GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST

GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST Title Report date Indicative discussion time required Please classify the paper as: • To note • To endo...
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GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST Title Report date Indicative discussion time required Please classify the paper as: • To note • To endorse • To approve Executive Summary

Please describe as appropriate the link to: • The Trust Strategic Objectives • The Trust In-Year Objectives • The Trust Mission • The Trust Values Please describe how this affects patients/staff/carers etc.

Assurance Framework and Trust Risk Register Dashboard June 2013 10 minutes To approve the Assurance Framework and ratings and note the Dashbaord & Risk Register The new combined Assurance Framework and Risk Register and Dashboard report with the 2013-14 Annual plan risks Risk are themed using the strategic objectives, the Assurance Framework contains the risks of the annual plan. Supports the management of risks for staff and patients

Please describe what stakeholders think NA about this. Please describe how this affects our: Supports the management of risks which • performance could affect performance • quality and safety • cost • activity Is what is described in the paper Yes affordable? Please explain when you will be able to October 2013, February 2014 report progress about this issue. Please identify the risks associated with None this issue and describe how they will be dealt with. Please set out in the report in risk register format the risks associated with the issue. Please describe the aspects of this paper None that might require wider stakeholder engagement or public consultation, and early engagement with Governors. Please identify any other significant impact None or outcomes (where applicable) in relation to Financial issues, Equality and Diversity, the NHS Constitution, Legal issues or Sustainable Development. Recommendation

Author/Presenting Director

To approve the Assurance Framework and ratings and note the Dashboard & Risk Register Andrew Seaton Director of Safety

Assurance Framework and Trust Risk Register Dashboard Main Board – June 2013

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GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST MAIN BOARD June 2013 ASSURANCE FRAMEWORK & TRUST RISK REGISTER DASHBOARD 1

Purpose of Report

1.1

To approve the new Assurance Framework (AF) and dashboard and note the Trust Risk Register (TRR).

2

Background

2.1

The Assurance Framework (appendix 1) is a Trust Board tool that monitors the most significant risks to the Annual Plan. Each year the Assurance Framework is refreshed so that it reflects the risks to the current Annual Plan. The top ten risks from the plan are added or consolidated with the previous year’s Assurance Framework to ensure continuity. Risks from the Trust Risk Register (appendix 2) that need to be mitigated to deliver the Annual Plan can also included in the Assurance Framework.

3.1

To show themed risks of both the AF &TRR the risks have been brought together under the strategic headings (e.g. Our Business) so that the risks associated with the Annual Plan (AF) and the current Trust risks can be linked visually.

3.2

To show the level of assurance carried by the monitoring evidence a simple rating scheme has been included as follows: Level 1

Management reviewed assurance

Level 2

Board reviewed assurance

Level 3

Independently provided assurance

3.3

It will be important for the Board to approve the assigned level of assurance as it will be relied on when reviewing the dashboard going forward.

3.3

In combination this provides the Board with a themed view of the Annual plan risks in the AF and the risks in the current TRR with an assessment of the level of assurance as suggested by KPMG.

3.4

Normally associated with the dashboard will be the more detailed information for both the AF &TRR

3

Recommendation To approve the 2013-14 Assurance Framework and ratings with the associated dashboard.

Author:

Andrew Seaton - Director of Safety

Presenting Director:

Andrew Seaton - Director of Safety

Date June 2013

AF & TRR Dashboard Main Board -June2013

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GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST

Current risk description from Assurance Framework

Strategic Objective Risk Register linked by theme to the Assurance Framework

Strategic Objective e.g. Our Patient Assurance Framework

Assurance Framework

Assurance Framework

Unable to manage unscheduled attendances\admissions within the current capacity

No further risks

No further risks

Last 12

Now 6

Assure 2

Trust Risk Register

M1a The clinical risk of delay in treating patients arriving at Accident and Emergency during periods of high demand or staff shortage Last 16

Now 16

Trust Risk Register

No further risks

Assure 2

Assurance Scale

Previous Risk Score

Current Risk Score

AF & TRR Dashboard Main Board -June2013

1. Management Reviewed Assurance 2. Board Reviewed Assurance 3. External Reviewed Assurance

Page 1 of 4

Our Business Assurance Framework

Assurance Framework

Assurance Framework

Trust Risk Register

Trust Risk Register

Reduction of income due to reduced demand , tariff changes, loss of services to competitors, or failure to agree appropriate contract levels through the new arrangements for commissioning specialised services

Failure to deliver financial plans

Failure to maintain the positive reputation of our organisation

M1 Inability to manage unscheduled admissions/ attendances within the current capacity leading to opening of unfunded beds and employment of agency staff, breaches for government targets

RO 40 Water ingress into telecoms infrastructure under new Women's Centre at GRH leading to potential service outage and significant health and safety risk of electrocution for technicians

Last

Now 10

Assure 2

Last

Now 10

Assure 2

Last

Now 10

Assure 3

Last 20

Now 20

Assure 2

DSp139 Possible inadequate capacity to store deceased patients until released to their families or funeral directors Last 16

Now 16

Assure 2

F6 Lack of certainty in the Specialist commissioning landscape leading to loss of income or failure to deliver QIPP Last 20

AF & TRR Dashboard Main Board -June 2013

Now 20

Assure 2

Last 20

Now 16

Assure 3

F2 Failure to demonstrate expected savings through workforce projects

Last 20

Now 20

Assure 2

C10 Contractual finance arrangements need to be agreed prior to commencement of building work of satellite treatment area Last 12

Now 12

Assure 2

Page 2 of 4

Our Service Assurance Framework

Assurance Framework

Assurance Framework

Trust Risk Register

Trust Risk Register

Failure to meet national target for reduction in clostridium difficile infections (56 cases)

Unable to manage unscheduled attendances\admissions within the current capacity

Inability to meet quality standards across all of our services

M1a The clinical risk of delay in treating patients arriving at Accident and Emergency during periods of high demand or staff shortage and during reconfiguration.

DSp 136 Increased separation of current episode of care record from main Trust health record

Last

Now 16

Assure 2

Last

Now 15

Assure 2

Last

Now 10

Assure 3

Last 25

Now 20

Assure 2

M11 Delay in providing routine endoscopy screening and surveillance. Last 20

Now 20

Assure 2

Last 15

Now 15

Assure 1

EFDEST ID1749 Loss of electrical power due to external power failures Last 16

Now 16

Assure 1

DSp1 Inability to maintain business continuity for the OPMAS computer systems Last New

AF & TRR Dashboard Main Board -June 2013

Now 15

Assure 2

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Our Staff Assurance Framework

Assurance Framework

Assurance Framework

Trust Risk Register

Trust Risk Register

Failure to engage appropriately with staff, leading to poor alignment of services and a de-motivation of the workforce

Failure to match the workforce profile with the clinical/service needs of the organisation

No further risks

No further risks

No further risks

Last

Now 16

Assure 2

Last

Now 9

Assure 2

Our Patients Assurance Framework

Assurance Framework

Assurance Framework

Trust Risk Register

Trust Risk Register

Failure to maintain 4hr wait target

Failure to discharge patients in a way which means their expectations.

No further risks

M1b Lack of middle grade doctors in the emergency department and other clinical areas

C4 Risk to patient / organisation due to delayed completion/ submission of discharge summaries

Last

Now 20

Assure 2

AF & TRR Dashboard Main Board -June 2013

Last

Now 15

Assure 2

Last 20

Now 20

Assure 2

Last 15

Now 15

Assure 2

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GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST TRUST RISK REGISTER – June 2013

M1b Lack of middle grade doctors in the emergency department and other clinical areas

Trust Risk Register Main Board – June 2013

Review date

Risk rating score

M1a The clinical risk of delay in treating patients arriving at Accident and Emergency during periods of high demand or staff shortage and during reconfiguration.

Responsible Assurance Director & Committee Key Meeting

Impact score

M1 Inability to manage unscheduled admissions/ attendances within the current capacity leading to opening of unfunded beds and employment of agency staff, breaches for government targets

Monitoring / mitigation

Likelihood score

Risk

Appendix 2

Director of Service Delivery

Finance and Performance

Monthly

4 (5)

5 (5)

20 (25)

Trust Board

Monthly

4

4

16

Trust Board

Monthly

5

4

20

Emergency Care Board • Weekly Emergency Care Board • Emergency Care Plan o Addressing three main areas of concern  Demand  Staffing (Medical & Nursing)  Beds and capacity • Further external review involving IST • Monthly Emergency Care project report

Director of Service Delivery Emergency Care Board

Director of Service Delivery Emergency Care Board

Page 1 of 4

Review date

Medical Director

Trust Management Team

Monthly

5

3

15

Finance & Performance committee

Monthly

4

5

20

Trust Management Team

Monthly

4

5

20

Risk rating score

Responsible Assurance Director & Committee Key Meeting

Impact score

Monitoring / mitigation

Likelihood score

Risk

C4 Risk to patient / organisation due to delayed completion/ submission of discharge summaries contravening Commissioning contract

• •

F2 Failure to demonstrate expected savings through workforce projects





Project team chaired by Medical Director Monthly monitoring – identifying top / bottom 10 compliant teams sent to divisional boards QC monitoring Project sponsors and leads assigned to each work stream with Project plans and mile stones. Divisional representatives responsible for ownership of actions within the Divisions.

Discharge Summary Steering Group Director of Human Resources & Organisational Development Workforce Review Board

M11 Delay in providing routine endoscopy screening and surveillance.





Trust Risk Register Main Board – June 2013

Implement agreed detailed plan to reduce waiting times and maintain the diagnostic waiting times at the required standard. Plan agreed with Commissioners to reduce waiting times by July 2013

Director of Service Delivery Finance and Performance Committee

Page 2 of 4

• • •

EFDEST ID1749 Loss of electrical power due to external power failures

• • • •

DSp 136 Increased separation of current episode of care record from main Trust health record

RO 40 Water ingress into telecoms infrastructure under new Women's Centre at GRH leading to potential service outage and significant health and safety risk of electrocution for technicians.

Trust Risk Register Main Board – June 2013

Review date

Close working with partners in existing and emerging commissioning organisations Trust adopting lead role for projects with a high risk involved. Trust working closely with NHSG and Specialist Commissioners to minimise risk in the transition period

Director of Finance

Trust Management Team

Monthly

4

5

20

Work completed on current standby generators to rectify start-up issues Design completed for HV ringmain on site Phase 1 works ( new suppression system to be completed by 31 May 13 Phase 2 works ( new HV ringmain to be completed by Sep/Oct 13

Director of Estates and Facilities

Trust Management Team

Monthly

4

4

16

Information Governance Committee

Monthly

5

3

15

TMT

Monthly

4

5

20

Risk rating score

Monitoring / mitigation

Impact score

F6 Lack of certainty in the Specialist commissioning landscape leading to loss of income or failure to deliver QIPP

Responsible Assurance Director Committee

Likelihood score

Risk

Finance and Performance Committee

E&F Board

• Standardisation of practice on CGH & GRH sites • Revised process for request of records in ACUs • Education and awareness programmes for Ward clerks, Senior nurses, and Directorate leads

Director of Service Delivery

• Re-provision of joints in a waterproof duct. Cutting and re-joining of approx 3,000 telephone connections.

Director of Clinical Strategy

Health Records group

CITS meeting

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Responsible Assurance Director Committee

Review date

Likelihood score

NEW DSp1 Inability to maintain business continuity for the OPMAS computer systems

OPMAS contingency Mitigation Plan Chemotherapy Sub Group Oncology, Haematology and Palliative Care Board

Dr F.Jewell

TMT

Monthly

3

5

15

SOP for escalation of capacity problems Capital scheme to improve CGH facilities Improvement of associated processes

Dr F.Jewell

TMT

Monthly

4

4

16

NEW DSp139 Possible inadequate capacity to store deceased patients until released to their families or funeral directors

Trust Risk Register Main Board – June 2013

Risk rating score

Monitoring / mitigation

Impact score

Risk

Page 4 of 4

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