guidelines on completing 1 May 18 Jan 21 statements for claims Appendix 5 Maximum payments considered 1 May 18 Jan 21 for ex-gratia payments Appendix 6 Ex-Gratia Claim Form 1 May 18 Jan 21 Appendix 7 Offer of Ex-Gratia Payment 1 May 18 Jan 21 Appendix 8 Opticians Form 1 May 18 Jan 21 Appendix 9 Third Party Claims 1 May 18 Jan 21

3 1 INTRODUCTION 1.1 Northumberland, Tyne & Wear NHS Foundation Trust (the Trust) provides a wide range of health care services in hospital, community, home and other care settings. 1.2 The Trust policy for the handling of claims has been drawn up to clarify the procedures to be followed in the event of a claim by or against the Trust and forms part of the Trust s risk management procedures. (Appendix 1) 1.3 The policy covers the management of all claims against the Trust, from patients, staff or third parties and the management of property expenses claims made by the Trust. 1.4 There are several types of claim that could be made against the Trust: Clinical Negligence Employers Liability Public Liability Property and Material Damage Ex-Gratia Claims Employment Law Vehicle Accidents Miscellaneous The Trust has authorised personnel to deal with each category of claim. For further details please see Appendix 2. 2 PURPOSE 2.1 The Trust recognises and accepts its responsibility to provide a safe and healthy workplace and a safe environment for its employees, patients and visitors. 2.2 The Trust recognises the potential for claims to be made against it alleging clinical negligence or personal injury and accepts that these need to be handled sensitively and speedily, to cause the minimum of stress to those involved. 2.3 The Trust undertakes to deal with claims as quickly as practicably possible in a cost effective manner. 2.4 The Trust operates an open and honest policy and therefore will endeavour to disclose accurate information, in accordance with the requirements of Clinical Governance, Woolf pre-action protocols and other relevant legislation. 2.5 The Trust operates a `lessons learnt strategy and any claim which highlights trends and risk issues will be brought to the attention of the Trust wide Quality and Performance Committee and other Trust groups by the appropriate authorised person. 1

4 2.6 The Trust will support and provide advice to all staff who are involved in the litigation process and keep them updated throughout the process. 2.7 All information and documentation relating to the claim and accrued in the course of the claim will be treated as confidential and not relayed to a third party. In the case of patients, disclosure of records requires the specific written consent of the patient or person nominated on behalf of a patient. The Data Protection Act 2018 legislation will be adhered to in relation to patients who are living. The Access to Health Records Act (1990) will be adhered to for patients who are deceased and children. 2.8 All claims will be dealt with in the Trust s name, rather than an individual member. Any member of staff receiving a letter of claim made against him or her personally and relating to an incident arising out of his or her employment should contact any of the authorised personnel immediately (Appendix 2). 3 DUTIES Executive Director of Nursing and Chief Operating Officer 3.1 The Executive Director of Nursing and Chief Operating Officer is the Board member with overall responsibility on behalf of the Board of Directors for the management and handling of claims, and will keep the Board informed of major developments in this area. The Executive Director of Nursing and Chief Operating Officer is responsible for ensuring that detailed procedures are developed, agreed and implemented throughout the Trust, and monitored as appropriate. 3.2 The Executive Director of Nursing and Chief Operating Officer is the Board member with responsibility for receiving NHS Resolution Risk Management reports for clinical claims with regard to learning. All Solicitor Risk Management reports are forwarded to the Incident Complaints and Claims Manager. Group Nurse Director Safer Care Executive Director of Nursing and Chief Operating Officer Safer Care 3.3 The Group Nurse Director Safer Care and Executive Director of Nursing and Chief Operating Officer Safer Care, shall ensure a robust system of claims management is in place underpinned by sound corporate governance arrangements. Head of Safety and Security 3.4 The Head of Safety and Security is responsible to ensure that claims are appropriately managed in line with this policy and will oversee the appeals process in respect of ex-gratia claims. 2

5 Incident Complaints and Claims Manager 3.5 The Incident Complaints and Claims Manager is responsible for the day to day handling of clinical negligence, employer s liability, public liability, property expenses, ex-gratia and other miscellaneous claims. 3.6 The Incident Complaints and Claims Manager will take any issues raised in NHS Resolution Solicitor Risk Management reports to the Patient Safety Committee for discussion and action, if necessary. Executive Director of Workforce and Organisational Development 3.7 The Executive Director of Workforce and Organisational Development is responsible for the day to day handling of employment law claims. Service Manager (General Services, NTW Solutions) 3.8 The Service Manager (General Services, NTW Solutions) is responsible for the day to day handling of Trust vehicle claims (excluding leased vehicles). Motor claims in relation to leased transport must be reported immediately to the leasing organisation. Locality Care Group Directors 3.8 It is the responsibility of the Locality Care Group Directors to review the claims activity of their services as they are reported and made aware, and to reflect with teams whether the claim or the incident that it resulted from could have been prevented. Associate Directors/Clinical Nurse Managers 3.9 It is the responsibility of the Associate Directors to ensure that when claims are received they support the Incident Complaints and Claims Manager to gather the appropriate information to support investigation of the claim It is the responsibility of Associate Directors to ensure that staff understand the requirements not to breach the confidentiality of patients when registering a claim as described below. All Employees 3.11 All employees employed by the Trust are required to assist in the investigation of claims against the Trust when appropriate. This will include providing reports and statements when required to do so. The Trust will ensure that all staff involved, will be adequately supported throughout the process All employees shall be responsible for reporting incidents (in line with Trust procedures) to allow for early investigation and remedial action to be addressed should a claim be submitted at a later date. 3

6 3.13 The authorised personnel who handle claims within the Trust will ensure that when a claim is notified, external bodies who need to become involved will be contacted. This could include NHS England, commissioners and local and neighbouring NHS Trusts Trust staff are required to uphold patient confidentiality at all times, including where staff seek to bring any legal claim against the Trust. Patient information must not be disclosed without seeking managerial authority, which may also require referral to the Trust Incident Complaints and Claims Manager and/or health records personnel Any member of staff seeking external legal advice regarding a claim, should not copy and disclose any patient information to their legal advisors without Trust approval, including accident/incident reports where patient details are included. To do so is a breach of key data protection and confidentiality requirements, which all staff are under a legal obligation to uphold. Any member of staff disclosing such information without Trust approval could be liable for disciplinary action. The incident and claims personnel will delete any third party information from any accident/incident report which is submitted regarding the claim. Corporate Decisions Team - Quality 3.16 The Corporate Decisions Team - Quality will receive information from Executive Directors relating to claims and any issues that need action The Senior Management Team will have responsibility to approve the policy. Quality and Performance Committee 3.18 The committee will receive a quarterly Safer Care report on all claims received and closed in that month and any themes or trends identified. Locality Care Groups Quality Meetings 3.19 Locality Care Groups Quality Meetings will receive claim information relating to their activity in the form of a quarterly report. This will bring together all their safety and patient experience activity into a central report. 4 INDEMNITY 4.1 Indemnity through NHS Resolution covers the actions of staff in the course of their NHS employment. It also covers people in certain other categories whenever the NHS body owes a duty of care to the persons harmed, including for example, locum bank and agency staff, medical academic staff with honorary contracts, students, those conducting clinical trials, charitable volunteers and people undergoing further professional education, training and examinations. GPs or dentists who are directly employed by the health authorities e.g. as public health doctors (including port medical officers and medical inspectors of immigrants at UK air/sea ports) are covered. 4

7 5 REPORTING 5.1 The corporate reporting structure for claims is outlined in Appendix The Trust will ensure compliance with the administration and reporting requirements of the Clinical Negligence Scheme for Trusts (CNST), the Non- Clinical Risk Pooling Scheme (RPST) and NHS Resolution and will provide appropriate database information which will be developed and updated accordingly. This includes adhering to the protocol timescales to acknowledge a claim. Also the forwarding of information in a timely manner to NHS Resolution to ensure they can meet protocol timescales for admission or denial of liability. 6 MEDIA INTEREST 6.1 At any stage a claim or potential claim may generate media interest. The Incident Complaints and Claims Manager will work closely with the communications department on all such claims. 6.2 The communications lead will agree draft press statements with the Chief Executive/ Executive Director of Nursing and Chief Operating Officer 6.3 Where court hearings are likely to generate media interest, the Incident Complaints and Claims Manager will notify the Communications Department and NHS Resolution and draft statements will be prepared in readiness, immediately dates are notified. 7 REMEDIAL ACTION 7.1 There is a need to establish the underlying cause(s) of claims through thorough investigation, to ensure that the cause of adverse events are properly understood, lessons learned and appropriate measures put in place to prevent or minimise a reoccurrence. The root causes of adverse events may lie in the management and organisational systems. 7.2 The Incident Complaints and Claims Manager will notify the Head of Safety and Security of any potential areas of risk highlighted by individual claims. 7.3 The Incident Complaints and Claims Manager will notify the Chief Executive / Executive Director of Nursing and Chief Operating Officer, relevant Locality Care Group Directors and Associate Directors of any serious allegations of clinical negligence, which may need to be acted upon immediately. 7.4 Responsibility for taking remedial action to prevent a recurrence of any incident, which has resulted in a claim against the Trust, lies with the Chief Executive, Executive Director of Nursing and Chief Operating Officer and Locality Care Group Directors. 5

8 7.5 When claims are settled, regardless of outcome, incident and claims personnel will send an to the director and managers of the service involved, outlining the background to the claim and the reasons for the outcome so that further remedial measures can be considered and, if necessary, actioned. 8 SOLICITOR S REQUEST FOR REPORTS AND STATEMENTS 8.1 A solicitor may approach a healthcare professional to provide a report about a patient or member of staff in one of two circumstances: Where there is a claim against the Trust Where there is a claim against a third party. 8.2 Requests for reports can relate to patients or about a member of staff if it is a member of staff who is making a claim. 8.3 If there is a claim against the Trust, a claimant s solicitor will sometimes approach a member of staff directly. There is no legal obligation for a member of staff to provide a statement (unless directed to by a Court). Any members of staff receiving a request for a report where there is a claim against the Trust should contact the Incident Complaints and Claims Manager for advice. 8.4 If the claim is not against the Trust then a report can be requested directly from the relevant healthcare professional or manager. The request from the solicitors must include signed authorisation from the person who the report is about. The healthcare professional/manager may prepare the report but must always be aware that the report could be used in subsequent Court proceedings and will be disclosed to the claimant and other parties. The person writing the report should also confirm with the solicitor, in what capacity they are being asked to write the report and notify them of any charges prior to the report being produced. 8.5 If the report is requested for Court, the duty of the person preparing the report is to the Court and the contents of the report must be factual. The writer must be comfortable confirming the contents of the report under oath in the witness box if so required. 9 PREPARATION OF STATEMENTS 9.1 With an increasing number of complex queries, complaints and claims it is becoming more common for staff to be asked to provide statements as a result of a complaint/claim/serious incident. When writing a statement, it is important to remember that, although the majority of statements will go no further, a statement may be copied to the complainant or used as evidence in defending a legal claim. Please remember however, that the Trust indemnifies its entire staff and is responsible for any complaint or claim made. 9.2 Guidance on completion of statements is enclosed at Appendix 4. 6

9 10 CRIMINAL INJURIES COMPENSATION AUTHORITY (CICA) / TEMPORARY INJURY ALLOWANCE (TIA), PERMANENT INJURY ALLOWANCE (PIA) 10.1 Ward Managers are required to forward all CICA requests for incident information to the Incident Complaints and Claims Manager who will ensure completion and link into any potential claim files CICA requests for reports from clinicians do not need to be forwarded to the Incident and Claims Department and can be dealt with by the individual clinician concerned The Incident and Claims Department will inform human resources personnel of all new employer liability claims in order that any staff receiving TIA or any other payments (other than their entitlement of salary) can be taken into account during a potential claim. 11 THIRD PARTY CLAIMS 11.1 The Trust receives requests from solicitors for payroll and human resource information when a member of staff is making a claim for personal injury against another party, other than the Trust. All such requests for information should be forwarded to the Incident and Claims Department in order that they can signpost solicitors to NHS Payroll Services for payroll information. Please see Appendix 9 for further information. 12 CONSULTATION AND COMMUNICATION WITH STAKEHOLDERS 12.1 This is an existing policy with additional / changed content that relates to operational and/or clinical practice and was therefore circulated to the following for a four week consultation period: o North Locality Care Group o Central Locality Care Group o South Locality Care Group o Corporate Decision Team o Business Delivery Group o Safer Care Group o Communications, Finance, IM&T o Commissioning and Quality Assurance o Workforce and Organisational Development o NTW Solutions o Local Negotiating Committee o Medical Directorate o Staff Side o Internal Audit 7

10 13 APPROVAL AND REVIEW OF DOCUMENT 13.1 This policy has been approved by the Business Delivery Group and will be reviewed on a 3 yearly basis unless by exception, i.e. due to change in legislation or standards etc. 14 POLICY ADMINISTRATIVE PROCESS 14.1 The development, consultation and dissemination of this policy has been undertaken in accordance with the Trust policy NTW(0)01 Development and Management of Procedural Documents and in conjunction with the policy administration process It has been circulated within the Chief Executive s weekly bulletin via a link to the Trust clinical policy bulletin and is available on the Trust Intranet site and also from policy administration Archiving of this policy will be in accordance with the Trust s policy NTW(0)01 Development and Management of Procedural Documents. 15 DEFINITIONS OF TERMS USED 15.1 The common law tort of negligence can give rise to an act for damages alleging the Trust has been guilty of a failure to take reasonable care of those who might foreseeably be affected by its acts or omissions. For negligence to be proved, it would have to be shown that the Trust owed a duty of care to the injured party, that the duty of care was breached, that injury resulted as a direct result of the breach and that loss was suffered as a result of injury. The Trust is vicariously liable for the acts or omissions of its employees who are acting in the course of their employment Clinical Negligence Claims are: A breach of duty of care by members of the health care professions employed by the NHS bodies or by others consequent on decisions or judgements made by members of those professions acting in their professional capacity in the course of employment, and which are admitted as negligent by the employer or are determined as such through the legal process Employers Liability claims are: Claims for damages made by an employee who has suffered bodily injury(ies) sustained whilst acting in the course of his or her employment and arising from the Trust s failure in its statutory duty to provide a safe place of work and operate a safe system of work Public Liability claims are Claims for damages made by a third party (e.g. patient, visitor) to whom the Trust owes a duty of care and who has suffered loss, damage or bodily injury(ies) (but not due to clinical treatment) as a result of the Trust s breach of duty. These claims also extend to damages arising from defective goods and equipment produced and supplied by the Trust. 8

11 15.5 Property Expenses claims are: Claims for compensation made by the Trust for accidental loss damage or destruction of premises owned or occupied by the Trust including items of equipment owned by the Trust, together with any resulting consequential losses. These claims also include other property related risks Ex-Gratia claims are payments which a health body is not obliged to make or for which there is no statutory cover or legal liability. An example is a payment to compensate for financial loss resulting from an act or failure of the body or its servants which does not give rise to a legal liability or the payment of compensation claims or damages. Such payments must be clearly related to and arise from the services which the body is authorised or required to provide. Other examples are payments made to meet hardship caused to persons by official failure or delay, or special payments to avoid legal proceedings against the Government on grounds of official inadequacy Employment Claims are: claims by staff or former members of staff for breaches of employment law, e.g. unfair dismissal, discrimination Vehicle Claims are: Claims for accidents involving Trust vehicles Miscellaneous Claims can be: Directors and Officers: Claims for damages made by any person or organisation alleging wrongful acts by a Board Member or other Officer of the Trust where that person was acting in good faith and in the course of their employment. Professional Indemnity/Income Generation: Claims for compensation and costs and expenses arising from a breach of professional duty, errors and omissions, libel, slander, etc Personal Accident: Claims for accidental bodily injury resulting in death or permanent disability and arising out of an assault occasioned during the course of his or her employment by a person or animal Criminal Injuries: Claims for compensation made for bodily injury that was not as a result of negligence or whereby the perpetrator is unable to be held liable 16 EQUALITY AND DIVERSITY ASSESSMENT 16.1 In conjunction with the Trust s Equality and Diversity Officer this policy has undergone an Equality and Diversity Impact Assessment which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner. 9

12 17 TRAINING 17.1 A claims process underpins the risk management arrangements for the organisation. No training is required for employees, awareness of the policy and contact details of the claims team for advice and support, is required for all employees. Up to date knowledge of current legislation is required by the claims team with support from legal professionals. 18 IMPLEMENTATION 18.1 The changes to this policy since its last ratification will be communicated to all teams through the policy dissemination process with the main changes identified on a summary sheet This policy and appendices once approved by Senior Management Team will be placed on the Trust intranet site and will be disseminated through the Trust s policy cascade system through the directorates, the following responsibilities for policy dissemination are currently in place: o Policy approval by SMT o Instructions sent to policy manager to disseminate through Trust o Group Directors receive policy and send through inpatient, community and specialist group management structures o Policy implementation date agreed o Policy implemented and goes live o Policy placed on intranet and accessible to all o Policy printed and placed in local folders 19 REVIEW UPDATING AND ARCHIVING OF POLICY 19.1 The policy will have a set date for review as identified on the front of the policy document, the appendices will only be updated as the needs of the organisation or national requirements dictate Responsibilities for changes and control are identified as follows: o The author of this policy has responsibility to identify the need for changes and will action accordingly, if the policy needs to be reviewed in advance of the review date it is the responsibility of the author to inform the policy manager. o The policy manager will co-ordinate the review date of all policies and will send reminders to the author irrespective of changes needed. o The policy manager will ensure that the co-ordinators are aware of the timescales for policies and will agenda accordingly for groups to review. o When a policy has been amended, reviewed and authorised by a group, the policy manager will ensure that the most up to date policy is posted on 10

13 the internet site as well as being disseminated as per the controls identified in section 18 above. 20 MONITORING AND COMPLIANCE 20.1 There are a number of ways in which the compliance to this policy and appendices will be monitored: Frequency of reporting 20.2 The Trust has in place reporting and monitoring systems for claims: o communications to Directors, Directorate Managers, Service and Ward Managers as new NHS Resolution claims are received outlining negligence allegations or specific allegations of health and safety breaches. o Monthly reports to Corporate Decisions Team on claims activity highlighting area themes/trends or areas of concern. o Bi-monthly reports to Board of Directors on claims activity. o Annual reports to Board of Directors on all claims activity. 21 STANDARDS / KEY PERFORMANCE INDICATORS NHS Resolution Risk Management Standards. NHS Resolution data specific to Mental Health / Learning Disability Trusts. Performance reporting on numbers of claims reported through monthly and annual claims reporting. This will include: o The number of claims received o The subject matter and outcome of each claim o Any matters of significance arising out of claims 22 FAIR BLAME 22.1 The Trust is committed to developing an open learning culture. It has endorsed the view that, wherever possible, disciplinary action will not be taken against members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken. 23 FRAUD AND CORRUPTION 23.1 In accordance with the Trust s policy NTW(O)23 Fraud and Corruption/Response Plan, all suspected cases of fraud and corruption should be reported immediately to the Trust s Local Counter Fraud Specialist or to the Executive Director of Finance 11

14 24 ASSOCIATED DOCUMENTS NTW(O)01 - Development and Management of Procedural Documents NTW(O)05 Incident Policy and Practice Guidance Notes NTW(O)07 Comments, Compliments and Complaints Policy NTW(O)20 Health & Safety Policy and Practice Guidance Notes NTW(O)33 Risk Management Policy 25 REFERENCES Data Protection Act 2018 Access to Health Records Act (1990) 12

15 Appendix A Equality Analysis Screening Toolkit Names of Individuals involved in Review Vicky Clark, Incident Complaints and Claims Manager Policy to be analysed Date of Initial Screening Review Date Service Area / Directorate Jan 2021 Patient Safety, Safer Care Directorate Is this policy new or existing? NTW(0)06 Litigation and Claims Management Existing What are the intended outcomes of this work? Include outline of objectives and function aims Update policy and additional appendix (number 9) relating to third party claims. Who will be affected? e.g. staff, service users, carers, wider public etc Staff, service users, wider public Protected Characteristics under the Equality Act The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them Disability Consider and detail any evidence on attitudinal, physical and social barriers. Language barriers may need British Sign Language/easy read versions, information required in accessible formats. Potential advocacy requirement. Sex Consider and detail any evidence on men and women (potential to link to carers below). Race N/A Consider and detail any evidence on difference ethnic groups, nationalities, Roma gypsies, Irish travellers, language barriers. Language barriers need for interpreters/accessible information, potential advocacy requirement. Age Gender reassignment (including transgender) Consider and detail any evidence across age ranges on old and younger people. This can include safeguarding, consent and child welfare. Consider and detail any evidence on transgender and transsexual people. This can include issues such as privacy of data and harassment. N/A 13

16 Sexual orientation. Consider and detail any evidence on heterosexual people as well as lesbian, gay and bi-sexual people Religion or belief N/A Consider and detail any evidence on people with different religions, beliefs or no belief. Marriage and Civil Partnership Pregnancy and maternity N/A Consider and detail any evidence on working arrangements N/A Consider and detail any evidence on working arrangements, part-time working, infant caring responsibilities. Carers N/A Consider and detail any evidence on part-time working, shift-patterns, general caring responsibilities. Other identified groups N/A Consider and detail other groups experiencing disadvantage and barriers to access. N/A How have you engaged stakeholders in gathering evidence or testing the evidence available? N/a How have you engaged stakeholders in testing the policy or programme proposals? N/a For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs: N/a Summary of Analysis Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life. N/a Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Where there is evidence, address each protected characteristic Eliminate discrimination, harassment and No impact 14

17 victimisation Advance equality of opportunity Promote good relations between groups What is the overall impact? No impact No impact Consider whether there are different levels of access experienced, needs or experiences, whether there are barriers to engagement, are there local variations and what is the combined impact? Addressing the impact on equalities Please give an outline of what broad action you or any other bodies are taking to address any inequalities identified through the evidence. From the outcome of this Screening, have negative impacts been identified for any protected characteristics as defined by the Equality Act 2010? No If yes, has a Full Impact Assessment been recommended? If not, why not? Manager s signature: Vicky Clark Date:

18 Appendix B Communication and Training Check list for policies Key Questions for the accountable committees designing, reviewing or agreeing a new Trust policy Is this a new policy with new training requirements or a change to an existing policy? If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below. Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice? Please give specific evidence that identifies the training need, e.g. National Guidance, CQC,NHS Resolutions etc. Please identify the risks if training does not occur. Existing No n/a Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training. Is there a staff group that should be prioritised for this training / awareness? Please outline how the training will be delivered. Include who will deliver it and by what method. The following may be useful to consider: Team brief/e bulletin of summary Management cascade Newsletter/leaflets/payslip attachment Focus groups for those concerned Local Induction Training Awareness sessions for those affected by the new policy Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session E Learning Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc. n/a n/a n/a n/a 16

19 Appendix B continued Training Needs Analysis Staff/Professional Group Type of training Duration of Training Frequency of Training All staff Awareness of policy - - Copy of completed form to be sent to: Training and Development Department, St. Nicholas Hospital Should any advice be required, please contact: (Option 1) 17

20 Monitoring Tool Appendix C Statement The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, policy authors are required to include how monitoring of this policy is linked to auditable standards/key performance indicators will be undertaken using this framework. Litigation and Claims Management Policy - Monitoring Framework Auditable Standard/Key Performance Indicators Frequency/Method/Person Responsible Where results and any Associate Action plan will be reported to implemented and monitored; (this will usually be via the relevant Governance Group). 1. A record of claims is maintained Recorded on Trust risk management database Safeguard when received by claims staff Corporate Decision Team - Quality 2. Information relating to claims is gathered and forwarded to NHS Resolution within legal timescales For every relevant claim in line with the Woolf reforms and NHS Resolution guidance by claims staff Corporate Decision Team - Quality 3. Monthly and quarterly Safer Care report with claims received and broken down by claim type, category including information on themes or trends Monthly/quarterly review of the number and types of claims by the Corporate Decisions Team Quality from information provided by Incident, Complaints and Claims Manager Corporate Decision team - Quality 4. Annual report on claims broken down by group and claim type Annual review of claims prepared by the Incident, Complaints and Claims Manager May s Trust Board meeting 18