REPORT (7) TRUST BOARD 30 th July 2015

Transcription

1 REPORT (7) TRUST BOARD 30 th July 2015 Subject Prepared by Approved by Presented by Board Assurance & Risk Framework (BAF) Richard Schofield, Company Secretary Richard Schofield, Company Secretary Richard Schofield, Company Secretary Purpose The Board Assurance & Risk Framework (BAF) highlights the current strategic risks and actions needed to address any assurance, and the actions in place to do this. Receive Approve Trust Objectives Quality People Partnership Resources Executive Summary The purpose of the report is to describe the extent to which risks to delivery of the Trust s strategic objectives have been identified and mitigated and to reflect the level of assurance in place, with changes to the BAF approved by the Board 2015 shown in blue. Assurance Framework The report provides information on the key risks and current level of assurance in meeting the Trust s objectives. Recommendation The Trust Board is recommended to review and approve the revised Board Assurance Framework. Corporate Impact Assessment CQC Regulations Covers all CQC outcomes and specific risk identified Financial Implications Legal Implications Equality & Diversity Workforce and Staffing Performance Management Communication Covered by all strategic risks Covered by all strategic risks Covered by all strategic risks Covered by all strategic risks Covered by all strategic risks Covered by all strategic risks

2 Acronyms / Terms used in Report AQP BAF BRAG CE CIOS CIP COO CQC CRB CRR CSDP DF DH DHR DPGME ED EDMD EMG ESD EY F&P FT GP I&E IBP IPR KCG KPI LTFM MD MDT NHSLA NR OD OMG PAF PCH PDR PEC PCT Any Qualified Provider Board Assurance & Risk Framework Business Recovery Action Group Chief Executive Cornwall & Isles of Scilly Cost Improvement Programme Chief Operating Officer Care Quality Commission Criminal Records Bureau Corporate Risk Register Clinical Site Development Plan Director of Finance Department of Health Director of Human Resources Director of Postgraduate Medical Education Emergency Department Executive & Divisional Management Board Executive Management Group Early Supported Discharge Ernst & Young Finance & Performance Foundation Trust General Practitioner Income and Expenditure Integrated Business Plan Integrated Performance Report Kernow Commissioning Group Key Performance Indicator Long Term Financial Model Medical Director Multi Disciplinary Team NHS Litigation Authority Non Recurring Organisational Development Operational Management Group Performance Assurance Framework Peninsula Community Health Performance Development Review Professional Executive Committee Primary Care Trust

3 PMG QIPP RAG RTT SHA SIP SLA TMC TWG WCH Performance Management Group Quality, Innovation, Prevention, Productivity Red Amber Green Referral To Treatment Strategic Health Authority Savings Improvement Programme Service Level Agreement Trust Management Committee Technical Working Group West Cornwall Hospital

4 Summary of Board Assurance & Risk Framework Risk Ref Exec Owner Potential Risk Potential threat to objectives (L*C) (L*C) Trust Board Oversight 5230 Medical Director National Hospital Standardised Mortality Ratio (HSMR) data indicates that the Trust has higher than average mortality, particularly at weekends, leading to; Concerns about the quality and safety of clinical care. Trust reputation. Increased likelihood of regulatory intervention Chief Operating Officer Certain specialties, due to lack of capacity or lack of clinical engagement, have been identified as having increased risk to providing consistent upper quartile performance, impacting on; Quality and safety Patient experience Income 1.1, Governance Committee Trust Board 3411, 4509, 4166 Chief Operating Officer 5229 Director of HR & OD Clinical and operational capacity pressures: risk to quality of care, reputation, registration and target performance including RTT backlog beyond sustainable levels within national targets Failure to effectively manage Health & Safety within the organisation may impact: a. staff and patient wellbeing; b. Trust reputation; c. Compliance with legal and regulatory obligations leading to prosecution and/or regulatory action 1.1, Finance, Performance & Investment Committee Governance Committee 3699, 3093 Director of HR & OD Low levels of staff engagement will impact upon the delivery of safe, high quality and compassionate care Director of Strategy Diverging objectives between partners puts at risk the development of whole system agreement on the configuration of future health and social care services resulting in; 2.1, Trust Board Finance, Performance & Investment Committee Failure to deliver integrated care Failure to use resources efficiently and effectively across the system Poor experiences for patients and service users 3690 Director of Strategy Increased competition in Cornwall and/or change of intentions as Finance, Performance & Page 1 of 17

5 Risk Ref Exec Owner Potential Risk Potential threat to objectives (L*C) (L*C) Trust Board Oversight locality commissioning develops, leads to a risk that: Investment Committee Certain clinical services currently offered by the Trust will be lost to other providers potentially impacting on the clinical viability of certain specialties Loss of income threatens the financial viability of the Trust Director of Strategy Application of Specialist Commissioning service thresholds through NHS England could: Finance, Performance & Investment Committee 5214 Director of Finance, Director of Strategy, Chief Operating Officer lead to certain specialist services no longer being offered by the Trust with potential impacts on service quality and patient experience. Risk of delivery of financial plan and in year statutory financial duties. Non delivery of CIP Failure to control costs to deliver income with affordable cost base Failure to deliver sufficient income to meet financial plan in 2015/16 4.1, Finance, Performance & Investment Committee Page 2 of 17

6 Board Assurance & Risk Framework for the delivery of Objectives The Board has overall responsibility for ensuring systems and controls are in place, sufficient to mitigate any significant risks which may threaten the achievement of the strategic objectives. Assurance may be gained from a wide range of sources, but where ever possible it should be systematic, supported by evidence, independently verified, and incorporated within a robust governance process. The Board achieves this, primarily through the work of its Assurance committees, through use of Audit and other independent inspection and by systematic collection and scrutiny of performance data, to evidence the achievement of the objectives. The core assurance mechanisms are: Board of Directors Audit Committee Governance Committee Finance, Performance & Investment Committee Risk Committee Charitable Funds Committee Internal Audit / External Audit / Clinical Audit External inspections / reports e.g. Care Quality Commission, NHSLA Deanery visits/ reports Peer review and accreditation Direct patient and staff feedback and service review Specifically commissioned reports Common information sources to evidence Assurance Performance and quality data re DH and contract targets Operational efficiency data Patient and staff survey results Data, trends, comparators for complaints, incidents and risks Clinical outcomes data e.g. mortality rates Financial data Project reports, milestone achievement Personal review/contact e.g. walk rounds, patient and staff story Page 3 of 17

7 Controls are the mechanisms put in place in order to reduce the likelihood and impact of risks, The Trust s overarching organisational controls are: The Executive Management arrangements and scheme of delegation Trust Management Committee CCG Contract Performance Meetings NHS Leaders forum/qipp Delivery Group Clinical Site Development Programme and Board Performance Assurance Framework and review (PAF) Trust approved policies, procedures, includes standing financial instructions and Standing Orders Financial and budget management arrangements The organisational development strategy and training and development plan The risk management process including risk registers Clinical supervision Appraisal process, PDRs and revalidation The recruitment process for staff, the checking of registration and monitoring of CRB compliance Board Memorandum on Quality Governance Star Chamber (Quality Impact Assessment for CIPS) Scope and Structure of BAF The BAF focuses on those risks which pose a significant risk to the delivery of the Trust s strategic objectives. The BAF is laid out by order of the Objectives, as agreed by the Board. This process enables the Board to be informed about all risks d at 15 and above. The Trust s Executive and Board performance reporting processes pick up all the routine data to support the delivery of objectives. Risk Risk is the impact of uncertainty on the achievement of objectives. The Board is concerned about any risk, which has the potential to threaten a Trust Objective. The Board Assurance & Risk Framework brings together all strategic risks expanding on the assurance, control and assurance and relevant action. Page 4 of 17

8 Reference in BAF table The risk ref column in the BAF refers to the identification number of the risk appearing on the Trust s risk register. Actions This column is to be used to either detail actions that are in progress to resolve in controls and assurance or actions requested at board to demonstrate assurances or resolve and the RAG indicated degree of assurance regarding the controls and actions in place Strategic Objectives 2015/16 The BAF follows the agreed ordering of the Strategic Objectives, which are as follows: Strategic Objective 1: QUALITY We will provide outstanding health care services that are safe, responsive, accessible and effective to meet patients needs and achieve best in class performance (Executive Director: Medical Director / Nurse Executive / Chief Operating Officer) 1.1 Consistent and safe services across 7 days - 24/7 1.2 Standardised, person centred pathways of care 1.3 Consistent NHS upper quartile performance and more ambitious benchmarks as appropriate 1.4 Excellent feedback from patients, carers, families, staff and our partners Strategic Objective 2: PEOPLE We will make best use of our expert skills and capabilities, invest in education, training and research to continually improve our practice, and offer fulfilling and valued careers (Executive Director: Director of HR & Organisational Development / Medical Director) 2.1 Inspirational multi-disciplinary leadership and effective management of all of our services 2.2 A resilient workforce that is proud to work for Royal Cornwall Hospitals Trust and effective and efficient deployment of our expert skills and capabilities 2.3 A thriving research, improvement and innovation portfolio that informs and improves patient outcomes Page 5 of 17

9 Strategic Objective 3: PARTNERSHIP We will collaborate and innovate with our partners to deliver integrated, patient-focused pathways of care and be the provider of choice in Cornwall and Isles of Scilly (Executive Director: Director of Strategic & Business Development) 3.1 New service models aligned with NHS Kernow s integrated vision for health and social care 3.2 Create a new service offer in East Cornwall in response to the ISTC contract, and achievement of growth under AQP 3.3 Strengthened clinical networks, new joint care models and partnership ventures to underpin the viability of services in Cornwall and Isles of Scilly Strategic Objective 4: RESOURCES We will be financially sustainable and make efficient use of our resources to provide safe and welcoming environments, modern equipment, facilities, and technology, to underpin service transformation. (Executive Director: Director of Finance & Performance / Chief Operating Officer / Director of Strategy & Business Development) 4.1 Achieve planned surpluses of 3.9m each year 4.2 Best in class productivity and efficiency standards, delivered through quality assured CIPs 4.3 Completion of our sites development plan phase 1, and achievement of expected patient and business benefits 4.4 Fully utilised and robust, electronic patient care and management systems, supporting high quality, efficient care 4.5 Successful work with partners to achieve our sustainability goals adding value to the economic health of Cornwall and Isles of Scilly Risk Matrix Page 6 of 17

10 Strategic Objective 1: QUALITY We will provide outstanding health care services that are safe, responsive, accessible and effective to meet patients needs and achieve best in class performance (Executive Director: Medical Director / Nurse Executive / Chief Operating Officer) 1.1 Consistent and safe services across 7 days - 24/7 1.2 Standardised, person centred pathways of care 1.3 Consistent NHS upper quartile performance and more ambitious benchmarks as appropriate 1.4 Excellent feedback from patients, carers, families, staff and our partners Risk & Source Owner / location Main Controls/ Risk ID: 5230 National Hospital Standardised Mortality Ratio (HSMR) data indicates that the Trust has higher than average mortality, particularly at weekends, leading to; Concerns about the quality and safety of clinical care. Trust reputation. Increased likelihood of regulatory intervention. Medical Director Controls: On call rotas for all acute specialties. Job planned 7 day working for all acute specialties. Limited elective work at weekends. Mortality Review Committee Divisional Quality and Learning Group Assurance: Trust Management Committee and Governance review data around mortality review and progress against the Mortality Improvement Plan. Inconsistent cover across specialities at weekends 20 Mortality Improvement Plan in progress with a 12 month target of reducing HSMR to 100 or below. Review of inpatient deaths Revision of escalation protocols Strengthened handover Implementation of outreach system Increased junior doctor cover out of hours Implementation of pathways Board Committee oversight: Governance Committee 15 (3x5) NHS Trust Development Authority visit. Page 7 of 17

11 Risk & Source Owner / location Main Controls/ Risk ID: 3702 Certain specialties, due to lack of capacity or lack of clinical engagement, have been identified as having increased risk to providing consistent upper quartile performance, impacting on: Quality and safety Patient experience Income Chief Operating Officer Controls: Scrutiny of clinical risk assessment reviewed at TMCG. Performance review and management process. Capacity planning linked to job plans. On-going recruitment in key areas. Specialty based action plans. Assurance: KPI monitored via governance and performance reports. Comprehensive clinical risk assessment as a routine process. Clearly defined clinical strategies for each Specialty. Assurance: Specialty level PAF including morbidity and mortality data partially implemented. Executive team specialty review was discussed at Governance Committee in June 2015, providing a clear view of which specialties still carried with assurance. 16 (4x4) Additional management resource identified as appropriate. ed business cases and recruitment plan for Ophthalmology. Booking Hub development for Cardiology and CIU environment upgrades. Coaching Programme for Gynaecology consultants. Board Committee oversight: Trust Board 9 (3x3) Divisional business plans and objectives. Risk ID: 3411 / 4509 / 4166 Clinical and operational capacity pressures: risk to quality of care, reputation, registration and target performance including RTT backlog Chief Operating Officer Controls: Performance review and management process. Capacity planning 2014/15 and ongoing revisions to elective recovery plan through weekly RTT meeting Lack of system wide prioritisation / to monitor pledges Speed of delivery of CSDP due to capital investment constraints. Uncontrolled growth in 25 (5x5) Jointly work with NHS Kernow and NHS partners reducing emergency activity and improving flow. Engagement with Council/OSC to lever improvement in delayed transfers of care issues. Investment in short term additional 20 (5x4) Page 8 of 17

12 Risk & Source Owner / location beyond sustainable levels within national targets Main Controls/ On-going recruitment for key specialties. ED action plan. Ambulatory Emergency Care Operational model Emergency Care Intensive Support Team system wide review. demand (non elective) impacting on elective work plan Complex discharges per week do not meet requirements. Further development of pathways and internal discharge processes. capacity. Pathway development work in Heart Failure and Chest Pain, COPD and Frailty. Membership of the National Ambulatory Care Network. Elective activity productivity plan at SMH Discharge Project Action Plan. Care Quality Commission Improvement Plan. Bed Model. Appropriate recruitment to key medical and nursing establishment Further consideration of elective activity delivery plan and cancellation due to medical outliers. Internal nurse recruitment campaign planned for late Summer/Autumn. System Resilience Group Winter and Bank Holiday plans. Board Committee oversight: Finance, Performance & Investment Committee CSDP investment strategy. CQC Action Plan. Major Incident Plan. Assurance: Performance against KPI, national and local targets and performance metrics scrutinised by Executive led Divisional Performance meetings; the Finance, Page 9 of 17

13 Risk & Source Owner / location Main Controls/ Performance and Investment Committee, with exception reports to the Trust Board. Risk ID: 5229 Failure to effectively manage Health & Safety within the organisation may impact: staff and patient wellbeing; Trust reputation; Compliance with legal and regulatory obligations leading to prosecution and/or regulatory action Director of HR and OD Controls Health & Safety Policies Health & Safety Committee Health & Safety Team Delegation of responsibility through line management chain. Assurance: Health and Safety Committee Ward & Specialty Executive Walkrounds Recent reviews into health & safety and intervention by HSE have demonstrated that the management of health & safety within the organisation is not robust and improvement is needed. 20 (4 x 5) Review of Health & Safety carried out and paper presented to TMC in April 2014 and to Trust Board in May Detailed action plan produced including:- development H & S Improvement Strategy, re-vitalising H & S Committee, Reporting to Trust Board, re-structuring of health & safety team, system and process improvement, policy development and implementation, training and development. Health and Safety Strategy has been approved at TMC and will be presented to the Trust Board in September (3 x 3) Review of resourcing has been approved at TMC. Areas for audit have been established and linked to the 11 areas identified as potential reinspection. In addition, self-audit tool is being finalised that will be rolled out to each department. Finally support from the Fire Safety Trainer once in post will start the audit process. Board Committee oversight: Governance Committee Page 10 of 17

14 Strategic Objective 2: PEOPLE We will make best use of our expert skills and capabilities, invest in education, training and research to continually improve our practice, and offer fulfilling and valued careers (Executive Director: Director of HR & Organisational Development / Medical Director) 2.1 Inspirational multi-disciplinary leadership and effective management of all of our services 2.2 A resilient workforce that is proud to work for Royal Cornwall Hospitals Trust and effective and efficient deployment of our expert skills and capabilities 2.3 A thriving research, improvement and innovation portfolio that informs and improves patient outcomes Risk & Source Owner / location Main Controls/ Risk ID: 3699 / 3093 Low levels of staff engagement will impact upon the delivery of safe, high quality and compassionate care. Director of HR & OD Controls Implementation of Our People Strategy including the delivery of a multi-disciplinary leadership development programme and the Health and Wellbeing Strategy. Development of a coordinated set of HR/OD Metrics against which all people related activity will be measured. Implementation of staff survey improvement plan at corporate, divisional and occupational group level. Delivery of projects to review policies/ procedures and systems to support the effective deployment of staff across the organisation. Control Gaps Historically low levels of engagement/ poor results from the staff survey and failure to deliver previous improvement plans. Inadequacy of previous people related processes to support the above. Embedding of Trust vision, strategic objectives, values and culture across the organisation. Lack of clear objectives at individual, team and divisional level. Existing poor levels of compliance within divisions in respect of mandatory training and PDR. 16 (4x4) Implementation of workforce element of Trust Improvement Plan including:- Re-launch of the Listening into Action Programme with a more clinical focus and led by the Chief Executive and Deputy Chief Executive. Implementation embedding of OD/ Cultural Change Strategy. Continued embedding of engagement activity. Development and delivery of revised communications and engagement strategy. Implementation of stakeholder engagement policy. Development/delivery of multidisciplinary leadership development programme. 12 (4x3) Quarterly staff friends and Launch of coaching and mentoring Page 11 of 17

15 Risk & Source Owner / location Main Controls/ family survey. Monthly pulse surveys. Performance Assurance Framework (PAF). Listening into Action will be evaluated as part of a nationally validated programme. Staff Survey. Embedding of Trust values and associated behaviour framework. Potential impact on levels of staff engagement arising from delivery of cost Improvement Plan Improvement programmes and workforce elements of the Our People Strategy. Potential impact on relationships with staff side and wider employee relations climate as a consequence of delivering pay modernisation agenda. programme. Rollout of Continued implementation of Health and Wellbeing Strategy. Implementation of revised HR Structure including Kernowflex and E- Rostering. Honest/robust engagement with staff side colleagues. Information sharing/collaboration with regional partners. Continued development of service line management. Assurance: Quarterly staff friends and family survey. Monthly pulse surveys. Introduction of revised Raising Concerns Policy and Process Board Committee oversight: Trust Board Performance Assurance Framework (PAF). Listening into Action will be evaluated as part of a nationally validated programme. Page 12 of 17

16 Strategic Objective 3: PARTNERSHIP We will collaborate and innovate with our partners to deliver integrated, patient-focused pathways of care and be the provider of choice in Cornwall and Isles of Scilly (Executive Director: Director of Strategy & Business Development) 3.1 New service models aligned with NHS Kernow s integrated vision for health and social care 3.2 Create a new service offer in East Cornwall in response to the ISTC contract, and achievement of growth under AQP 3.3 Strengthened clinical networks, new joint care models and partnership ventures to underpin the viability of services in Cornwall and Isles of Scilly Risk & Source Owner / location Main Controls/ Risk ID: 3692 Diverging objectives between partners puts at risk the development of whole system agreement on the configuration of future health and social care services resulting in: Failure to deliver integrated care Failure to use resources efficiently and effectively across the system Poor experiences for patients and service users Director of Strategy & Business Development Controls NHS Kernow (NHSK) Governance through Leadership Summit, Whole System Resilience Network (WSRN), Urgent Care Board Provider meeting held on 19 th November 2014 and 10 th February 2015 to outline the potential options for locality models Issues escalated through TDA/NHS England review meetings. Controls Lack of substantive formal, robust system wide Governance arrangements with structured reporting processes Significant in assurance as evidenced in the lack of substantive strategy and plan for health economy 20 (4x5) On-going CEO and Chair escalation with other system leaders Work with NHSK through SRG WSRN, to align plans and make differences more explicit Board strategic review updated to determine RCHT position and approach to be refreshed 2015/16 opportunities PCH services and Case for Cornwall have the potential to significantly reduce this risk. Board Committee oversight: Finance, Performance & Investment Committee 15 (3x5) Page 13 of 17

17 Risk & Source Owner / location Main Controls/ Risk ID: 3690 Increased competition in Cornwall and/or change of intentions as locality commissioning develops, leads to a risk that: Certain clinical services currently offered by the Trust will be lost to other providers potentially impacting on the clinical viability of certain specialties Director of Strategy & Business Development Controls Any Qualified Provider (AQP) response Elective Surgery Programme Locality/GP engagement sessions Children s Partnership Board and Strategy Patient Services Commercial Manger commenced in September 2014 Controls Refreshed Communication and promotion strategy Claims regarding future and ISTC (Bodmin) contract Assurance Regular, robust business market share intelligence to inform service line plans being developed as part of Baseline Review 20 (4x5) Constructive dialogue with Consultant LLPs to be refreshed in context of speciality plans Accelerate work with Peninsula Community Health (PCH) to look at service integration to be covered by the assessment of the service transfer. Board Committee oversight: Finance, Performance & Investment Committee 16 (4x4) Loss of income threatens the financial viability of the Trust. Board agreed strategic response to Children s Services Tender at its meeting in January Project outcomes from above, reporting to Trust Management (TMC) Discussion of progress on strategic aims at Board Strategy Days and Trust Board. Page 14 of 17

18 Risk & Source Owner / location Main Controls/ Risk ID: 3684 Application of Specialist Commissioning service thresholds through NHS England could Lead to certain specialist services no longer being offered by the Trust with potential impacts on service quality and patient experience. Director of Strategy & Business Development Controls Contract meetings with Commissioners (local and national) Internal derogation/assurance processes - completed Engagement with NHSK and Plymouth NHS Trust Assurance Derogation returns and action plans through TMC - completed Business case appraisals through TMC approved 5th Vascular Surgeon Controls Respond to most recent guidelines regarding Emergency Surgical Services Assurance Alignment with NHSK on strategic plan (see above) Evidence of joint strategy from PHT where appropriate, requires continued Executive focus 20 (4x5) Continued horizon scanning and networking to inform, influence national direction and local application Action in place to influence Senates and provide evidence for Surgical Services Review and Vascular Direct engagement with Kernow Health (GPs in Cornwall) Productive meeting 13 th November 2014 with commissioner and Plymouth regarding resolution for vascular await confirmation of agreed model, on-going dialogue in place. Board Committee oversight: Finance, Performance & Investment Committee 12 (3x4) Board meetings and actions with Plymouth NHS Trust Page 15 of 17

19 Strategic Objective 4: RESOURCES We will be financially sustainable and make efficient use of our resources to provide safe and welcoming environments, modern equipment, facilities, and technology, to underpin service transformation. (Executive Director: Director of Finance & Performance / Chief Operating Officer / Director of Strategy & Business Development) 4.1 Achieve planned surpluses of 3.9m each year 4.2 Best in class productivity and efficiency standards, delivered through quality assured CIPs 4.3 Completion of our sites development plan phase 1, and achievement of expected patient and business benefits 4.4 Fully utilised and robust, electronic patient care and management systems, supporting high quality, efficient care 4.5 Successful work with partners to achieve our sustainability goals adding value to the economic health of Cornwall and Isles of Scilly Risk & Source Owner/ Location Main controls/ assurances assurances current residual Risk ID: 5214 (4723 / 4739 / 4740) Risk of delivery of financial plan and in year statutory financial duties Non delivery of CIP Failure to control costs to deliver income with affordable cost base Failure to deliver sufficient income to meet financial plan in 2015/16 Director of Finance, Director of Strategy & Business Development, Chief Operating Officer Interim Director of Financial Recovery Controls: Executive oversight of Financial Plan Development of CQUIN action plan 2015/16 delivery Monthly monitoring of CIP schemes by TMC, Finance, Performance and Investment and Board. Monthly challenge of highest value CIP schemes by FP&I Committee. : Financial plan approved by Board in March Executive review of CQUIN delivery framework CQUIN framework Delivery risk Failure to secure additional income will increase CIP target. High level of expensive variable pay. 25 (5x5) Revised CIP accountability framework Programme Management Office (PMO) additional support team in place from October 2014 to support CIP programme. Elective activity performance recovery plan focussed on SMH. supported by ORI and UNIPART. Development of 3 year financial recovery plan as part of Performance Improvement Framework (PIF) as part of Trust Performance Recovery Plan Exploration with health partners opportunity to revisit fines and tariff risk options. Refreshing financial plan post Quarter 1 review for 2015/ (4x5) Revised 2018 programme arrangements. Page 16 of 17

20 Risk & Source Owner/ Location Main controls/ assurances assurances current residual Limited assurance on CIP due to shortfall in savings plan. Page 17 of 17