Structured Assessment 2015 Cwm Taf University Health Board. Audit year: 2015 Issued: January 2016 Document reference: 705A2015

Transcription

1 Structured Assessment 2015 Cwm Taf University Health Board Audit year: 2015 Issued: January 2016 Document reference: 705A2015

2 Status of report This document has been prepared as part of work performed in accordance with statutory functions. In the event of receiving a request for information to which this document may be relevant, attention is drawn to the Code of Practice issued under section 45 of the Freedom of Information Act The section 45 Code sets out the practice in the handling of requests that is expected of public authorities, including consultation with relevant third parties. In relation to this document, the Auditor General for Wales and the Wales Audit Office are relevant third parties. Any enquiries regarding disclosure or re-use of this document should be sent to the Wales Audit Office at info.officer@audit.wales. The team who delivered the work comprised, Jackie Joyce, James Foster, Kevin Sutch, Mike Jones, Dave Burridge and Dave Thomas. Page 2 of 30 - Structured Assessment Cwm Taf University Health Board

3 Contents Governance arrangements continue to evolve but some aspects, particularly ICT, are making insufficient progress, and achieving financial balance for remains a challenge. Summary Context 4 Main conclusions 4 Recommendations 6 Detailed findings The Health Board continues to monitor savings plans effectively, and has a good record of achieving financial balance, but whilst it again forecasts a breakeven position for , it faces significant financial challenges and needs to manage risks relating to planned savings and directorate sign-up to budgets The Board has set a clear vision and continues to strengthen governance arrangements, and its challenge is to further improve governance arrangements supporting the Quality and Safety Committee, address internal control weaknesses and develop a performance management framework Although the Health Board has change management arrangements in place to support delivery of its IMTP there are improvements needed if ICT is to effectively support service delivery Appendices 2014 structured assessment recommendations 27 Page 3 of 30 - Structured Assessment Cwm Taf University Health Board

4 Summary Context 1. Cwm Taf University Health Board (the Health Board) provides healthcare services to the population of Merthyr Tydfil and Rhondda Cynon Taf, estimated to be around 300,000 people. It had expenditure of 651 million in and employed around 8,000 members of staff. 2. The Structured Assessment examines the Health Board s arrangements that support good governance and the efficient, effective and economical use of resources. As in previous years, the work in 2015 has assessed the robustness of the Health Board s financial management arrangements, the adequacy of its governance arrangements and the management of key enablers that support effective use of resources. In examining these areas, we have considered the progress made against improvement issues identified last year 1. The audit work was structured under the following areas: Financial planning and management, including: financial health and financial planning. Arrangements for governing the business, including: strategy, governance arrangements and internal control. Enablers of effective use of resources, including: change management and technology. 3. During 2015, Healthcare Inspectorate Wales (HIW) undertook a follow-up review to check on the progress made with recommendations that were identified in its original review of governance in HIW stated: Overall, HIW is pleased and encouraged with the progress that has been made by the health board since the initial review in Most, if not all of the areas, have seen significant improvements. The recommendations made as a result of this follow up review also highlight the areas which require further improvement. Sixteen further recommendations were made covering the following broad areas: clinical teams and leadership, non-officer members, risk, patient complaints, concerns and claims, trend analysis, action planning and shared learning, communication of vision and objectives, staff development and appraisal. 4. We have taken appropriate account of HIW s findings in undertaking our structured assessment work. Main conclusions 5. Last year s structured assessment work indicated that whilst governance and use of resources arrangements were broadly sound, they needed further development in specific areas. During 2015, the Health Board has made good progress in addressing 1 Recommendations made in 2014 together with a summary of progress are set out in Appendix 1. 2 Healthcare Inspectorate Wales, Follow-up Review of Governance Arrangements at Cwm Taf University Health Board, August Page 4 of 30 - Structured Assessment Cwm Taf University Health Board

5 many of our 2014 structured assessment recommendations and a summary of progress is set out in Appendix Our overall conclusion from 2015 structured assessment work is that governance arrangements continue to evolve but some aspects, particularly ICT, are making insufficient progress, and achieving financial balance for remains a challenge. 7. The reasons for reaching this conclusion are set out below. Financial planning and management 8. The Health Board continues to monitor savings plans effectively, and has a good record of achieving financial balance, but whilst it again forecasts a breakeven position for , it faces significant financial challenges and needs to manage risks relating to planned savings and directorate sign-up to budgets. 9. Specifically, we found: The Health Board achieved financial balance in , as in previous years. We reported last year that the process established for identifying and delivering savings was sound, but internal stakeholder engagement in signing up to saving plans could be improved, and that this would be key to sustainable and recurring efficiencies going forward. In the Health Board is currently reporting that it will break even assuming the additional funding contained within its three-year IMTP is received. However, it is unlikely to deliver all of its 14.6 million savings targets, and to date only about half of the directorate budget plans have been signed off by the Clinical/Executive Director. This again suggests that improvement has been slower than anticipated in getting internal stakeholder buy-in to the savings process. Arrangements for governing the business 10. The Board has set a clear vision and continues to strengthen governance arrangements, and its challenge is to further improve governance arrangements supporting the Quality and Safety Committee, address internal control weaknesses and develop a performance management framework. 11. In reaching this conclusion, we found: The Health Board's three-year strategic plan (IMTP) sets out a clear vision. The approach to strategic planning combined with the creation of the Programme Management Office (PMO) provides a sound basis for taking the organisation forward and supporting improvement activity, however, progress reporting against the plan could be strengthened. The Board demonstrates good strategic leadership, good conduct, effective administration and a commitment to openness and quality improvement. Page 5 of 30 - Structured Assessment Cwm Taf University Health Board

6 The sub-committee structure covers the Health Board s business and supports governance requirements but the Health Board recognises there is scope to improve arrangements in specific areas, in particular, governance arrangements supporting the Quality and Safety Committee. Overall the Board receives adequate information and is further strengthening and refining management information to support effective scrutiny and decision making, however, the information presented to the Board shows that it faces challenges in meeting some key national performance targets. Internal controls are generally effective in meeting current assurance requirements but some aspects, including controlling overpayments to staff, control over disposal of assets, and data used to calculate Continuing Healthcare provisions, require improvement. Enablers of effective use of resources 12. Although the Health Board has change management arrangements in place to support delivery of its IMTP there are improvements needed if ICT is to effectively support service delivery. 13. In reaching this conclusion, we found: the Health Board has adequate change management arrangements in place to underpin the IMTP but the approach to benefit realisation needs to be strengthened; and the level of investment and commitment to ICT in the Health Board is not effectively supporting the delivery of healthcare, and addressing previous recommendations has been slow. 14. The findings underpinning these conclusions are summarised in the next section of this report. Recommendations 15. Recommendations arising from 2015 structured assessment work are set out below. Financial planning and management R1 Improved stakeholder engagement will be key to delivering sustainable efficiencies and savings. Whilst this is an ongoing process the Health Board needs to ensure that: a. current savings plans are signed off; and b directorate savings plans are signed off prior to the start of the financial year. R2 The Health Board should simplify its Monthly Finance Updates to ensure the key messages are not lost and are more easily understood. Page 6 of 30 - Structured Assessment Cwm Taf University Health Board

7 Arrangements for governing the business R3 R4 R5 R6 R7 R8 R9 Ensure that IMTP progress reporting: a. incorporates progress against the stated in-year priorities; and b. clearly identifies progress against what the Board had planned to achieve at that point in time. Map performance measures to the Board Assurance Framework to ensure that there are no gaps in assurance. Review website content in relation to key corporate documents and plans to ensure that current versions are clearly signposted to improve accessibility by members of the public. Develop and embed forward work programming in all sub-committees and groups that support the Board. Develop and adopt a Performance Management Framework to enhance accountability arrangements. Develop succession planning for the existing cohort of Independent Members and develop induction arrangements in anticipation of terms of office ending. Put in place arrangements to achieve a uniform level of operational practice across all committees in terms of chairmanship and scrutiny. R10 Consider whether that as a minimum at least one Independent Member of the Audit Committee has recent relevant financial experience. If this is not the case the Health Board should consider other arrangements, such as appointing an associate non-executive with that relevant experience. R11 Develop a mechanism to ensure that the Wales Audit Office recommendations that predate January 2014 and which are still valid are appropriately monitored. Enablers of effective use of resources R12 As part of programme and project management arrangements develop: a. robust benefit realisation approaches and methodologies which are used throughout the life of a project; b. clearly identified arrangements to support the transition of projects to operational business as usual; and c. reporting arrangements that require assessments or evaluations of benefits achieved during the life of projects. Page 7 of 30 - Structured Assessment Cwm Taf University Health Board

8 Detailed findings Governance arrangements continue to evolve but some aspects, particularly ICT, are making insufficient progress, and achieving financial balance for remains a challenge 16. The findings underpinning this conclusion are summarised below, grouped under the themes of financial planning and management, arrangements for governing the business and enablers of effective use of resources. Findings highlight strengths and developments, as well as the risks and challenges still facing the Health Board. Financial planning and management The Health Board continues to monitor savings plans effectively, and has a good record of achieving financial balance, but whilst it again forecasts a breakeven position for , it faces significant financial challenges and needs to manage risks relating to planned savings and directorate sign-up to budgets 17. In reaching this conclusion, we found: The Health Board achieved financial balance in , as in previous years. We reported last year that the process established for identifying and delivering savings was sound, but internal stakeholder engagement in signing up to saving plans could be improved, and that this would be key to sustainable and recurring efficiencies going forward. In , the Health Board is currently reporting that it will break even assuming the additional funding contained within its three-year IMTP is received. However, it is unlikely to deliver all of its 14.6 million savings targets, and to date only about half of directorate budget plans have been signed off by the Clinical/Executive Director. This again suggests that improvement has been slower than anticipated in getting internal stakeholder buy-in to the savings process. Page 8 of 30 - Structured Assessment Cwm Taf University Health Board

9 Table 1: Financial management Strengths and developments The Health Board has a strong record in delivering financial balance and is forecast to break even again in The three-year rolling financial plans for the periods to and to have been approved and signed off by the Welsh Government. We reported last year that the process established for identifying departmental savings is robust, which required budget holders to sign directorate business plans confirming they are deliverable and that they have completed a quality impact assessment on care and service provided. The Board receives detailed Monthly Finance Updates documenting the current position, and highlighting key risks and progress to date. This information is consistent with the figures and message reported to the Welsh Government. Risks and challenges As at month 7 in , the Health Board was continuing to forecast breakeven for the year but this was dependent upon: Improved run rate on savings plans which to date are significantly behind schedule. At the current rate there would be a shortfall of 2.8 million against total saving plans of 14.6 million. Receipt of additional funding from the Welsh Government that is detailed within the three-year plan. To date 3.5 million of this has yet to be confirmed. We reported in that despite having a process in place not all budget plans were signed off by the Clinical/Executive Director. We commented that stakeholder engagement and sign-up to the process was key to the delivery of sustainable efficiencies. It is disappointing to note that at Month 7 approximately half of the directorate budget plans for remain unapproved by the Clinical/Executive Director. The Health Board s aim was rightly to get all these plans signed and approved prior to the start of Consequently, it is not surprising that savings achieved to date remain behind target. The Monthly Finance Update paper to the Executive Board is very detailed but it is not always clear what the high-level messages are. For example, it is not easy to reconcile the Executive Summary, Areas of Concern and Year End Forecast Key Points. There is a danger that readers outside of the Finance department will be unclear of the messages. This ties in to the point above on improving stakeholder engagement. Page 9 of 30 - Structured Assessment Cwm Taf University Health Board

10 Arrangements for governing the business The Board has set a clear vision and continues to strengthen governance arrangements, and its challenge is to further improve governance arrangements supporting the Quality and Safety Committee, address internal control weaknesses and develop a performance management framework 18. In reaching this conclusion, we found: The Health Board s three-year strategic plan (IMTP) sets out a clear vision. The approach to strategic planning combined with the creation of the PMO provides a sound basis for taking the organisation forward and supporting improvement activity, however, progress reporting against the plan could be strengthened. The Board demonstrates good strategic leadership, good conduct, effective administration and a commitment to openness and quality improvement. The sub-committee structure covers the Health Board s business and supports governance requirements but the Health Board recognises there is scope to improve arrangements in specific areas, in particular, governance arrangements supporting the Quality and Safety Committee. Overall, the Board receives adequate information and is further strengthening and refining management information to support effective scrutiny and decision making, however, the information presented to the Board shows that it faces challenges in meeting some key national performance targets. Internal controls are generally effective in meeting current assurance requirements but some aspects, including controlling overpayments to staff, control over disposal of assets, and data used to calculate Continuing Healthcare provisions, require improvement. 19. The findings underpinning these conclusions are summarised in the following sections and tables. Page 10 of 30 - Structured Assessment Cwm Taf University Health Board

11 Strategic planning The Health Board's three-year strategic plan (IMTP) sets out a clear vision. The approach to strategic planning combined with the creation of the PMO provides a sound basis for taking the organisation forward and supporting improvement activity, however, progress reporting against the plan could be strengthened 20. The findings underpinning this conclusion are summarised in Table 2. They are based on our review of the Health Board s strategic planning arrangements and the extent to which the South Wales Programme (SWP) is reflected in the Health Board s Integrated Medium Term Plan (IMTP). Table 2: Strategic planning Strengths and developments IMTP Cwm Taf Cares was endorsed by the Board in May 2015 and received ministerial approval in June. It contains a clear vision, setting out five strategic objectives: to improve quality, safety and patient experience; to protect and improve population health; to ensure that the services provided are accessible and sustainable into the future; to provide strong governance and assurance; and to ensure good value-based care and treatment for our patients in line with the resources made available to the Health Board. Priorities are clearly and succinctly stated for and include: develop a clinical service strategy, implement primary and community plans, develop integrated services, meet the 62-day cancer target, involve patients in service design, improve data quality, address sickness absence and achieve financial balance. A short public-facing summary of the plan was produced following engagement with key stakeholders. Risks and challenges More could be done to clearly sign post members of the public to the current IMTP and its summary on the Health Board s website. Board Tab has IMTP version dated 2 April 2014; and Our Plan Tab has IMTP version dated 31 March Delivering identified savings from cross-cutting themes is challenging and impacting upon financial position of the Health Board. The Health Board is seeking to improve IMTP reporting to the Board. IMTP reporting needs to be: sufficient to ensure that not only key milestones but key delivery outcomes and performance are clearly reported against what the Board had planned to achieve at that point in time; and more clearly reporting progress against the stated priorities. Risks associated with the SWP are not clearly articulated in the IMTP: the financial impact of the SWP is not clearly identified; there is limited detail about mitigation of risks; and there is limited detail about the impact on the workforce. Page 11 of 30 - Structured Assessment Cwm Taf University Health Board

12 Strengths and developments (continued) Good approach to IMTP project monitoring arrangements across the organisation: directorate-based service changes monitored through Clinical Business Meetings, Corporate Business Meetings and Operations Board; the eight cross-cutting themes monitored through the Executive Programme Board; Executive Programme Board monitors and scrutinises performance of plans; support arrangements in place for directorates to develop plans and delivery improvements; and Welsh Government quarterly summary report to the Board in July and November 2015 structured around six areas: planning and partnerships, quality, performance, workforce, governance and finance including risk assessment. Establishing a Programme Management Office to support implementation of IMTP cross-cutting themes. Good approach for updating the IMTP: local planning framework including clear timetable; and revised approach to savings. The IMTP provides broad coverage of the SWP and also outlines some contingency arrangements during implementation. There is good coverage on developments like the expansion of neonatal services at Prince Charles Hospital (PCH), but less detail about other service changes, such as 24-hour consultant-led A&E at the Royal Glamorgan Hospital (RGH). Progress is being made on: the acute medicine model at the RGH which commenced September 2015; the Business Justification Case for the Diagnostic Hub developed; and developing and implementing plans for Paediatric and Obstetric services. Recent appointment of an Assistant Director for Service Transformation and Innovation increases senior capacity. Risks and challenges (continued) The financial impact of the SWP is not clearly identified in the IMTP. Capital works to accommodate new paediatric and obstetric services in PCH are behind schedule and the Health Board is awaiting further capital investment sign-off by the Welsh Government. Page 12 of 30 - Structured Assessment Cwm Taf University Health Board

13 Board effectiveness The Board demonstrates good strategic leadership, good conduct, effective administration and a commitment to openness and quality improvement 21. The findings underpinning this conclusion are summarised in Table 3. Table 3: Board effectiveness Strengths and developments The Board has in place the following arrangements which are supporting good governance and the effective operation of the Board: Recently developed Board Assurance Framework (BAF). Annual business cycle and action log. Focus on quality assurance and quality improvement with development of: Quality Strategy , annual delivery plan and a Patient Experience Plan Publicly accessible Board papers and an increasing range of performance information in the public domain through Board papers, however, some papers are not on the website eg, the chair s report appendices November 2015 Board meeting and the performance information on website (About Us Performance) are dated Committed to providing sub-committee papers in the public domain and work is ongoing to achieve this in Board meetings demonstrate improving levels of scrutiny and challenge with generally good responses from Executives: historically stable cadre of independent members who provide scrutiny and challenge; and independent members value board development sessions which support training, consider governance issues and wider legislative changes. Risks and challenges Assurance could be improved by mapping performance measures against individual risks identified in the BAF to ensure coverage, and any gaps identified should have measures developed as per the Wales Audit Office recommendation R5 in last year s Structured Assessment. Openness and transparency could be further enhanced by: ensuring that appropriate Board and sub-committee papers are publicly available and accessible on the website in 2016; and website clearly signposting users to information that is current ie, performance information and IMTP. Important to ensure succession planning and development arrangements are in place and effective for new sub-committee chairs in 2016 including Quality & Safety Committee and Audit Committee. An Induction programme for new members will be required as the terms of office for: three independent members end in 2016; four independent members end in 2017 including the Chairman; and Chair of Stakeholder Reference Group s term ends in Page 13 of 30 - Structured Assessment Cwm Taf University Health Board

14 Strengths and developments (continued) Commitment to engaging with public/stakeholders including quarterly geographical Public Involvement Forums and developed a Citizen Engagement Implementation Plan Revised scheme of delegation being consulted on which aligns to Standing Financial Instructions. Standing Orders updated to reflect revised committee structure including revised timescale for issuing Board and committee papers to one calendar week. Committed to improving the efficiency of distributing Board and sub-committee papers electronically rather than as paper hardcopies. Report formats and content to sub-committees improving. Risks and challenges (continued) It is acknowledged by the Health Board that meeting the 10-day timescale for issuing Board and sub-committee papers was a challenge and the timescale has been reduced to one calendar week. The Health Board will need to ensure that the reduced timescale does not impair the Board and subcommittees ability to consider reports. The Health Board may need to reconsider the timescales when new independent members are appointed. The role of citizens in evaluating service changes could be more explicit in the Citizen Engagement Plan. Governance structures The sub-committee structure covers the Health Board s business and supports governance requirements but the Health Board recognises there is scope to improve arrangements in specific areas, in particular, governance arrangements supporting the Quality and Safety Committee 22. The findings underpinning this conclusion are summarised in Table 4. Page 14 of 30 - Structured Assessment Cwm Taf University Health Board

15 Table 4: Governance structures Strengths and developments The sub-committee structure covers the organisation s business and governance requirements with no obvious gaps and minimal duplication: work planned to improve links between the Quality and Safety and Corporate Risk committees during 2016; creation of a Finance, Performance and Workforce committee in October 2015; work planned to create Capital Programme Board as a Board sub-committee; Integrated Governance Committee provides key role in ensuring that key areas of business are captured within the work of the sub-committees and that there are no gaps and monitoring the Integrated Governance and Accountability Action Plan; and sub-committees have all completed self assessments but analysis not yet available. Terms of Reference of sub-committees are reviewed on an annual basis and updated: currently reviewing advisory groups to strengthen their role including Health Professionals Forum and the Stakeholder Reference Group. Reporting house style adopted and recently revised to link closely with IMTP strategic objectives. Risks and challenges Terms of reference for sub-committees do not make it clear how the underpinning operational and locality arrangements link to the committees ie, which groups report to them. There is scope to adopt a standard terms of reference template for Board sub-committees to improve coverage and consistency. Such a template could usefully: identify which sub-committee the operational groups are required to report to, and inform work of the sub-committees include a specific requirement for sub-committees to: produce and operate a forward work programme; to undertake an annual self-assessment; and to produce an annual report to the Board. Ensure that all other forums and groups that support the Board have terms of reference including the Working in Partnership Forum and the Capital Programme Board. Forward work programmes are not consistently adopted by committees: only two sub-committees have and use forward work programmes; and there is an intention to adopt a standardised forward work programme format across all sub-committees. Our observations have indicated that the quality and depth of scrutiny can vary between sub-committees. Challenge will be to achieve a uniform level of practice across all committees in terms of chairmanship and scrutiny. Page 15 of 30 - Structured Assessment Cwm Taf University Health Board

16 Strengths and developments The Audit Committee has the necessary business processes in place in terms of agenda management, engagement with internal and external audit, cross referral of issues to other sub-committees, tracking of actions and recommendations and self assessment of its performance. Risks and challenges The development and operation of a forward work programme should be considered, and should include: use of self-assessment analysis to inform specific development activities; an annual review of: assurance and risk management systems, BAF, SOs and SFIs; terms of reference; and interrelationships and work programmes of other committees. Momentum in addressing outstanding audit report recommendations needs to be maintained with Executives being appropriately held to account for any delays. The NHS Audit Committee Handbook paragraph 5.1 says: Given the importance and complexity of the Committee s work it is unlikely that membership is best suited to non-executives who are new to their role or who do not have a background of operating on equivalent committees in other organisations. As a minimum one member of the Committee must have recent relevant financial experience, and the other members must ensure that they receive induction and training in their role, including some basic financial literacy and an understanding of internal control. Increasingly, there is value in more than one member of the Committee bringing relevant skills or experience, including financial, risk management and clinical, given the nature of the business. In our view relevant financial experience would give an independent member an ability to understand and challenge management and the auditors on the technical accounting issues being reported. Page 16 of 30 - Structured Assessment Cwm Taf University Health Board

17 Strengths and developments The Quality and Safety Committee continues to improve its operation but the Health Board recognises further developments are required to improve its arrangements. Key developments include: improving agenda management, structured to maximise time for scrutiny; quality summits twice a year for operational unit presentations on quality improvement initiatives; strengthening directorate exception reports; quality hub established; and clinical informatics sub-group established and quality dashboard being developed. Ongoing improvement activities to improve committee operation and next phase include: review membership; supporting sub structure to identify reporting requirements; attendance re: accountability; refresh Q&S delivery plan ; and agenda planning to allow greater time for review of quality report. Risks and challenges Despite a more disciplined agenda management meetings are lengthy and the complexity and size of meeting agendas make it challenging to balance more in-depth scrutiny with general oversight. A number of reports to the committee have been incorrectly classified as for note when they were for approval. The development of a forward work programme could assist operation of the committee by setting out an annual calendar of activities that schedules: regular planned agenda items and the receipt of reports and presentations from operational units. Some papers, particularly directorate exception reports could be further refined to more clearly articulate risks and how they are being addressed. The self-assessment which has been carried by the Committee needs to be analysed and the outputs used to inform the forward planning and development of the committee. Opportunity as part of Independent Member succession planning to further review and strengthen operational arrangements with the new Chair in Page 17 of 30 - Structured Assessment Cwm Taf University Health Board

18 Strengths and developments Finance & Performance Committee is effective with: strong chairmanship and robust scrutiny and challenge; good follow-up of issues with management to seek assurance that relevant action is being taken with sufficient pace; maintaining of focus on areas where performance has not been good or high risk areas eg, ophthalmology and specific service deep dives ; work to drive the development of clinical efficiency metrics and reporting; adopting sound principles for forward programme items: anything that has improved for three months consecutively placed on Agenda (Good news) for Info; anything that has declined for three months consecutively placed on Agenda (Improvement Plan); and any area with DSU intervention reviewed at every meeting until intervention is withdrawn. Governance arrangements supporting sub-committees are in place but there are important aspects which need to be improved. The current review of these arrangements needs to be concluded swiftly and acted upon: A review of support arrangements is in progress: to map quality and safety groups; and assess what is working well and what needs to be improved. Quality Improvement Group oversees Quality Strategy and its Delivery Plan. Local governance arrangements in place in directorates eg, Acute Services Quality Forum, Locality and Clinical Business Meetings and Localities and Primary Care Quality and Safety Committee. Risks and challenges Appropriate succession planning in relation to Independent Member turnover will be needed to ensure this committee maintains its momentum and sound working arrangements. The Quality and Safety Committee does not have full assurance that reporting is comprehensive and reflects all issues: There is a need to conclude the mapping and assessment of quality and safety groups swiftly and act upon findings to: ensure effective underpinning of governance arrangements; address issues in the continuity of assurance reporting from groups to the Quality and Safety Committee as some groups have yet to report; and ensure directorate based reporting of quality and safety arrangements are effectively escalating issues to the appropriate forum and ultimately to Quality and Safety Committee. Page 18 of 30 - Structured Assessment Cwm Taf University Health Board

19 Management information and performance against key targets Overall the Board receives adequate information and is further strengthening and refining management information to support effective scrutiny and decision making, however, the information presented to the Board shows that it faces challenges in meeting some key national performance targets 23. The findings underpinning this conclusion are set out in Table 5. Table 5: Management information and performance Strengths and developments The most recent iteration (November 2015) of the Integrated Performance Dashboard to Finance & Performance Committee: reporting dashboard structured around the Health and Care Standards (April 2015) and there is a summary page including performance and trend for each of the seven themes of the Health and Care Standards; and summary report identifies new indicators. Improvements in quality of information are supporting scrutiny and decision-making, however, the development of data quality assurance process no longer visible through summary page. Improved range/application of information: stronger patient experience reporting; and quality and safety dashboards being developed. Commitment to continuing the development of management information: extended range of measures eg, primary care and commissioning; automating performance information via Business Intelligence System; and developing clinical efficiency and workforce measures. A range of information is available in a number of separate documents and reports including performance, finance, quality and patient experience. Risks and challenges Although there are data and information on many aspects of service provision the Health Board needs to consider the purpose of each of its performance reports to ensure they are fit for purpose. Depending on the purpose of the Integrated Performance Dashboard there are areas that could be improved so that the Board can oversee the totality of the organisation s activity and performance: mapping performance measures to the Board Assurance Framework; stronger focus and links to delivery of the IMTP outcomes and time bound actions; inclusion of key measures for Patient Experience; extend range of measures for Dignified Care; use of forecasting techniques; identifying individuals accountable for actions; providing insight to help the Board understand the drivers of performance and judge the appropriateness of the identified improvement actions; more use of RAG rating/colour coding to help the reader quickly gauge performance against target; clearly assigned responsibilities for actions; and inclusion of key financial information. Page 19 of 30 - Structured Assessment Cwm Taf University Health Board

20 Strengths and developments Risks and challenges (continued) The Health Board faces challenges in meeting and maintaining performance against some key national performance targets, in particular, four-hour A&E waits, RTT waiting times, cancer targets and stroke bundles, and more needs to be done to improve performance against these. Conclude the development of the Quality and Safety dashboard swiftly and report frequently and consider detailed indicator/measure reviews on a rotational basis. Internal controls Internal controls are generally effective in meeting current assurance requirements but some aspects, including controlling overpayments to staff, control over disposal of assets, and data used to calculate Continuing Healthcare provisions, require improvement 24. The findings underpinning this conclusion are summarised in Table 6. Table 6: internal controls Strengths and developments Work has been undertaken to produce assurance frameworks to underpin the governance arrangements: Board Assurance Framework approved in March 2015; Risk Management Strategy approved in 2014; and Quality Strategy approved and Annual Delivery Plan developed. Risks and challenges The Health Board does not have a Performance Management Framework. Although there is recognition that Clinical Audit should feature more prominently as a key source of board assurance the Health Board should ensure that there is appropriate reporting and tracking of actions to address clinical audit recommendations. Page 20 of 30 - Structured Assessment Cwm Taf University Health Board

21 Strengths and developments Internal controls are generally effective: Well-planned/delivered programme of internal audit work; Effective counter fraud service; Updating SOs/SFIs and previously generally effective; AGS and AQS reported in line with requirements: scrutiny arrangements in place; and AQS audited by internal audit and received substantial assurance. AQS publicly accessible with an online and print version. Arrangements for addressing audit recommendations and monitoring implementation were put in place in 2015 but only relate to Wales Audit Office reports issued since January 2014: Audit committee receives all Wales Audit Office reports and management responses; Established an approach for tracking audit recommendations completion: tracking log; and oversight by Board Secretary. Regular reporting to Audit Committee supports monitoring and scrutiny: reports contain details of progress and actions to be taken; summary table of outstanding recommendations; and provides challenge to pace and effectiveness of response. Audit Committee where appropriate refers some reports/actions to Quality and Safety Committee for ongoing monitoring. Risks and challenges Our Audit of Financial Statements report presented to the Audit Committee and Board in June 2015 highlighted three areas of significant control concerns: There were a number of accounting errors in relation to the disposal of fixed assets. The number of errors highlights significant control failings within the systems in place for recording and accounting for fixed asset disposals. The number and value of overpayments to staff who have left employment but continue to get paid are concerning. The total value of the overpayments was 234,288, and although arrangements have been made to recover this we consider this level of overpayment to highlight a weakness in internal control that needs to be addressed. The data used by the Health Board to calculate the Continuing HealthCare (CHC) provisions may have significant errors. Some aspects of responding to audit can be further improved: management responses presented alongside the report by executive lead; develop a mechanism to ensure that the Wales Audit Office recommendations that predate January 2014 and which are still valid are appropriately monitored; and actions taken to appropriately scrutinise and evidence recommendations have been addressed before they are reported as completed. Page 21 of 30 - Structured Assessment Cwm Taf University Health Board

22 Enablers of effective use of resources Although the Health Board has change management arrangements in place to support delivery of its IMTP there are improvements needed if ICT is to effectively support service delivery 25. In reaching this conclusion, we found: the Health Board has adequate change management arrangements in place to underpin the IMTP but the approach to benefit realisation needs to be strengthened; and the level of investment and commitment to ICT in the Health Board is not effectively supporting the delivery of healthcare and addressing previous recommendations has been slow. Change management The Health Board has adequate change management arrangements in place to underpin the IMTP but the approach to benefit realisation needs to be strengthened 26. The findings underpinning our conclusion are summarised in Table 7, and are underpinned by brief assessments of specific change management projects on stroke and palliative care services. Table 7: change management Strengths/developments Investment made in 2015 to support delivery of IMTP change programmes most notably in creating the Programme Management Office (PMO). Change programmes managed through two main approaches each with management and oversight arrangements: Directorate-based service changes managed through Clinical Business Meetings; and Cross-cutting themes managed through Executive Programme Board. Challenges/risks/opportunities There are capacity risks until PMO fully established and operational. Co-ordination between separate oversight arrangements for directorate and cross-cutting projects. Ensure there are clearly identified arrangements in place to identify and support the transition phase of project to operational business as usual. Update reports provide assurance rather than a description of activity eg, Stroke update reports to Executive Programme Board in February and March Page 22 of 30 - Structured Assessment Cwm Taf University Health Board

23 Strengths/developments (continued) Key aspects of project management methodology adopted eg, Project Initiation Document, an identified Executive sponsor, project team project manager and project planning. Change Management Guidelines/Toolkit (January 2014) included in the Employee Engagement Resource Centre but they needs to reflect recent developments in approach eg, PMO. Clear project reporting via Clinical Business Meetings and Executive Programme Board but reporting tends to focus on activities rather than impact/outcomes/benefits. Highlight/Status reports on cross-cutting themes highlight achievements, slippage, risks, concerns and clearly identify decisions required from Executive Programme Board. Monitoring and reporting of benefit realisation are weak. Benefits are not regularly reported as part of project progress reporting or as part of the cross cutting highlight reports. Finance and Performance Committee forward look for identifies progress towards implementing IMTP and it will scrutinise both organisational and directorate projects. Challenges/risks/opportunities (continued) To develop benefit realisation assessment and reporting throughout project implementation in addition to end of project evaluation to identify wider learning to improve project arrangements. Monitoring and reporting arrangements should clearly include assessments/evaluation of benefits achieved during the life of projects. Overall the Stroke project was well managed during development and implementation but some project management arrangements could be strengthened and some performance outcomes are not yet realised Strengths/developments Good level of option appraisal and evaluation to identify stroke service model. Extensive consultation with patients and stakeholders. PID included a project plan with key activities and timescales. Good level of scrutiny from the Executive Board and the Health Board. Challenges/risks/opportunities Ongoing/regular progress reports should focus on providing assurance that benefits (service, financial and patient) are being delivered as anticipated. Clarity required about the point at which the project closes and service moves to Business as Usual. There is a need to further develop the approach to evaluation to ensure that anticipated benefits are clearly identified and robustly evaluated. Page 23 of 30 - Structured Assessment Cwm Taf University Health Board

24 Strengths/developments (continued) Regular project progress reporting to Executive Programme Board but no clear reporting of expected benefits/outcomes during project implementation. Positive clinical engagement/commitment and drive during both project development and implementation. The project has had all the necessary elements up to the implementation of the revised service. Training delivered to staff and also key stakeholder (WAST) on new service arrangements. Challenges/risks/opportunities (continued) Clarity required on the financial benefits of service changes and how these are monitored on an individual project basis. To ensure that the new pathway is implemented consistently with external stakeholders. Recent development of Task and Finish Group, with support from the Delivery Unit, to explore service performance issues re Stroke Bundle performance. The palliative care project has been managed well with effective partnership working to date but challenges remain to secure funding and deliver new build and service improvements Strengths/developments Palliative and End of Life Care Strategy agreed in Long list of eight service options identified and consulted on and shortlisted to four for further development and in December 2014 new build option selected. PMO is part of the project team. Project management arrangements in place and project well managed so far. Health Board funding contribution identified and allocated. Staff have been consulted and have been included in the decision making process as have other stakeholders. Third party Partnership Application submitted and feasibility study being undertaken and outcome was expected in August 2015 but not yet received. Challenges/risks/opportunities Majority of funding required for new build is dependent on a third party. There is currently no agreed contingency plan in place if third party funding is not secured. Detailed project implementation planning and public engagement and communication intended to commence in October Page 24 of 30 - Structured Assessment Cwm Taf University Health Board

25 ICT and use of technology The level of investment and commitment to ICT in the Health Board is not effectively supporting the delivery of healthcare, and addressing previous recommendations has been slow 27. The above conclusion is drawn from work we have previously undertaken in 2015 on ICT capacity and resources, and a follow-up review of progress that has been made in implementing recommendations from previous IM&T audits. 28. Our diagnostic work indicates that although there are some positive aspects the current level of investment and commitment to ICT in the Health Board is not fully effectively supporting the delivery of healthcare and there is scope to integrate systems and reduce the reliance on paper. In particular, our work found that: overall spend on ICT is below average for Wales and remains below the recommended level of spend; staffing levels for ICT are around average for Wales with the exception of information management staff which is the lowest in Wales; there is a lower level of commitment to ICT than other health boards, and the systems and resources lack integration; the Health Board has the lowest number of devices although accessing PCs is generally less problematic than in many other health boards; the condition of ICT equipment and the reliability of systems appears typical of Wales although records for managing downtime are incomplete; there are good arrangements for training which support proficiency in the use of systems and the quality of the information contained on them; and the mainstream clinical ICT systems are not fully effective in supporting doctors to provide patient care. 29. Our follow-up review of previous IM&T audits demonstrated that whilst the Health Board is strengthening arrangements in the areas we identified as weaknesses, overall progress against our previous recommendations has been slow. In particular, our work found that: Although most departments have used the Health Board s standard approach to business continuity planning, the available corporate template has not been followed comprehensively; the IT department does not have a disaster recovery plan and testing of disaster recovery and business continuity plans is limited. Appropriate software, hardware and access controls are used as part of backup delivery but there is no backup policy, and not all procedures and backup approaches are adequately documented. Caldicott governance arrangements have been strengthened, and training methods improved but some relevant staff are yet to do this training. Page 25 of 30 - Structured Assessment Cwm Taf University Health Board

26 There are a number of initiatives to strengthen data quality arrangements, including a data quality audit programme, annual report and the addition of key staff but some of the governance arrangements require improvement. The Health Board does not have an approved ICT strategy. There are some plans to create one with the help of external contractors but, without an agreed ICT Strategy, the Health Board has nothing to formally base its ICT policies, governance structure, and infrastructure developmental decisions upon. Although there are arrangements in place to track and monitor progress against recent Wales Audit Office audit recommendations the IM&T related recommendations are not included. It is unclear how the Health Board can be assured that audits are appropriately considered and acted upon to facilitate further improvement. Page 26 of 30 - Structured Assessment Cwm Taf University Health Board

27 Appendix structured assessment recommendations The 2014 structured assessment recommendations and a summary of progress made against each are set out below. Recommendation Summary of progress R1 R2 Articulate a clearer Board assurance framework which ensures that the Board receives suitable assurances on service performance and the delivery of its IMTP Cwm Taf Cares. In particular: conclude the recent review of committee structures and membership and communicate changes clearly across the organisation; and ensure that the organisation undertakes regular and robust self-assessments. Improve transparency and openness by making committee papers publicly accessible and review the use and purpose of the independent member secure site. The Health Board has made progress in addressing this recommendation. A Board Assurance Framework has been developed during As detailed above there is more that can be done to strengthen progress reporting of Cwm Taf Cares. There is an ongoing review of committee structures and during 2015 there was a change in the remit of the Finance and Performance Committee to cover workforce. The committee is now called the Finance, Performance and Workforce Committee. All committees have undertaken a self-assessment either electronically or as a hardcopy. The results are still being analysed. Capacity issues within Corporate Services combined with a desire to learn from other Health Boards have meant that limited progress has been made in addressing this recommendation. The Heath Board is committed to making papers publicly available in 2016 and has begun some preparatory work in order to meet this timescale. Page 27 of 30 - Structured Assessment Cwm Taf University Health Board

28 Recommendation Summary of progress R3 R4 R5 Develop and implement systematic monitoring arrangements for external audit recommendations. Ensure that sign-off and accountability arrangements within the Cwm Taf Cares planning process are clearly understood and accepted by directorates. Further develop performance measures and indicators to monitor and manage risk areas, for example: workforce indicators related to the removal of training posts and the use of locum/agency staff. The Health Board has made progress in addressing this recommendation. During 2015 the Health Board developed a Wales Audit Office recommendations tracker which is now reported to every Audit Committee. The tracker contains details of progress made against Wales Audit Office recommendations issued since January There is a summary table clearly indicating those recommendations that are out of date. The arrangements are developing. Although the sign-off and accountability arrangements are in place across the organisation, only half of the directorate plans were actually signed off as of October For the process to be effective it requires buy-in from stakeholders, needs embedding within organisational practices and stakeholder compliance. Some progress has been made in addressing this recommendation. The Health Board is developing a number of performance measures in key risk areas, for example, information is available on bank and agency staffing numbers which will be incorporated into dashboards. Page 28 of 30 - Structured Assessment Cwm Taf University Health Board

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