CLAIMS MANAGEMENT POSITIONAL STATEMENT Appendix 2 Introduction 1 This report provides the Board with a statement of current ongoing claims, both personal injury and clinical negligence brought against the Welsh Ambulance Services NHS Trust ( the Trust ). It also reports on actions taken in relation to claims management within the Trust from 23 June 2008 to the end of July. It excludes road traffic collision claims, except those which include a claim for personal injury. Background 2 The Welsh Risk Pool ( the WRP ) entered into a Service Level Agreement with the Trust commencing 23 June 2008 for the provision of claims management support and services. Pursuant to this agreement, the WRP Claims Manager works within the Trust for two days per week to actively manage claims and offer advice and guidance on the direction of and strategic developments within the area of claims management. Current Claims 3 The initial exercise undertaken was to review the current position on all open claims on Datix and to determine, as a benchmark, the number of active claims being managed by the Trust. This was achieved by obtaining Datix reports on all open claims, reconciling that report to the actual claims files transferred to Headquarters from the regions and referring to the quantum reports prepared by the Trust s various legal advisors. The current position regarding ongoing active claims is set out below in respect of each Region by claim category. Clinical Negligence Claims: Region Current Claims as 31 July 2008 Current Claims as stated as 23 June 2008 New Claims Received North 1 0 1 0 Central & 4 3 1 0 West South East 4 6 0 2 Total 9 9 2 2 Claims Closed
Personal Injury Claims Region Current Claims as 31 July 2008 Current Claims as stated as 23 June 2008 New Claims Received North 13 10 1 2 Central & 32 35 2 5 West South East 43 84 7 41 Total 88 129 10 48 Claims Closed 4 The current claims profile according to the Trust s Datix database indicates that the Trust has 9 active clinical negligence claims and 88 active personal injury claims. 5 However, it should be noted that there are 3 moderately active claims which are historic. These claims have been ongoing for a number of years and have not been inputted onto the Datix database. 6 The position should be noted until such time as the next steps have been completed, when more accurate statistics should be available and a formal trend analysis of claims can be performed. Next Steps: To Analyse the active claims on Datix against LASPAR and the financial information retained by the Trust s Finance Department to effect a reconciliation of the information held to ensure consistency. Changes Implemented 7 Since 23 June 2008, a number of practical changes have been implemented regarding the management of claims. These changes are reflective of the requirement of the new Welsh Risk Pool Claims Management Standard, introduced on 1 April 2008. They are designed to ensure that the Trust will be able to show compliance with the same for its assessment for the 2008-2009 period. This will be considered further below. Practical Changes: File Closing Forms have now completed on all concluding claims to ensure that all aspects of the claim have been considered and appropriately concluded and that relevant information has been inputted into Datix. Action Plans on concluded claims is a specific requirement of the Welsh Risk Pool Claims Management Standard and also one of the conditions of WHC
(97) 17 for the continued operation of the Trust s delegated authority to settle negligence claims below 1 million. WRP 2 Forms are to avoid the need to complete these forms on a regular basis. It has been agreed with the Welsh Risk Pool that quantum reports will be provided on a 6 monthly basis to support the provision of the necessary information and to reduce the administrative burden on the Trust. Centralisation of Claims Management the management of claims has been transferred to the Trust s Headquarters which has produced, in the first instance, the following tangible benefits: The reduction in workload for the Regional Claims and Complaints Co-ordinators enabling them to concentrate on active complaints management. The provision of specific direction on claims investigation for the Regional Claims and Complaints Co-ordinators. One section is now responsible for ensuring that Datix is updated for all claims which, in the long term, will give consistency and completeness in the information recorded. All claims are overseen by the Claims Manager who is a practising solicitor. Internal Pre-Action Protocol Investigations are now undertaken in-house. The automatic instruction of solicitors on receipt of a letter of claim has ceased. All claims are now evaluated upon receipt and initial investigations including the gathering of information, documentation and interviewing of relevant staff are undertaken in-house. Once the information has been collated, the Claims Manager will determine an appropriate course of action. High value and complex claims will form the subject matter of instructions to external solicitors, small value claims and those where liability is conceded will continue to be managed in-house. These actions reflect the appropriate role of a Claims Manager and in the long term should produce tangible savings in legal costs for the Trust. One of the areas in which this approach should prove effective, is in relation to needle-stick injuries and this together with the adoption of safety cannulas should ensure the minimisation of these types of claim and their associated costs in terms of damages and legal expenses. Next Steps: To review the Trust s Claims Management Policy and Procedure to ratify and reflect practices Welsh Risk Pool Standard 5 Claims Management 8 The Trust was assessed against the Welsh Risk Pool Standard 5 Claims Management for the period 2007-2008 and achieved a score of 59%. This represented the lowest score in Wales given that the national spread, excluding the Trust s score, was 79%-100%.
9 This also represented a reduced score against previous years assessments. Period of Assessment Score 2007-2008 59% 2006-2007 No assessment undertaken 2005-2006 95% 2004-2005 95% 10 The Areas for Assessments in which the Trust achieved reduced scores were: Area for Assessment 1 - Area for Assessment 2 - Area for Assessment 6 - the Accountability framework was unsupported in that appropriate reports had not been delivered to the Board to ensure that the Board were kept up to date regarding claims management issues, statistics and trends. there was not an appropriate Claims Manager in post for the period of assessment pursuant to the requirements of WHC (97) 17 there was no evidence provided of a suitable system for learning lessons within the Trust and for sharing and disseminating such information. Internal Audit 11 The Complaints and Claims management functions of the Trust are currently undergoing an audit by Mersey Internal Audit. The scope of the audit is limited in relation to claims and will focus upon the following areas; Whether the Trust has a Board approved Claims Management Policy in place which reflects national guidance/protocols in this area; That such a policy is adhered to on a on-going basis; Whether claims leads have sufficient resource; That there are appropriate mechanisms to ensure corrective action is taken and lessons are learnt; and That claims are documented and monitored on an on-going basis. Welsh Risk Pool Mock Claims Management Standard 12 With affect from 1 April 2008, the Welsh Risk Pool has introduced a new Claims Management Standard following a twelve month consultation period with the All Wales Claims and Risk Managers Networks and all NHS organisations within Wales. 13 The new standard places considerable emphasis on the approaches taken by an organisation in relation to learning from events, the processes through which this
is achieved, and how the lessons learned are evaluated, monitored and shared within the organisation. 14 A mock assessment was undertaken for the Trust in April 2008 against the new standard using the period 2007-2008 as the period of assessment, to determine how it might perform against this new standard. 15 The Trust scored 49% in the mock assessment achieving low scores in the areas already identified but particularly in relation to learning from events. Again this represented the lowest mock score nationally with the spread of scores ranging from 59%-92%, excluding the Trust s score. 16 An action plan has been devised for the Trust, which is attached in Annex 1. Next Steps: To meet with relevant personnel and groups to determine appropriate processes for learning from events. To determine realistic timescales for achieving the actions set out in the action plan. To implement the action plan. Conclusions 17 With regard to its claims management function, the Trust has recently undergone a period of difficulties, moving from a position of stability when it was achieving good Welsh Risk Pool Standard 5 Claims Management scores of 95%, to a time of great instability and uncertainty. This led to reduced standard assessment scores, but more importantly and increased dependence upon the advice and input of external solicitors, together with a corresponding increase in the associated legal costs and lack of consistency and accuracy in relation to claims data collected. 18 During this period of instability, national benchmarking standards in claims management have changed and the Trust is now required to move forward its claims management agenda particularly in relation to accountability and learning from events, if it is going to comply with the new standard. An action plan has been drafted to identify the actions required, although, a complete set of timescales have still to be determined. 19 Whilst the hurdles are significant to achieving the objectives of good claims management and compliance with national standards, they are not insurmountable. Since June 2008, the position has stabilised and initial work has been undertaken to cleanse data whilst reviewing how and when external solicitors and instructed, but particularly with a view to using their expertise more cost effectively and appropriately. A continuation of this work together with a review of the action plan and a determination of how the objectives of the new claims management standard can be implemented within the Trust should achieve the desired objectives of timely and cost effective management of claims with adherence to national standards.
Annex 1 Welsh Risk Pool Claims Management Standard MOCK ASSESSMENT ACTION PLAN Purpose of Standard: The purpose of this standard is to ensure that the organisation has an effective process for managing claims made by patients and staff, which is linked, to both the complaints and incident reporting system and that the conditions for the operation of the delegated authority for settlement of claims to a limit of 1 million are met by NHS organisations managing claims Rationale and Risk: Efficient and early handling of claims can have a significant and positive effect on the financial, professional and reputational well-being of organisations and the physical and emotional well being of their patients and which supports the conditions for operation of the delegated authority REFERENCES: 1. WHC (2000) 13 Risk Management and Organisational Controls. 2. WHC (97) 17 Clinical Negligence and Personal Injury Litigation: Claims handling. 3. WHC (97) 7 Clinical Negligence and Personal Injury Litigation: Structured settlements. 4. WHC (99) 128 Handling clinical negligence claims: Pre-Action Protocol. 5. AS/NZS 4360:1999 Risk Management 6. Risk Management the NHS. NHS Executive 7. Social Security (Claims and Payments) Regulations 1979 8. Lord Woolf s Inquiry Access to Justice 9. Pre-action protocol for the resolution of clinical disuputes 10. Pre-action protocol for personal injury claims 11. ALARM/UCL Clinical incident investigation 12. HSC 1999/123 Controls Assurance Statements 1999/2000: Risk Management & Organisational Controls 13. HSC 1999/193 Handling clinical negligence claims 14. HSC 1999/193 Good practice guide for Convenors 15. Guidelines on implementing Controls Assurance in the NHS. NHS Executive. November 1999
Area for Assessment 1: Accountability There is an Executive Board member, with clear responsibility for clinical negligence and personal injury litigation issues, who will keep the Board informed of major developments. Guidance: The organisation must demonstrate that it has designated an Executive Board member with responsibility for claims management issues, who keeps the Board informed of all significant issues pertaining to the Trust s claims profile and claims handling record. This can be achieved where an Executive Board member can demonstrate the delivery of a reporting specification to the Board or a duly authorised delegated committee, demonstrated via the Trust s scheme of delegation. Claims management is integral to clinical governance and the formal reporting structure must ensure that those senior staff or groups with responsibility for Clinical Governance are included. No. Area for Assessment Action(s) Taken or Proposed 1.1 There is a designated Executive Director responsible for claims management. Determination of Executive Director to assume Claims Lead Evidence in Board Minute Evidence in Claims Policy Responsibility Chief Executive Projected Actual 1.2 There are reports on claims to the Board or duly authorised committee by the designated Board member, advising of key issues and/or major issues or developments affecting the organisation Sixthly monthly claims reports Annual Claims Report Determine audience of reports Distribution & dissemination lists etc Reflect the above in Claims Policy/Procedure Determine contents of such reports to include key issues and trends affecting the organisation
1.3 A formal reporting structure has been identified which includes both Clinical Negligence and Personal Injury claims. Determine formal reporting structure Evidence in Claims Policy/Procedure Cross reference into relevant Policies/Procedure /Strategies for both Clinical Negligence and Personal Injury Claims
Area for Assessment 2: Accountability The Trust has defined access to a designated Claims Manager, who has received external training in claims management and who can demonstrate sufficient experience in clinical negligence and personal injury litigation and has status and seniority within the organisation to manage claims actively Guidance: The organisation should have or have access to, a dedicated claims or litigation manager who has the relevant skills and knowledge to handle all claims. Although experience is valid and valuable it is dependant on caseload and mix. Evidence should be provided of ongoing training and professional competency. The Claims Manager must hold a recognised formal qualification in claims management or is working towards the qualification. This should be supported by continuing professional educational development and updating. In addition, the Claims Manager should be able to demonstrate seniority and status within the organisational structure sufficient to carry influence within the organisation and that he/she can exercise direct access to the Executive Director with responsibility for claims for the organisation. No. Area for Assessment Action(s) Taken or Proposed 2.1 The claims manager holds or is working towards a recognised formal claims management or relevant qualification. The Trust has entered into an SLA with the Welsh Risk Pool in relation to the provision of claims management services and for the duration of the SLA can relay on the fact that the allocated Claims Manager is a qualified and practising solicitor Responsibility Proposed Actual Pursuant to SLA 23/06/08 23/06/08
2.2 The Claims Manager can demonstrate experience, knowledge and skills to handle claims. 2.3 The Claims Manager can demonstrate on going updating and continuing professional development in the area of claims management Example of evidence: Updating sessions Attendance at conferences Preparation of relevant training Attendance at the Claims Managers Network 2.4 The Trust can demonstrate that the Claims Manager and the claims management process is given sufficient priority and profile within the Trust and that its Claims Manager has sufficient seniority within the Trust and can exercise direct access to the Executive Director with Board Responsibility for claims Examples of evidence: Organisational charts Minutes of Meetings The Trust has entered into an SLA with the Welsh Risk Pool in relation to the provision of claims management services and for the duration of the SLA can relay on the fact that the allocated Claims Manager is a qualified and practising solicitor The Trust has entered into an SLA with the Welsh Risk Pool in relation to the provision of claims management services and for the duration of the SLA can relay on the fact that the allocated Claims Manager is a qualified and practising solicitor and undertakes all necessary CPD to maintain her practising certificate with The Law Society How can the Trust show that its gives the person with responsibility for claims management profile with the organisation? How can the Trust show that it gives claims management support and profile across the organisation? Claims Manager = seniority? Direct access? Pursuant to SLA 23/06/08 23/06/08 Pursuant to SLA 23/06/08 23/06/08
Area for Assessment 3: Processes There is a clear policy on the handling of clinical negligence and personal injury claims, which conforms to Annex A of Circular WHC (97)17 and WHC (99)128 Guidance: Trusts should have a written policy on the handling of clinical negligence and personal injury claims, approved by the Board or duly authorised delegated committee covering:- Board level responsibility and relevant delegations of authority Role of and access to a Claims Manager When legal advice should be sought The involvement of front line staff The availability of a procedure for handling claims The use of a claims data base What and how claims management links into other systems Delegated limits How nuisance claims are categorised and should be dealt with The form and content of reports to the Board or duly authorised committee Its obligations in relation to novel, contentious or repercussive claims in relation to identification and reporting Use of Annex B Checklists No. Area for Assessment Action(s) Taken or Proposed 3.1 There is a policy which conforms to the required standards and provisions Review Claims Policy Ensure strategic reference to all issues required by the WHC Responsibility Claims Manager Projected Actual 3.2 The policy is in existence and has been reviewed and approved in accordance with the organisation s Ascertain compliance with local Policy Claims Manager
policy review procedure. 3.3 There is a minute of the Board or duly authorised committee approving the policy. Determine whether the Policy is to be approved by the Trust Board or a duly approved Committee? If the latter, seek formal ratification by Trust Board and stipulate delegated approval process in Policy Evidence with Trust Board Minutes approving the delegation Place Policy before duly approved Committee Claims Manager
Area for Assessment 4: Processes There is a well understood and clearly documented procedure for handling claims which embraces the requirements of WHC(97)17 Guidance: Claims management systems should embrace and allow, as appropriate, for: More pre-action contact with claimants; Better and earlier exchange of information; Better pre-action investigation; The organisation to be in a better position to settle claims earlier, without the need for expensive litigation; and Court proceedings to run efficiently and to timetable if litigation does become necessary. The organisation should demonstrate that: The procedure sets out the circumstances in which legal advice will be sought There is a scheme for delegation for officers within the organisation to make offers to settle claims below Board level The procedure contains guidance on how claims will be dealt with within the organisation, including liaison with third parties such as the Welsh Risk Pool, solicitors and claimants; The procedure complies with Welsh Risk Pool claims reporting requirements; The procedure details the timescales for the exchange of relevant information with claimants as per the civil procedure rules; The procedure states that the claims manager is notified immediately of any reported incidents or complaints that could potentially result in a claim; The procedure states that the conduct and control of all claims and claims documentation is the responsibility of the claims manager; The claims manager receives quarterly updates on the progress of all claims from appointed solicitors, the Welsh Risk Pool etc; The procedure requires that every effort be made to discuss and negotiate settlement prior to court proceedings and includes guidance on the use of:
face to face discussions with the claimant regarding the claim, early evaluation of the claim by a legal expert, internal and/or pro-active resolution of claims, advice by an expert, and Alternative Disputes Resolution/Mediation There is a procedure for the process of handling claims, which includes: setting-up a record on the claim, maintaining a claims review system, establishing an account of the original incident, identifying and maintaining all records related to the incident, establishing and maintaining contact with all staff involved, obtaining in-house or external expert view, instructing solicitors and monitoring their involvement and costs, negotiating out-of-court settlements liaising with the WRP. No. Area for Assessment Action(s) Taken or Proposed 4.1 There is a procedure that conforms to the guidance and WHC requirements Review Claims Procedure Ensure strategic reference to all issues required by the WHC Responsibility Claims Manager Projected Actual 4.2 The Board or duly delegated committee has approved the procedure Determine whether the Procedure is to be approved by the Trust Board or a duly approved Committee? If the latter, seek formal ratification by Trust Board and stipulate delegated approval Claims Manager
process in Policy/Procedure Evidence with Trust Board Minutes approving the delegation Place Procedure before duly approved Committee
Area for Assessment 5: Processes The Trust has complied with its obligations under the WRP Reimbursement Claims Procedure (reviewed July 2005) Guidance: The WRP Reimbursement Claims Procedure contains requirements regarding the following areas:- Making a claim to the WRP requires the use of specified documentation Claims may be rejected by the WRP Advisory Board for failure to satisfy certain conditions Some claims coming before the WRP Advisory Board have reimbursement refused in either whole or part pending the provision of further information Any interim claims for reimbursement must be submitted within 56 days of the cumulative balance reaching 100,000 All final claims for reimbursement must be submitted within 56 days of the case being resolved and the costs being paid in full No. Area for Assessment Action(s) Taken or Proposed 5.1 There have been claims for reimbursement during the period of assessment None required Responsibility Projected Actual 5.2 All claims for reimbursement received during the period of assessment are supported by a WRP1, Costs Schedule and Annex B None required 5.3 During the period of assessment, there None required
have been no more than 50% of claims submitted to the WRP subject to requests for additional information under WRP 8 forms 5.4 There have been no claims for reimbursement rejected for reimbursement on the basis of the information contained in the Annex B by the WRP Advisory Board during the current period of assessment None required 5.5 There have been no claims representing more than 50% of claims submitted for reimbursement returned to the Trust by the WRP Advisory Board due to a failure of the original Annex B with either a partial or nonreimbursement supported with a request for further and additional information deferred for payment None required 5.6 There have been no claims for reimbursement during the period of assessment which have been penalised for failure to comply with the 56 day rule Ensure process in place to monitor claims for reimbursement Claims Manager 01/07/08 01/07/08 5.7 All claims resolved with damages paid below excess have been notified to the WRP within 3 months of settlement using WRP 3 forms Ensure process in place to monitor claims for reimbursement Claims Manager 01/07/08 01/07/08 5.8 All claims resolved with damages paid below excess have been the subject of action planning to identify and learn lessons Ensure process in place to monitor claims for reimbursement Claims Manager 01/07/08 01/07/08
5.9 The Trust has either notified the WRP of the quantum of any claims which are likely to settle above excess and which are being handled by external solicitors other than Welsh Health Legal Services on WRP 2 forms or it has provided its year end quantum reports to the WRP Ensure process in place to monitor claims for reimbursement Claims Manager 01/07/08 01/07/08
Area for Assessment 6: Processes There is a system for learning lessons from claims, complaints and incidents. Guidance: There are a number of different systems for review of claims, complaints and incidents and the organisation has in place processes to learn, review, monitor, evaluate and audit actions taken to ensure the loop has been closed. This should include a process by which all claims are reviewed before closure and an appropriate senior manager is responsible for ensuring that any necessary remedial action is taken and general lessons disseminated. The responsibilities for the flow of information should be formal and not assumed. Further to ensure that the implications are appreciated throughout the organisation; a high-level review group should be formed and tasked with the functions of ensuring that the loop is closed. It is recommended that there should be the input of a Non-Executive Director into such a group. The terms of reference for this group should clearly identify the responsibilities for investigation and identifying lessons and structure/process should be put in place to reflect how lessons learned would be disseminated within the organisation. Within the mechanisms identified, there must be clear responsibilities for ensuring that what action has been proposed has actually been undertaken within appropriate timescales. Review and action planning should include: identifying the failures in the systems which lead to the claim ensuring that remedial action is identified ensuring the remedial action is taken action planning in respect of remedial action monitoring implementation to defined timescales evaluating and auditing both the implementation but also the efficacy on remedial action This should also include means of identifying items for inclusion on the organisation s relevant
risk register as claims should not be overlooked as a source of continuing risks. No. Area for Assessment Action(s) Taken or Proposed 6.1 The Trust has in place a defined and formalised process or procedure through which it sets out its objectives and practically how it learns lessons from claims This entire section needs to be the subject of discussions with relevant groups to determine appropriate processes Responsibility Projected Actual 6.2 The Trust has in place procedures to review lessons learned from claims 6.3 The Trust has in place procedures to monitor the implementation of any lessons learned from claims 6.4 The Trust has in place procedures to evaluate the efficacy of actions taken to implement lessons learned from claims 6.5 The Trust has in place procedures to audit actions taken regarding lessons learned from claims 6.6 A Review Group has been established by the Board to examine the implications of and any lessons which can be learnt from: Claims received, Claims settled, Incidents reported which may
result in claims, Complaints received which may escalate into a claim. 6.7 The minutes of the Review group should clearly demonstrate action as a result of reviews. 6.8 There is evidence demonstrating that action is taken on claims to bring about improvements in patient care and services 6.9 There is evidence that the Review Group incorporates risk management lead officers or there are formal channels of communication between the risk management lead officers and claims / complaints managers. 6.1 0 6.1 1 Where a claim has been identified as a patient safety incident but was not previously reported through the incident reporting process, there is evidence that the person with responsibility for risk management is informed and a report is sent to the National Patient Safety Agency (NPSA) via the National Reporting and Learning System (NRLS) retrospectively Any outstanding requirements for remedial action are added to an appropriate risk register within the organisation when it is identified
Area for Assessment 7: Processes There is a claims database, (manual or computerised) with information on all claims, which provides regular information to the Trust Board or Group, including: number of claims aggregate value of claims in progress details of any major individual claims progress and likely outcome of ongoing claims including expected settlement date value of claims settled and final outcomes trends of specialities/departments/individuals involved proposals regarding remedial action arising out of claims There are linkages between information on claims, and information on risks, incidents, complaints and audit. Guidance: Reports should be analysed at a level which will enable the Board or the Committee to form a view of emerging trends and the organisations claims profile generally. The organisation should be able to demonstrate that: An identification and analysis report of patterns and trends in all reported claims is produced for the Risk Management Committee and Board on a regular basis (e.g. quarterly). There should also be appropriate linkages between directorates, complaints management, risk management, clinical audit and with directorates and departments within the organisation. Relevant information and feedback on reports is circulated at all management levels within the organisation. Such feedback should include information on the actions taken to reduce or eliminate reported claims, and any changes in working practices.
No. Area for Assessment Action(s) Taken or Proposed 7.1 There is a claims database which collects information on all claims Undertake a benchmarking exercise to ensure that the Trust s Datix database of claims is accurate and up to date Responsibility Claims Manager Projected 01/09/08 Actual 7.2 There are regular reports to the Trust Board or Committee. Sixthly monthly claims reports Annual Claims Report Reflect the above in Claims Policy/Procedure Corporate Secretary/ Claims Manager 31/09/08 Determine contents of such reports to include key issues and trends affecting the organisation and specifically to include the points stipulated in the guidance 7.3 There is evidence of relevant information and feedback on these reports being circulated at all management levels of the organisation. Determine audience of reports Distribution & dissemination lists etc Corporate Secretary 7.4 There is a document or chart describing the links (computerised or otherwise) between information on claims, complaints, incidents and other risk information. Develop appropriate flowchart Include in Claims Policy Claims Manager
Area for Assessment 8: Processes Central approval by the Welsh Assembly Government is required for claims exceeding the limit of the delegated authority of 1 million or for any claims which raise novel, contentious or repercussive features Guidance: The former Welsh Office introduced a very substantial increase in the delegated limit for out of court settlement of clinical negligence and personal injury claims in March 1995. Provided that the guidance contained in WHC (97)17 and this standard are met, NHS organisations can continue to settle claims without prior approval from the Welsh Assembly Government up to a limit of 1 million. Claims exceeding or anticipated to exceed 1 million require prior approval for settlement or concession of liability by the Welsh Assembly Government as do claims which are novel, contentious or repercussive No. Area for Assessment Action(s) Taken or Proposed 8.1 Where there have been claims settled during the period of assessment outside of the delegated authority, these have approval by the Welsh Assembly Government. Responsibility Include obligations in Claims Procedure Claims Manager Projected Actual
Area for Assessment 9: Processes The WRP Advisory Board are required to identify a minimum of 30 claims for reimbursement made on the WRP for review within the financial year. The purpose of the review is to consider the manner in which the incident, complaint and claims were handled by the member organisation, whether lessons were learned and practices made safer with the primary purpose being to identify good practice in the management of incidents, complaints and claims for the benefit of all NHS organisations. Guidance: When claims reviews are undertaken, frequently outstanding clarification is required. Often the claim review is delayed awaiting this information and appropriate escalation processes are required to ensure that the claims manager is supported in obtaining the necessary information. Lessons learnt from claims reviews need to be taken forward within the organisation (cross reference with area for assessment 6) to minimise the risk of reoccurrence and contribute to improvements in patient and staff safety. No. Area for Assessment Action(s) Taken or Proposed 9.1 There is a process in place to support the provision of information for claims reviews, for example, availability of Determine and map process to be used Draft section for inclusion in the Claims Policy/Procedure Responsibility Claims Manager Projected Actual notes and/or correspondence within the Trust. 9.2 The organisation has an escalation process in place to expedite a Determine available resources within the Trust Claims Manager
response from staff (clinicians and non-clinicians) involved in the claim, where a timely response has not been forthcoming. Seek Board support for escalation process by including a strategic objective in Claims Policy 9.3 The process applied to lessons learnt within area for assessment 6 is applied to claims reviews undertaken by WRP assessors. Draft suitable escalation process for inclusion in the Claims Procedure Cross reference outcomes of Claims Reviews into the learning lessons processes adopted by the Trust and referred to under AFA 6 Claims Manager
Area for Assessment 10: Audit There is a system, which ensures that a representative sample of claims for reimbursement, made on the Welsh Risk Pool, is audited for accuracy by Internal Audit. Guidance: Claims usually take a number of years from receipt of claim to settlement and can involve a large number of payments and repayments; this gives rise to a potential for mistakes to occur. The Welsh Risk Pool requires that claims for reimbursement and repayment are made within specific timescales. An audit is carried out on 25 claims or 25% of all claims (which every is the fewer number) made against the Welsh Risk Pool to ascertain the accuracy of reports, costs, compensation claimed and that any claims / refunds have been dealt with in line with the WRP reimbursements. No. Area for Assessment Action(s) Taken or Proposed 10. 1 There is evidence of an audit within the period of assessment. The Trust needs to ensure that claims management remains on its annual audit programme although limited to the issues identified in the above guidance Responsibility Projected Actual