An Organisation-wide Document for Ensuring a Systematic Approach to Risk Management Training
NHS Trust
An Organisation-wide Document for Ensuring
a Systematic Approach to Risk Management Training
Version:
Ratified by:
Date ratified:
Name of originator/author:
Name of responsible committee/individual:
Name of executive lead:
Date issued:
Review date:
Target audience:
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An Organisation-wide Document for Ensuring a Systematic Approach to Risk Management Training
Contents
1
Introduction............................................................................................................. 4
2
Purpose.................................................................................................................... 4
3
Explanation of Terms .............................................................................................. 4
4
Duties ...................................................................................................................... 4
4.1
4.2
5
Duties within the Organisation ............................................................................................... 4
Committees and Groups with Overarching Responsibilities .................................................. 5
A Systematic Approach to Risk Management Training ........................................... 6
5.1
5.2
5.3
5.4
5.5
Training Needs Analysis (TNA) ................................................................................................ 6
Training Action Plan(s) ............................................................................................................ 7
Training Prospectus................................................................................................................. 7
Recording Attendance and Completion of Training............................................................... 7
Non-attendance at Training (Including Persistent Non-attendance) ..................................... 7
6
Equality Impact Assessment ................................................................................... 8
7
Monitoring Compliance with the Document .......................................................... 8
7.1
7.2
8
Process for Monitoring Compliance ....................................................................................... 8
Standards/Key Performance Indicators .................................................................................. 8
References ............................................................................................................... 8
8.1
9
Guidance from Other Organisations ....................................................................................... 8
Associated Documentation ..................................................................................... 9
Appendix A - Training Needs Analysis and Action Planning Process Tool ................... 10
Appendix B - Training Needs Analysis (Supplementary Guidance) .............................. 13
Appendix C - Template Document for Ensuring a Systematic Approach to Risk
Management Training .................................................................................................. 14
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An Organisation-wide Document for Ensuring a Systematic Approach to Risk Management Training
Review and Amendment Log
Version No
Type of Change
Date
Description of change
V.3
Annual review
Mar 2011
Update to section 8 ‘References’
Update to Appendix A ‘An Example Training
Needs Analysis and Action Planning Process
Tool’
V.3
Amendment
Mar 2011
Addition of amendment log
Addition of example of definition
Addition of examples of associated documents
V.4
Annual review
Mar 2012
Update to section 4 ‘Duties’
Update to section 5 ‘A Systematic Approach to
Risk Management Training’
V.4
Amendment
Mar 2012
Change to format including automated
contents page
Please Note the Intention of this Document
This document has been developed with the aim of providing a model document template.
However, any documentation subsequently produced must follow its own rules and include details
of all the requirements set out in sections 1-9, where relevant. The organisation may use this
template and adapt it to reflect procedures within the organisation or alternatively use a document
already in existence. Whichever approach is used the organisation must ensure it is compliant with
the minimum requirements of the relevant National Health Service Litigation Authority (NHSLA) Risk
Management Standards.
a
To assist the organisation, areas have been identified in the margins where the section
within the template document relates to the minimum requirements for the criterion in the
relevant NHSLA Risk Management Standards.
It is important that the document should follow any pre-existing guidance within the organisation in
relation to style and format of documentation. Please note that a template document entitled An
Organisation-wide Document for the Development and Management of Procedural Documents can
be found on the NHSLA website which may provide the organisation with additional guidance.
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An Organisation-wide Document for Ensuring a Systematic Approach to Risk Management Training
1
Introduction
Give an overview of the importance of ensuring that there is a systematic approach to risk
management training. State that the overall aim of the document is based on reducing
clinical risk and increasing patient safety. The organisation should recognise this will be
achieved through management and staff awareness of the risks associated with not
receiving relevant and timely risk management education, and the introduction of
appropriate measures to minimise these risks. Reference should be made to any significant
legislative or guidance documents that have been recently published.
2
Purpose
Within this section the organisation should provide the rationale for the development of the
document. It should include a description of how the organisation intends to ensure that
the process for implementing a systematic approach to risk management training is
managed in the most effective way. The document should have a specific focus on each of
the minimum requirements within this process, as identified in the NHSLA Risk Management
Standards, and not just a general overview of training management.
The document must describe the organisation’s whole-systems approach to managing risk
management training. It must ensure that clear procedures are in place to inform and
support all those involved throughout each stage of the process.
3
Explanation of Terms
This section should list and describe the meaning of the terms used within the context of this
document.

Training Needs Analysis
A breakdown, usually presented in the form of a spreadsheet or table, which
contains as a minimum: all staff groups; all training required by each group; and the
frequency of training required by each group. The training needs analysis (TNA) may
also include further details such as who will provide the training, the specific training
package to be used, etc.
The following list is a guide only and is not exhaustive:
4

Risk management training

Permanent staff
Duties
Give a brief overview of the roles, responsibilities and accountabilities for the
implementation of the organisation’s process. This section should be a brief overview only
and the details of the process for managing this should be incorporated within later sections
of the document. The following list is a guide only and is not exhaustive:
4.1
Duties within the Organisation
Some example responsibilities have been identified below; however, these should
be considered within the context of the individual organisational structure.
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An Organisation-wide Document for Ensuring a Systematic Approach to Risk Management Training
Chief Executive
This section should state that the chief executive is ultimately accountable for the
implementation of this organisation-wide process.
Education Manager
This section will need to identify the roles and responsibilities of the individual who
has overall responsibility for the day to day management of education. This section
should include a description of the manager’s communication links, both within and
outside the organisation.
Education Staff
This section will need to identify the roles and responsibilities of all those involved in
the day to day delivery of risk management training.
Administration Staff
This section should include who is responsible for recording and monitoring all risk
management training activity within the organisation.
Manager(s)
The roles and responsibilities of manager(s) involved in the process for ensuring a
systematic approach to risk management training should be documented. This
section should include a description of their specific duties relating to the
implementation of the local educational programme.
All Staff
This section should define the responsibilities of all staff. It should emphasise the
individual responsibilities of all staff in relation to complying with the educational
objectives of the organisation in addition to any legislative or professional
educational commitments.
4.2
Committees and Groups with Overarching Responsibilities
Trust Board
For effective implementation of the Organisation-wide Document for Ensuring a
Systematic Approach to Risk Management Training there must be active support
from the most senior members of the organisation. Organisations should detail how
the chief executive and the nominated directors are to gain assurance that this
document is being implemented within the organisation. There must be effective
cooperation at all levels of the organisation in order for this process to be successful.
Committees/Groups
This section should identify the committee/group which will have overall
responsibility for ensuring a systematic approach to risk management training. The
section should include:

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how this committee/group links with all the other relevant risk management
committees;
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
the role this committee/group has with ensuring continuous development of
this document;

the role the committee/group has in the analysis of the approach to risk
management training;

how this committee/group communicates both up to board level, and down
to the local management levels; and

how the committee/group facilitates organisational learning and
improvement as a result of monitoring the provision of risk management
training.
It would be considered good practice if the organisation developed terms of
reference for this committee/group including: accountability, responsibility,
authority, membership (including identified co-opted members and deputies),
meeting schedule and quorum, etc. In addition the terms of reference should be
dated and signed. The roles and responsibilities of the committee that is
instrumental in the decisions relating to effective risk management training should
be documented.
5
A Systematic Approach to Risk Management Training
This section should provide a description of the process for ensuring a systematic approach
to risk management training. The process must include a methodical way to analyse the
training needs; to plan, develop, and implement the training programme; and to assess the
programme’s implementation and results. This can be summarised under the headings
below. Please note that this is not an exhaustive list and the organisation may wish to
include additional headings.
a
5.1
Training Needs Analysis (TNA)
There are many approaches that organisations may take to the analysis of training
needs. This section should describe the process, taking an analytical approach to
determine what risk management training is required for all staff. It usually involves
collecting data, which can be gathered from several sources including staff surveys
and feedback, management observations, workshops and business meetings. The
aim should be to objectively identify the training needs of all employees, from which
it will be possible to build a plan that offers appropriate, cost-effective opportunities
to fill the identified gaps.
The findings from the analysis, as a minimum must include:

a list of topics defined as risk management training by the organisation
(must include all those referred to in the NHSLA Standards TNA Minimum
Data Set);

the staff groups required to attend each type of training; and

the frequency of updates required for each type of training.
This detail should then be summarised; this could be in the form of a matrix or a
table, as per Appendix A - Training Needs Analysis and Action Planning Process Tool.
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An Organisation-wide Document for Ensuring a Systematic Approach to Risk Management Training
Further guidance on completing your organisation’s TNA is provided in Appendix B Training Needs Analysis (Supplementary Guidance).
b
5.2
Training Action Plan(s)
This section should provide a description of the process for the development of
training action plan(s). The training action plan(s) should be developed from the
TNA, which will have identified the specific training requirements within the
organisation and the individual needs of the employees. Ideally a clear link between
the training objectives and the business objectives should be provided. The
description should take into consideration the training required, numbers involved,
where and when the staff will undertake the training, any costs likely to be incurred
and the training budget. It should be written in an easy to read format and contain
sufficient information to adequately inform senior managers, in particular those
with budget allocation responsibilities.
c
5.3
Training Prospectus
This section should provide a description of the process for the development of a
training prospectus. This should be developed from the training action plan(s), and
would therefore reflect the training agreed during the training needs analysis
process. A training prospectus in its simplest format is a compilation of all the
course programmes provided by an organisation, and could be presented in either a
paper or electronic format. For the training prospectus to be a meaningful and
informative document, for each course provided it must include: the key aims and
objectives; whether the course is mandatory or desirable; the venue for the training;
details of the tutor or how the training will be delivered; and the course duration,
dates and times.
d
5.4
Recording Attendance and Completion of Training
This section should provide a description of the process by which the organisation
ensures that employees attend and complete the relevant training programmes. It
should provide a description of the process by which the organisation coordinates all
records of training. Records of all training completed should be documented and
securely filed. Ideally the trainer and trainee should sign against each element of a
course programme and details of this training should be maintained on a central
database. It is acknowledged that various media can be used to record the
completion of training programmes and to collate training records.
The
methodology chosen by the organisation should be fully described within the
document.
e
f
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5.5
Non-attendance at Training (Including Persistent Non-attendance)
This section should provide a description of the process by which the organisation
follows up those employees who fail to attend the allocated training programmes. If
this process varies for different staff groups the variances in the process should be
included in the documentation. By implementing a robust monitoring system,
organisations will be able to recognise at an early stage when employees have failed
to attend an allocated training programme. Organisations should consider the
actions to be taken in cases where employees habitually fail to attend training
programmes. Positive and negative incentives could be used, for example, the
organisation may prevent an employee from undertaking any desirable training until
all the required elements of mandatory training have been completed.
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6
Equality Impact Assessment
The organisation should identify who will undertake the Equality Impact Assessment which is
required to consider the needs and assess the impact of this document in accordance with
the Organisation-wide Document for the Development and Management of Procedural
Documents. The Equality Impact Assessment Tool found at Appendix E of the Organisationwide Document for the Development and Management of Procedural Documents could be
completed and form part of the body of the document, but as a minimum a statement
should be included within the document to demonstrate that an Equality Impact Assessment
has been carried out and that the document does not discriminate, highlighting any areas of
good practice or risk areas requiring attention.
g
7
Monitoring Compliance with the Document
7.1
Process for Monitoring Compliance
This section should identify how the organisation plans to monitor compliance with
the Organisation-wide Document for Ensuring a Systematic Approach to Risk
Management Training. As a minimum it should include the review/monitoring of all
the minimum requirements within the NHSLA Risk Management Standards. The
following list is a guide to issues which could be considered within this section and
should be added to where appropriate:
7.2

Who will perform the monitoring?

When will the monitoring be performed?

How are you going to monitor?

What will happen if any shortfalls are identified?

Where will the results of the monitoring be reported?

How will the resulting action plan be progressed and monitored?

How will learning take place?
Standards/Key Performance Indicators
This section could contain auditable standards and/or key performance indicators
(KPIs) which may assist the organisation in the process for monitoring compliance.
8
References
This section should contain the details of any reference materials reviewed in the
development of the procedural document.
Listed below are some useful sources of reference material:
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8.1
Guidance from Other Organisations

Boorman, Dr S. (2009) NHS Health and Well-Being Review – Final Report

Boorman, Dr S. (2009) NHS Health and Well-Being Review – Interim Report
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9

Chartered Institute for Professional Development (CIPD) (2008) ‘What’s new from
CIPD research?’ CIPD website page

Chartered Institute of Personnel and Development (CIPD) (2003) Focus on the
learner: The Change Agenda

Department of Health (2000) An Organisation with a Memory. Report of an Expert
Group on Learning from Adverse Events in the NHS

McNamara. C. (1997) ‘Systematic Approaches to Training and Development’ Free
management library website

NHS Employers (2010) ‘Health and safety essential guide’ NHS Employers website
pages

Sloman. M. (2005) Change Agenda: Training to Learning

Trulove. S (2006) Training in Practice
Associated Documentation
This section should provide a cross reference to any other related organisational procedural
document(s). The following list is a guide only and is not exhaustive:
V.4

Training needs analysis

Training prospectus
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Appendix A - Training Needs Analysis and Action Planning Process Tool
Example Training Needs Analysis (TNA) and Action Planning Process
The table below represents an example of how an organisation could present its TNA. The
development of a training matrix will vary depending upon the organisation’s size, structure and
services it provides. The matrix itself is a table which simply depicts what training the organisation
provides, who should attend the training, and the frequency with which the training should be
repeated. Additional columns have been added to the table to facilitate the creation of an action
plan for the delivery of the identified training. This is the information that would be included within
the training prospectus. The table is the end point of what should have been a significant review of
training activities across the organisation. This should ensure the training depicted can realistically
be delivered within the agreed timeframes, taking into account national recommendations,
resources and funding available.
Organisations are reminded that the NHSLA Risk Management Standards do not dictate the level or
frequency of training that should be provided to your staff. This is for the organisation to decide
utilising the training expertise within the organisation. Organisations must ensure that as a
minimum the topics identified within the NHSLA Risk Management Standards (TNA Minimum Data
Set) are included within the TNA. The table below is intended for guidance purposes only.
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Training Needs Analysis and Action Planning Process
Type of training
Staff groups
requiring training
How often this
should be
undertaken
Length of
training
Delivery
method
Responsibility for
delivering training
Location of
attendance records
Health Record-Keeping Training
Investigation of Incidents,
Complaints and Claims Training
Risk Awareness Training for
Senior Management
Moving & Handling Training
Harassment & Bullying Training
Violence & Aggression Training
Slips, Trips & Falls (Staff & Others)
Training
Slips, Trips & Falls (Patients)
Training
Hand Hygiene Training
Inoculation Incident Training
Consent Training
Transfusion Process Training
Venous Thromboembolism
Training
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Type of training
Staff groups
requiring training
How often this
should be
undertaken
Length of
training
Delivery
method
Responsibility for
delivering training
Location of
attendance records
Medicines Management Training
Clinical Supervision Training
Clinical Risk Assessment Training
Observation of Patients Training
Dual Diagnosis (Mental Health &
Substance Misuse) Training
Rapid Tranquilisation Training
Medicines Management Training
Resuscitation Training
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Appendix B - Training Needs Analysis (Supplementary Guidance)
Training Needs Analysis (Supplementary Guidance)
1
The topics included in the template document need to take into account additional topics specific to mental health & learning disability and ambulance
services. Different organisations have different TNA Minimum Data Sets which should be consulted when developing the TNA.
2
If training in one topic is incorporated within another training session this should be indicated on the TNA. For example, if hand hygiene training is
incorporated into infection control training this should be documented on the TNA. Or training on slips, trips & falls (staff and others) may be part of
corporate induction.
3
Be realistic in the training you intend to deliver. Take into account timeframes, resources and financial implications of delivering the training.
4
Be specific when considering staff groups. Be careful of these being too generic, for example: all managers, all nurses, all medical staff. If this is not
accurate, you will not achieve compliance.
5
If there are differing levels of training this will need to be accounted for within the TNA. For example, resuscitation training can be delivered at basic and
more specialist levels. All of these will need to be included within the TNA.
6
Make sure the training within the overarching organisation-wide documentation and that identified within the TNA correlate. If the document and TNA do
not match, the organisation could potentially loose a significant number of compliance points.
7
To ensure accuracy, the organisation may choose to cross reference to the TNA without specifically identifying training requirements within the overarching
document. For example within the organisational ‘moving & handling’ document the training section could direct the reader to the organisation’s TNA. This
allows the TNA to remain a living document that can be reviewed and updated without the need for policies to be constantly changed.
8
The mode of delivery is not confined to classroom teaching; there are many ways in which training can be delivered remotely from training packages or
through cascade training. These should be included within the TNA.
9
The organisation needs to be aware of who is collating and analysing the training records. Without this knowledge it is impossible to calculate if the training
is being delivered in accordance with the TNA.
10
The frequency of training should be decided by the organisation based upon national recommendations and organisational needs. This may vary for
different staff groups and should be clearly identified within the TNA.
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An Organisation-wide Document for Ensuring a Systematic Approach to Risk Management Training
Appendix C - Template Document for Ensuring a Systematic Approach to Risk
Management Training
NHS Trust
An Organisation-wide Document for Ensuring a
Systematic Approach to Risk Management Training
Version:
Ratified by:
Date ratified:
Name of originator/author:
Name of responsible committee/individual:
Name of executive lead:
Date issued:
Review date:
Target audience:
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Contents
1
Introduction........................................................................................................... 17
2
Purpose.................................................................................................................. 17
3
Explanation of Terms ............................................................................................ 17
4
Duties .................................................................................................................... 17
4.1
4.2
5
Duties within the Organisation ............................................................................................. 17
Committees and Groups with Overarching Responsibilities ................................................ 17
A Systematic Approach to Risk Management Training ......................................... 17
5.1
5.2
5.3
5.4
5.5
Training Needs Analysis (TNA) .............................................................................................. 17
Training Action Plan(s) .......................................................................................................... 17
Training Prospectus............................................................................................................... 17
Recording Attendance and Completion of Training ............................................................. 17
Non-attendance at Training (Including Persistent Non-attendance) ................................... 17
6
Equality Impact Assessment ................................................................................. 17
7
Monitoring Compliance with the Document ........................................................ 17
7.1
7.2
8
References ............................................................................................................. 18
8.1
9
Process for Monitoring Compliance ..................................................................................... 17
Standards/Key Performance Indicators ................................................................................ 18
Guidance from Other Organisations ..................................................................................... 18
Associated Documentation ................................................................................... 18
Appendix A – Training Needs Analysis ......................................................................... 18
Appendix B – Checklist for the Review and Approval of Procedural Documents ........ 18
Appendix C – Version Control Sheet ............................................................................ 18
Appendix D – Plan for Dissemination ........................................................................... 18
Appendix E – Equality Impact Assessment Tool ........................................................... 18
Examples of the Checklist for the Review and Approval of Procedural Documents, Version Control
Sheet, Plan for Dissemination and the Equality Impact Assessment Tool can all be found within the
Organisation-wide Document for the Development and Management of Procedural Documents on
the NHSLA website.
Appendix B in the Organisation-wide Document for the Development and Management of Procedural
Documents contains a flowchart to assist with the process for the creation and implementation of
procedural documents.
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Review and Amendment Log
Version No
V.4
Type of Change
Date
Description of change
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An Organisation-wide Document for Ensuring a Systematic Approach to Risk Management Training
1
Introduction
2
Purpose
3
Explanation of Terms
4
Duties
5
4.1
Duties within the Organisation
4.2
Committees and Groups with Overarching Responsibilities
A Systematic Approach to Risk Management Training
5.1
Training Needs Analysis (TNA)
5.2
Training Action Plan(s)
5.3
Training Prospectus
5.4
Recording Attendance and Completion of Training
5.5
Non-attendance at Training (Including Persistent Non-attendance)
6
Equality Impact Assessment
7
Monitoring Compliance with the Document
7.1
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Process for Monitoring Compliance
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7.2
8
Standards/Key Performance Indicators
References
8.1
9
Guidance from Other Organisations
Associated Documentation
Appendix A – Training Needs Analysis
Appendix B – Checklist for the Review and Approval of Procedural Documents
Appendix C – Version Control Sheet
Appendix D – Plan for Dissemination
Appendix E – Equality Impact Assessment Tool
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