Trust Board Meeting. Trust Secretary, Linda Storey. Trust Secretary, Linda Storey

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1 ENC 6 Meeting Trust Board Meeting Date 7 th July 2016 Title of Paper Board Assurance Framework Version 1.0 July 2016 Lead Director Author Trust Secretary, Linda Storey Trust Secretary, Linda Storey PURPOSE OF THE PAPER To provide Version 1.0 of the Trust s Board Assurance Framework for the first Quarter of 2016/2017 (April to June) for the Board to review, discuss and approve. SUMMARY OF THE KEY POINTS The Trust Board has agreed a new format for its Board Assurance Framework (BAF) following work at two Board Seminar sessions in May and June This version of the BAF is the first version using the new format. The BAF shows the status of the 12 biggest risks to the delivery of the Trust s Annual Plan/objectives for 2016/2017. RECOMMENDATIONS The Trust Board is recommended to: Review, discuss and approve Version 1.0 of the Board Assurance Framework 2016/2017. Make any recommendation for further action in relation to the risks. LINKS Strategic Objectives BAF Risk No. 12 that we do not develop a clear five year strategic plan to support our 2020 service vision. Where risks either singly or collectively impact on the Trust s strategic objectives, they are reflected on the Trust s Board Assurance Framework. Annual objectives Work to address risk management directly links to annual objective No. 13. Improve the Governance of the Trust ensuring that the CQC Well-Led Standard is met. Monitor / CQC / Regulatory Requirements CQC Fundamental Standards, Regulation 17 Good Governance 1

2 IMPACT Patient Experience BAF Risk No. 1 That the quality and safety of care we provide does not improve in line with our commitment in the Patient Care Improvement Plan. In order to deliver high quality patient centred care it is essential that the Trust accurately identifies and mitigates its risks. Quality & Safety BAF Risk No. 1 That the quality and safety of care we provide does not improve in line with our commitment in the Patient Care Improvement Plan. BAF Risk No. 2 that we continue to provide inadequate care for patients attending our Emergency Department. BAF Risk No. 3 that we continue to provide inadequate care for patients of our maternity and neonatal services. BAF Risk No. 4 that improvements in community services do not deliver a reduction in demand for acute hospital care. BAF Risk No. 5 that our emergency care pathway does not improve resulting in continued delays for patients and poor flow through the hospital. BAF Risk No. 6 that we are not able to recover performance on the national elective standards including referral to treatment times and cancer as planned. BAF Risk No. 7 that we cannot deliver safe, Financial BAF Risk No. 7 that we cannot deliver safe, BAF risk No.9 Delivery of Annual Plan within resources available. Financial implications are associated with the mitigation of a number of the risks where business cases/resource is required. In addition, if the Trust fails to mitigate key clinical and financial risks this may lead to potential financial consequences through the cost of increased controls, and subsequent externally driven impact, such as associated financial costs related to claims, complaints, incident investigations, contract queries and penalties. Workforce BAF Risk No. 7 that we cannot deliver safe, BAF Risk No. 8 that we are not successful in our work to establish a clinically-led engaged and empowered culture. Equality & Diversity BAF Risk No. 7 that we cannot deliver safe, Estates BAF Risk No. 10 that we cannot deliver our planned programme of hospital estate improvement including ITU, neonatal unit, second maternity theatre and a plan for ED. IM&T No specific BAF risk related to IM&T. However a 2

3 Communications/ Engagement number of the risks will include IM&T elements. BAF Risk No. 8 that we are not successful in our work to establish a clinically-led engaged and empowered culture. RISKS If the Trust fails to identify and put in place appropriate mitigations to reduce risks to clinical care delivery, physical assets and contractual and regulatory requirements, the Trust will suffer the effect of any negative impact should these be realised. In addition, to ensure that the Trust is removed from special measures it needs to provide sufficient assurance to external regulators that it is sufficiently sighted on key risks within the organisation that negatively impact upon its ability to mitigate against a variety of known and emerging risks. PREVIOUS CONSIDERATION:- 1. The Board at its seminar meetings in May and June 2016 reviewed and agreed a new approach to the Board Assurance Framework. 2. The Trust Executive Team has proposed the 12 major risks to the delivery of the Trust s Annual Plan and objectives. NEXT STEPS:- The next version of the BAF will be submitted to the Trust Board meeting on 6 th October

4 BOARD ASSURANCE FRAMEWORK VERSION 1.0 JULY BACKGROUND 1.1 The Care Quality Commission inspection in September 2015 identified the following issues in relation to risk management: A lack of effective Risk Management. Corporate Risk Register did not provide an accurate comprehensive reflection of the Trusts key risks. Lack of robust oversight and ownership of key risks at Divisional and Board Level. Divisional Risk Registers not updated, reviewed or supported by robust actions. Long standing risks not updated. 1.2 To address the above a series of actions have been taken and reported to the Board separately. 1.3 The purpose of the Board Assurance Framework (BAF) is to provide the Trust Board with a simple but comprehensive method for the effective and focused management of the principal risks to meet the Trust s annual plan and objectives. It also provides a structure for the evidence to support the Chief Executive s Annual Governance Statement. 1.4 The internal audit review of the Board Assurance Framework at the end of 2015/2016 found it to require improvement and made the following recommendations: All risks within the BAF to be scored inherently and residually to assist the reader to determine the effectiveness of the controls put in place to manage the risks. Trust Board to receive an updated version of the BAF at least 3 times per year. Significant risks to the Trust need to be actively reviewed and challenged by the Trust Board, via the BAF, and scoring of risks adjusted to reflect the severity of consequences. Strategic objectives should be SMART to enable appropriate measurement of success at any point in time. 2016/17 BAF to include any residual risks arising from the CQC action plan that have not been addressed. Sources of assurance to show frequency of reporting to assist the reader to determine the effectiveness of the assurance. Results of external assurances to be identified within the BAF, such results to state the date of receipt of the assurance to assist the reader to determine the effectiveness of the assurance. Ensure scoring across related documentation, i.e. BAF and Corporate Risk Register is consistent. 4

5 2. PROCESS UNDERTAKEN TO REDEVELOP THE BOARD ASSURANCE FRAMEWORK 2.1 A review of the BAF has been undertaken and two Trust Board Seminar sessions have focussed on this. As a result, a new template has been developed, agreed and worked up. In addition it was agreed that for 2016/2017 focus would be on the biggest strategic risks to the delivery of the annual plan and objectives for the year strategic risks have been identified and worked up into the new BAF template by the Executive Director Leads. 2.3 Each strategic risk is owned by an Executive Director Lead and a Board Committee and will be responsible for monitoring the progress on risk mitigation. 2.4 The BAF will be reviewed and updated on a quarterly basis and presented to the Trust Board. 2.5 The Trust Board will receive a one page dashboard overview plus 12 one page templates (one for each risk). 2.6 The Trust Board agreed that as the year progresses it will move its BAF focus to consider longer term risks to success over the next 3 to 5 years. It is expected that this will be done in the early autumn as part of the work on the 5 year strategic plan. 3. OVERVIEW OF THE BOARD ASSURANCE FRAMEWORK VERSION 1.0 JULY Summary Overview The Trust currently has 12 BAF risks. The heat map below provides an overarching view of these. The level of risk (risk score) is in italics in the top left of each box and the number of risks at each level is shown in brackets. Consequence Likelihood 1 No Harm Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic 1 Rare 2 Unlikely Possible (1) 15 4 Likely (3) 16 (5) 20 (3) 5 Almost Certain

6 3.2 A dashboard is shown at the front of the BAF (attached) which shows the current status of each risk. The residual scores are to be agreed and the risk movement scores will be inserted for the next version once the movement of the scores across the quarter are known. 4. NEXT STEPS 4.1 The timetable to submit the next update of the BAF to the Trust Board in October 2016 is shown below: Action Responsibility Deadline Output Monitoring Committee Review & Update of BAF Risks sent to Trust Secretary Executive Directors 09/09/2016 Updated BAF Risk Sheets N/A Review & write summary BAF position Further review following TQE Review of BAF Trust Secretary 16/09/2016 Updated BAF and Summary Report Executive Directors & Trust Secretary Chair of Audit Committee 29/09/2016 Updated BAF and Summary Report 05/10/2016 Verbal Feedback to Trust Board 06/10/2016 Updated BAF reviewed, discussed and approved at Trust Board 06/10/2016 Trust Quality Executive 22/09/2016 Audit Committee 05/10/2016 Trust Board 06/10/ Work will be undertaken to identify the residual risk score for each of the risks prior to the next version. 4.3 The Board Committees will incorporate the review of their BAF risks into their work plans. 5. RECOMMENDATION The Trust Board is recommended to: a. Review, discuss and approve Version 1.0 of the Board Assurance Framework 2016/2017. b. Make any recommendation for further action in relation to the risks. 6