West Hertfordshire Hospitals NHS Trust Board Assurance Framework September Assurances on the effectiveness of controls

Transcription

1 Principle risk description Key controls Sources of s on the of controls control Actions planned/ update Trust Objective 2014/15: Achieve continuous improvement in the quality of patient care that we provide and the delivery of service across all areas Principal Risk 1: Failure to maintain the quality of patient experience Lead Executive: Chief Nurse and DIPC Failure to meet quality indicators Failure to deliver the quality aspects of contracts with the commissioners Breach of CQC regulations CIPs impact on safety or unacceptably reduce service quality Poor bed management processes impact on patient safety Staff attitude and behaviours having a negative impact Potential effect: Poor patient experience and standards of care Inaccurate or inappropriate media coverage Demotivated staff Potential loss of licence to practice Potential loss of reputation Financial penalties may be applied Development of patient experience strategy Onion meetings Safety Thermometer Feedback from complaints & claims, Patient Choice, Patient Opinion and PALS Friends & Family test Incident ing Developing our Organisation new values and behaviours CQUIN & contract monitoring process Quality impact review process of all CIP plans. Whistleblowing policy Clinical governance meetings Patient Safety, Quality and Risk Appraisal / Reported to : Patient Experience Integrated Performance Report Report from Patient Quality and Risk Audit Report Annual nursing skill mix review National patient and staff surveys Patient ed outcome measurers (PROM) National clinical audits Audit review Infection Prevention and Control Serious Dates to be added when sources of s are ed to No integrated patient experience strategy No current gap in identified ti Patient experience strategy in level (RAG rating)

2 revalidation Quality Account priorities Pressure ulcer reduction plan incident Patient stories walkabouts

3 Principle risk description Key controls Sources of s on the of controls control Trust Objective 2014/15: Creating a clear and credible long term financial strategy CQC Domain: Well Led? Actions planned/ update level (RAG rating) Risk 2: Failure to develop a financially sustainable future Lead Executive: Chief Financial Officer Failure to agree sufficient funding for emergency activity. Failure to instil effective financial control. Failure to identify/achieve required levels of efficiency (EP). Delayed outcome of west Hertfordshire wide services review. Failure to agree sufficient financial support during period of transformation. Potential effect: FY15 plan/target not achieved. Cash support required in excess of that planned. External intervention. Loss of market share. Extended timetable for delivery of sustainable and financially viable acute Trust. Deterioration to reputation. Budget setting and business planning process Budget management process Contract monitoring process Standing Financial Instructions (SFIs) Annual audit plan and Local Counter Fraud plan. Monitoring of EP Monthly TDA integrated delivery meetings Monthly divisional review group TDA funding application process Reported to : Monthly finance Monthly Finance Audit Other sources: Internal Audit External Audit Regular review of EP by Finance Review meetings with commissioners Outcomes of monthly IDM meetings Reported to : Dates to be added when sources of s are ed to Finance Monitoring of adherence, escalation and action. EP Engagement and ownership Embedded governance system and processes On-going identification of efficiencies Other Skilled workforce Investment planning and delivery. Gap: Establish: Estates Strategy Group Capital Finance Planning and Control Group Investment Appraisal Group Control Gap Finance: Review and establish escalation process Control Gap EP: Agree Executive Sponsors Establish Delivery Group Establish 2 year rolling EP

4 Control Gap Other: Roll-out training and programme

5 Principle risk description Key controls Sources of s on the of controls control Actions planned/ update level Trust Objective 2014/15: Achieve continuous improvement in the quality of patient care that we provide and the delivery of service across all areas Principal Risk 3: Failure to maintain operational Lead Executive: Chief Operating Officer(s) Failure of national targets (A&E, cancer, RTT) Failure to reduce delayed transfers of care Failure of accurate ing and poor data Poor clinical engagement Potential effect: High numbers of people waiting for transfer from inpatient care Delays in patient flow, patients not seen in a timely way Reduced patient experience Failure of KPI s and selfcertification Services may be unaffordable Quality of care provided to patients may fall Loss in reputation Failure to meet contractual requirements Failure to gain FT status Daily Onion meetings Daily operational meetings Development of an unscheduled care programme Split role of Chief Operating Officer into planned and unplanned care Support by IST to establish a best practice referral to treatment (RTT) policy Monthly operational management meeting (OMG) Working closely with NHS partners around discharge (IADT) Implementing cancer improvement action plan Implementation of seven day working Review of 6-week diagnostic wait Strengthened Reported to : Monthly finance Monthly Integrated s Unscheduled care programme Audit Report RTT programme Cancer improvement plan Other sources: System-wide urgent care dashboard Delivery plan to transformation Dates to be added when sources of s are ed to Unscheduled care programme to be embedded Best practice referral to treatment (RTT) policy to be established Keeping Daily Onion meetings 'fresh' and relevant Cancer improvement action plan to be embedded Implementatio n of seven day working within the national timeframe Further of integrated Embedding and continual Pace of IMT work plan to further strengthen ing and validation Robust standard operating procedures, processes and policies not yet in place in all operational areas Ensure IMT involvement in all workstreams for operational All service s and changes within the operational work-streams will be supported by robust standardised operational policies and procedures Cycles of audits planned for all initiatives to ensure

6 clinical engagement Divisional reviews Monthly Trust Leadership review of Divisional Performance reviews

7 Principle risk description Key controls Sources of s on the of controls control Actions planned/ update Trust Objective 2014/15: Achieve continuous improvement in the quality of patient care that we provide and the delivery of service across all areas Principal Risk 4: Failure to sustain an engaged effective workforce Lead Executive: Director of Workforce Assuranc e level Difficulty recruiting and retaining high-quality staff in certain areas Low levels of staff satisfaction, health & well-being and engagement Insufficient provision of training, appraisals and Potential effect: Failure to deliver required activity levels / poor staff Low levels of staff involvement and engagement Increase in of staff leaving the Trust Poor patient experience and outcomes Poor CQC assessment results Poor patient survey results Loss of reputation Reduced ability to embed new ways of working Development of a new HR service model Developing our Organisation Programme (DO) New values and behaviours Improved values based recruitment and induction processes Staff engagement and awareness programme in place Divisional staff survey action plans Education and processes in place Appraisal compliance and training attendance monitored Team job planning Reported to : Workforce s Integrated Staff survey action plan Friends and family staff survey Other sources: Dates to be added when sources of s are ed to Delivery Embedding new HR service model Further of the Developing our Organisation Programme (DO) Embedding the new values and behaviours across all areas of the organisation

8 Principle risk description Key controls Sources of s on the of controls control Actions planned/ update Trust Objective 2014/15: Achieve continuous improvement in the quality of patient care that we provide and the delivery of service across all areas Setting out our future clinical strategy through clinical leadership in parternship and with whole system working Principal Risk 5: Failure to achieve the transformation delivery programme Lead Executive: Director of Transformation Failure to maintain the of organisational culture Failure to maintain capacity and focus on longer term planning Organisational barriers impede the Trust s ability to apply innovative models of care and patient pathways Failure to receive funding Failure to achieve culture of continuous improvement Potential effect: Failure to increase utilisation of high value resources and inability to reduce delivery costs Failure to deliver new patient pathways Failure to embed robust governance and processes Poor patient experience and outcomes Performance issues Services fail to achieve long term sustainability Recruitment of a substantive Director of Transformation and appropriate support Development of a robust transformation delivery plan Organisational restructure to improve fundamental capacity and capability within the organisation Working in partnership with health and social care colleagues to design a whole system approach to the running of future services Seeking appropriate funding to support the programme Monthly divisional reviews Reported to : Monthly transformation delivery programme West Herts Strategic Review Integrated Other sources: CQC assessment Patient feedback Reduced number of complaints Weekly update to Executive Team Bi-monthly Transformation meetings Bi-weekly Dates to be added when sources of s are ed to Receipt of funding to support the programme Delivery of robust transformation delivery plan Performance management reviews in Governance structure to be confirmed No current gap in identified Delivery plan signoff by Transform ation on 20 August 201 Substantiv e Director commence s in past on 15 September 2014 level

9 Loss of reputation Delivery Group meetings Trust Leadership Executive

10 Principle risk description Key controls Sources of s on the of controls control Trust Objective 2014/15: Setting out our future clinical strategy through clinical leadership in partnership and with whole system working Principal Risk 6: Failure to have strong leadership and governance systems in place Our corporate governance structure is new and is not owned/understood by the organisation We have an out-of-date Framework (BAF); Our is new and needs to develop experience and skills Potential effect: Failure to deliver quality checking systems to manage risk and assure the health, welfare and safety of people who receive care Poor patient experience and outcomes Performance issues (clinical and financial) Loss of reputation Reduction in level of trust Our corporate governance structure is new and is not owned/understoo d by the organisation New substantive leadership team in place (from October 2014) Refresh and of new corporate governance and quality governance risk management and processes plan agreed including 360 reviews, observation and days (with support from the Good Governance Institute (GGI)) Executive director programme in Reported to : Chief Executive s to Director of Corporate Affairs and Communicati ons s to (in relation to corporate governance) Chief Nurse s to (in relation to quality governance) Trust Secretary s to (in relation to corporate governance) Integrated Dates to be added when sources of s are ed to Actions planned/ update level Lead Executive: Director of Corporate Affairs and Communications L l Appointment of substantive Trust Secretary bstae Further of integrated None identified at 8/8/2014

11 place (with support from Talent Works) Communication of new board and committee structure Appointment of substantive Trust Secretary Development of refreshed and revised Framework Review of risk management approach Establishment of a new Patient Quality, Safety and Risk Introduction of new integrated (for and Trust Level Executive ) Plans in place to test the organisation against the Quality Governance Framework (QGAF) and Governance Framework (BGAF) ed to the Monthly s and minutes to the with Chairs giving verbal updates as necessary Annual review of s terms of reference and work plans Quarterly review of Framework Review of QGAF and BGAF test and resulting action plan/s to be ed to the Risk registers ed to the Other sources: days

12 Principle risk description Key controls Sources of s on the of controls control Actions planned/ update Trust Objective 2014/15: Achieve continuous improvement in the quality of patient care that we provide and the delivery of service across all areas Principal Risk 7: Failure to deliver services due to residual estates issues Lead Executive: Chief Financial Officer Historical lack of investment in maintenance Buildings inefficient and expensive to maintain over 50% of buildings being C or below Over 40m investment needed across the three sites Breach of statutory requirements Potential effect: Inability to provide safe and suitable environment for patient care Demotivated workforce Difficult to recruit estates professionals Reduction in services Not meeting sustainability agenda Recruitment and retention of staff Poor patient experience and Substantial financial support received from stakeholders for immediate and emergency work on essential services Development of a backlog maintenance programme Development of a professional, adaptable estates and facilities team Creation of a detailed investment portfolio which takes into account legal requirements, risk analysis, future and reduction of short term plans with no longevity Working in Reported to : Health and Safety PLACE Watford Health Campus Asbestos GAP analysis Other sources: Support and commendation from statutory bodies such as Health and Safety Executive Reduction in service failures Public satisfaction survey results Dates to be added when sources of s are ed to Gap analysis being drawn up Formal s and audits will be available in August/Sept to create baseline in knowledge base Reviews and surveys into statutory compliance issues still being completed J Without the accredited information from the audits and surveys the final s and certificates cannot be included in the. Gap analysis framework has been created, action plans and responsible persons have been identified Meetings with statutory bodies and HSE have been undertaken to gauge the requirements to achieve satisfactory approvals level

13 outcomes Poor CQC assessment results Poor patient survey results Loss of reputation Reduced ability to embed new ways of working partnership with Watford Council and Kier on the plans for the Watford Health Campus

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15 Principle risk description Key controls Sources of s on the of controls control Actions planned/ update Trust Objective 2014/15: Achieve continuous improvement in the quality of patient care that we provide and the delivery of service across all areas Principal Risk 8: Failure to deliver improvements in information technology (ICT) and decision support Lead Executive: Chief Information Officer ICT: The current ICT service provision is not fit for purpose, carries significant operational risk, and will not support delivery of future phases of the Information Management and Technology strategy. Trust needs to adopt an integrated Patient Electronic Record System to track and manage patient care along the patient pathway. The system will integrate all patient-centric administrative and clinical information. Risk of loss of services and damage to equipment. Risk of delay to business continuity and potential loss of clinical data. Inability to deploy modern hardware and software and provide more agile ways of working. Poor service, operational and patient and staff experience. Five year contract with CGI Group provide a full managed ICT service, inluding the below: Development of an infrastructure and service management programme that supports clinical and non-clinical applications. Investment in computers and other ICT equipment. Provision of reliable helpdesk services, including a 24/7 helpdesk. Faster networks, improved telephone systems and increased IT security. Contract controls in place to monitor, value for money and benefit delivery. CGI contract: Contract negotiated with Trust Finance, IT and procurement teams. Legal of contract by DLA Piper. Trust governance: Informatics Group oversight of programme delivery and service management panels. Informatics Group ing through TLEC to Trust. No gaps currently identified. Trust approval of governance and contract control. Governance and contract control paper to be taken to Finance and Trust (September 2014). IM&T Strategy refresh to be undertaken (plan to Trust November 2014). level AMBER

16 Decision Support: There is insufficient capability and capacity in the Informatics department to provide in-house ing and analysis services with insight. The current ICT service does not support the introduction of modern hardware and software to support provision of timely and easily-accessible and quality information. Ineffective governance and ownership for monitoring operational data at a senior level. The does not have adequate that the organisation is delivering effective clinical care. We cannot demonstrate monitoring, understanding and ownership of and quality at all levels of the organisation. Coding: Coding in greater detail requires more time is spent researching case notes. There is an increased volume of data requests from clinical divisions and management New integrated in place from July 2014, with enhanced exception ing. Re-formatted divisional reviews scheduled from August CEO to chair divisional reviews quarterly from September Informatics Group ing through TLEC to Trust. Internal and external audits of ing. Internal and external coding audits. Divisional reviews not yet functioning effectively. Integrated requires further work. Insufficient regarding data quality. Capability and capacity review of Information Team (by November 2014). Provision of Information drop in sessions to support senior managers (by September 2014). Delivery of divisional and clinician scorecards (Sept 2014). Audits of ing. Establish Information PMO to manage internal and external information requests. Business case to address resource and education gaps (to OMG August 2014, TLEC Sept AMBER AMBER

17 team on an ad-hoc basis. There is a lack of succession planning, with a number of staff nearing retirement. There is an over reliance on contract coders to fill gaps in resource. The above can increase data quality risks. There is a need for intensive training, supervision and support to ensure high calibre of workforce to reduce the reliance on contract staff. 2014). Recruitment and retention action plan (by November 2014, assuming approval of business case). Undertake coding audits. Risk that accurate payments are not made to the Trust under Payment by Results. Inability to fully inform strategic and local decisions for capacity and service planning. Unable to provide sufficient detail on clinical and outcomes. Risk of lost income and inaccurate data.