nhs rushcliffe ccg assurance framework · the ccg and other services 2015/16 amber 3 3 high low...
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NHS Rushcliffe CCG Assurance Framework
March 2016
Date placed
on
Assurance
Framework
L I
GB35
Director Outcomes
and Information
Director Nursing and
Quality
Governing Body
May-13
Failure to achieve the EMAS performance
targets with a disproportionate performance
between city and county. This means
patients in the county may be at greater risk
of harm. In addition, the nature of
complaints received by EMAS demonstrate
a growing concern around quality
RED 5 4 HIGH HIGH
GB36
Director Outcomes
and Information
Director Nursing and
Quality
Governing Body
12-Nov-13Failure to achieve the 4 hour ED
performance targetRED 5 4 HIGH HIGH
GB39Director of Nursing
and Quality 19-Nov-15
LA budget constraints: Following LA budget
constraints, there is a miss-match in the
resources available to fund health and
social care services and the demand on
those services which may affect patient
experience, the quality of service
provision and outcomes for patients.
RED 4 4 HIGH HIGH
GB40Director of Nursing
and Quality 19-Nov-15
Home care quality monitoring: There are
not currently well established processes for
monitoring the quality of home care
providers which means that patients may be
receiving inappropriate and/or poor quality
care
AMBER/
RED3 4 HIGH HIGH
ASSURANCE FRAMEWORK SUMMARY
Trend since
last GB
meeting
Risk scoreRisk
No.
Lead & Sub
CommitteeRisk narrative
Residual
Risk rating
Risk rating
19
November
2015 GB
meeting
Risk rating
17 March
2016 GB
meeting
Date placed
on
Assurance
Framework
L I
Trend since
last GB
meeting
Risk scoreRisk
No.
Lead & Sub
CommitteeRisk narrative
Residual
Risk rating
Risk rating
19
November
2015 GB
meeting
Risk rating
17 March
2016 GB
meeting
Chief Finance Officer 19-Nov-15
Financial position at NUH may affect
system resilience resulting in extra costs to
the CCG and other services 2015/16AMBER 3 3 HIGH LOW
Chief Finance Officer 19-Nov-15
Financial position at NUH may affect
system resilience resulting in extra costs to
the CCG and other services 2016/17
AMBER/
RED4 3 HIGH HIGH
GB43Director of Outcomes
and Information30-Mar-16
Year to date the CCG is below standard on
certain cancer waiting times. The CCG is
working with the wider footprint on overall
performance and a remedial action plan has
been agreed. Specific indicators below
standard include Cancer 2ww breast
symptoms 85.22%; 62d Urg RTT Screening
75%; and Cancer 31d DTT 95.84%, 31d
DTT surgery 92%
AMBER/
GREEN3 2 LOW LOW
GB42
L I L I
GB 35
Director Outcomes and
Information
Director Quality and Patient
Safety
Governing Body
Failure to achieve the EMAS performance targets with a disproportionate performance
between city and county. This means patients in the county may be at greater risk of
harm. In addition, the nature of complaints received by EMAS demonstrate a growing
concern around quality
RED 5 5 RED 5 4
Better Patient Care Programme Board to monitor progress against the QIP.
The formal monitoring of the QIP is by the 'Oversight Group', led by the Trust Development Authority with NHSE, Lead Commissioner and EMAS.Ongoing
Bi-monthly Governing Body report and discussion Ongoing
Prolonged Wait Report - clinical audit on patients experiencing missed response times - reviewed by Quality and Risk Committee 01-Jan-15
Clinical Risk Summit reported to Governing Bodies and EMAS recovery plan produced following Summit 01-May-15
01-Dec-15
Ten minute protocol reviewed and relaunched 01-Mar-16
GB 35 RISK DETAIL
Strategic Objective 2 Improve the quality of health services in relation to health inequalities, health outcomes, patient safety, access and patient experience.
Controls Date
Assurance Domain 3 Delivering better outcomes for patients.
Risk
No.Lead & Sub Committee Risk narrative
Residual
Risk rating
Risk scoreInitial Risk
Rating
Risk Score
Contract Review Process led by Hardwick CCG on behalf of associate CCGs. Mansfield and Ashfield CCG lead for Nottinghamshire Ongoing
Director of Outcomes and Information, Head of Outcomes and Information and Senior Service Improvement Manager attend regular divisional monitoring meetings Ongoing
Deep Dive Review at Governing Body 19-6-15 and Audit Committee 12-1-15 and 27-1-16 Ongoing
EMAS Better Care Programme and Quality Improvement Plan following Clinical Risk Summit (October 2013) 01/10/2014/Ongoing
First responder operational plan implemented to establish pathway for first responder scheme 01-Mar-16
Commissioners' Report - produced monthly by NHS Hardwick CCG and shared with contract associates Ongoing
External/Internal Assurance Date
Provider met with commissioners to share issues and discuss support for financial position, improvement of current performance levels, and reducing the level of clinical risk
associated with prolonged waits.
Root Cause Analysis of missed Red 1 and Red 2 8 minute response times - reviewed by Quality and Risk Committee 01-Jan-15
Harm review now formalised and undertaken regularly
A harm review has been undertaken by EMAS Medical Director and Rushcliffe Governing Body GP of Red 1 breaches for Q.1. No adverse harm identified and process established
for ongoing review and assurance to associate commissioners. EMAS action includes staff recruitment, fleet replacement, expansion of first responder scheme in rural areas.
01-Jan-16
Action plan target date
Date info addedADDITIONAL INFORMATION e.g. The considerations taken when deciding on the risk rating or information to further inform the governing body on risks which remain
high despite on-going actions
CQC report awaited.
Gaps in controls and assurance and the action plans in place
01-Oct-15
01-Mar-16
CQC inspection completed mid November 2015. 15-Nov-15
L I L I
GB 36
Director Outcomes and
Information
Director Quality and
Patient Safety
Failure to achieve 4 hour ED performance targetAMBER
RED5 3 RED 5 4
Audit Committee Deep Dive review of ED Performance 27 January 2016
Urgent care centre opened Oct-15
Performance delivered in quarter 1 2015/16 was above the 95% target; Standard not achieved in Quarters 2 and 3
Ongoing
Urgent Care Daily Sit Rep to NHS England Ongoing
External/Internal Assurance Date
Urgent care dashboard produced on a daily basis to support daily conference calls that include all health and social care organisations Sep-15
Escalation telephone calls for Chief Officers and NUH Senior Management at 5 pm each day that performance is below 85% Jan-16
Remedial Action Plan agreed with NUH which includes financial sanctions for non-delivery of specific actions or non-delivery of required performance improvement. RAP
monitored and escalated through Contract Executive Board.Jan-16
CCGs continue to impose fines against the provider for the under delivery of the performance standard as defined in the NHS Standard Contract On-going
Friends and Family test response performance reported within Quality Premium section of Quality and Performance Report; outcome monitored through Quality Scrutiny Panel Ongoing
Assurance Domain Delivering better outcomes for patients.
Strategic Objective Improve the quality of health services in relation to health inequalities, health outcomes, patient safety, access and patient experience.
GB 36 RISK DETAIL
Risk
No.Lead & Sub Committee Risk narrative
Initial Risk
rating
Risk Score Residual
Risk rating
Risk score
CCG Quarterly Assurance Meetings Ongoing
Controls Date
System Resilience Implementation Group meeting weekly across south UOP. Workstreams: admission avoidance; effective rehabilitation and discharge; demand and capacity -
with comprehensive work programme and sub-groups to oversee service improvement, transformation and performance Ongoing
Oct-15
NHS England Scrutiny meetings attended by Chief Officer Ongoing
Date info
added
Urgent care centre opened Oct-15
May-15Director of Urgent Care and two Project Managers to support implementation of System Resilience Implementation Group
ADDITIONAL INFORMATION e.g. The considerations taken when deciding on the risk rating or information to further inform the governing body on risks which
remain high despite on-going actionsDate info added
Gaps in controls and assurance and the action plans in placeAction plan target
date
Detailed joint analysis completed to determine the benefit and risks of reducing elective capacity beyond that historically carried out. This analysis determined that the level of
benefits of freed bed capacity did not outweigh the risk of subsequent delays to elective patients and the subsequent risk of failure of the NHS Constitution Standards.Jan-16
Detailed analysis of 150 patients deemed to be'stranded' to System Resilience Implementation Group and action plan is being developed Mar-16
L I L I
GB 39 Director Quality and
Patient Safety
LA budget constraints: Following LA budget constraints, there is a miss-match in the
resources available to fund health and social care services and the demand on those
services which may affect patient experience, the quality of service
provision and outcomes for patients.
RED 4 4 RED 4 4
Action
plan
target
date
Date info
added
Nov-15
Awaiting final details of proposals following closure of consultation. Health implications of final proposals to be assessed once known. Jan-16
ADDITIONAL INFORMATION e.g. The considerations taken when deciding on the risk rating or information to further inform the governing body on risks which
remain high despite on-going actionsDate info added
In 15/16 BCF scheme to protect social services Jan-16
BCF 16/17 in development including an evaluation of the impact of 2015/16 BCF Jan-16
Health implications of final proposals to be assessed once known.
Gaps in controls and assurance and the action plans in place
Local Authority update to Governing Body Dec-15
CCG response to proposals submitted as part of consultation process and Governing Body paper in Jan 2016 on proposed budget changes Jan-16
Greater Nottingham Board working as a unit of planning with all stakeholders to ensure development of sustainable models for future health and social care Ongoing
External/Internal Assurance Date
Controls Date
Social Care Director is member of CCG Governing Body Ongoing
Better Care Fund plan in place and monitored by BCF Programme Board Ongoing
Nottingham County Council presented budget proposals ahead of formal consultation Jan-15
GB 39 RISK DETAIL
Risk
No.Lead & Sub Committee Risk narrative
Initial Risk
Rating
Risk Score Residual
Risk
rating
Risk score
Assurance Domain 1
Assurance Domain 3
Clinically commissioned, high quality services
Better outcomes for patients
Strategic Objective 4 Design, procure and monitor services to achieve the best possible clinical and patient experience outcome
L I L I
GB40 Director Quality and
Patient Safety
Home care quality monitoring: There are not currently well established processes for
monitoring the quality of home care providers which means that patients may be receiving
inappropriate and/or poor quality careAMBER
RED3 4
AMBER
RED3 4
Action
plan
target
date
Date info
added
Nov-15
Nov-15
Joint quality assurance processes with the LA still need to be developed.
ADDITIONAL INFORMATION e.g. The considerations taken when deciding on the risk rating or information to further inform the governing body on risks which
remain high despite on-going actionsDate info added
Quality Improvement Forum to be established by CityCare
Gaps in controls and assurance and the action plans in place
Work continues by contracting team to establish the new contracts with all providers. Nov-15
External/Internal Assurance Date
Controls Date
Meeting regularly with new homecare providers and the County Council to mobilise the new contracts which include a quality schedule as quickly as possible. Nov-15
Audit tool to monitor provider quality being devised for use by CHC Jan-16
GB40 RISK DETAIL
Risk
No.Lead & Sub Committee Risk narrative
Initial Risk
Rating
Risk Score Residual
Risk
rating
Risk score
Assurance Domain 1
Assurance Domain 3
Clinically commissioned, high quality services
Better outcomes for patients
Strategic Objective 4 Design, procure and monitor services to achieve the best possible clinical and patient experience outcome
L I L I
Financial position at NUH may affect system resilience resulting in extra costs to the CCG
and other services 2015/16AMBER
RED4 3 AMBER 3 3
Financial position at NUH may affect system resilience resulting in extra costs to the CCG
and other services 2016/17AMBER
RED4 3
AMBER
RED4 3
Action
plan
target
date
Date info
added
Financial penalties as outlined in contract are routinely imposed and this is reported to the Governing Body Ongoing
Cancer performance forms part of regular discussions with NHS England Locality Team as part of regular assurance meetings Ongoing
OngoingNottingham City CCG lead commissioner hold fortnightly discussion with NUH cancer leads and attend the Patient Target List meeting
Three Remedial Action Plans have been agreed and implemented Ongoing
Remedial Action Plan includes financial consequences of non-delivery Ongoing
Gaps in controls and assurance and the action plans in place
Quality Team has undertaken harm reviews which has identified a low level of clinical risk associated with the delays
Remedial Action Plan has an agreed date for recovery which is 1st April 2016 Feb-16
Contract Monitoring Meetings with providers Ongoing
Contract Executive Boards/ Meetings Ongoing
External/Internal Assurance Date
Chief Finance Officer financial scenario planning presentation to Governing Body Nov-15
The Contract Executive Board and the Quality and Performance Committee will monitor performance against the Remedial Action Plans. The CCG will have oversight Ongoing
Controls Date
Monthly performance and finance reporting to the Governing Body Ongoing
Detailed reports to QIPP group for rigorous performance monitoring Ongoing
GB42 RISK DETAIL
Risk
No.Lead & Sub Committee Risk narrative
Initial Risk
Rating
Risk Score Residual
Risk
rating
Risk score
Assurance Domain 1
Assurance Domain 3
Clinically commissioned, high quality services
Better outcomes for patients
Strategic Objective 4 Design, procure and monitor services to achieve the best possible clinical and patient experience outcome
GB42 Chief Finance Officer
Feb-16
Risk scoring reduced for 2015/16 to 3*3=9, remains at 4*3=12 for 2016/17 Jan-16
Deep dive planned for Audit Committee on 30th March 2016
ADDITIONAL INFORMATION e.g. The considerations taken when deciding on the risk rating or information to further inform the governing body on risks which
remain high despite on-going actionsDate info added
GB43 Chief Finance Officer
GB43 RISK DETAIL
Risk
No.Lead & Sub Committee
Nottingham City CCG lead commissioner hold fortnightly discussion with NUH cancer leads and attend the Patient Target List meeting
Assurance Domain 1
Assurance Domain 3
Strategic Objective 4
Controls
The Contract Executive Board and the Quality and Performance Committee will monitor performance against the Remedial Action Plan. The CCG will have oversight
Quality Team has undertaken harm reviews which has identified a low level of clinical risk associated with the delays
Three Remedial Action Plans have been agreed and implemented
Cancer performance forms part of regular discussions with NHS England Locallity Team as part of regular assurance meetings
Remedial Action Plan includes financial consequences of non-delivery
Financial penalties as outlined in contract are routinely imposed and this is reported to the Governing Body
External/Internal Assurance
Remedial Action Plan has an agreed date for recovery which is 1st April 2016
ADDITIONAL INFORMATION e.g. The considerations taken when deciding on the risk rating or information to further inform the governing body on risks which remain
high despite on-going actions
Deep dive planned for Audit Committee on 30th March 2016
Gaps in controls and assurance and the action plans in place
Year to date the CCG is below standard on certain cancer waiting times. The CCG is
working with the wider footprint on overall performance and a remedial action plan has been
agreed. Specific indicators below standard include Cancer 2ww breast symptoms 85.22%;
62d Urg RTT Screening 75%; and Cancer 31d DTT 95.84%, 31d DTT surgery 92%
RED
GB43 RISK DETAIL
Risk narrativeInitial Risk
Rating
Nottingham City CCG lead commissioner hold fortnightly discussion with NUH cancer leads and attend the Patient Target List meeting
Clinically commissioned, high quality services
Better outcomes for patients
Design, procure and monitor services to achieve the best possible clinical and patient experience outcome
Controls
The Contract Executive Board and the Quality and Performance Committee will monitor performance against the Remedial Action Plan. The CCG will have oversight
Quality Team has undertaken harm reviews which has identified a low level of clinical risk associated with the delays
Three Remedial Action Plans have been agreed and implemented
Cancer performance forms part of regular discussions with NHS England Locallity Team as part of regular assurance meetings
Remedial Action Plan includes financial consequences of non-delivery
Financial penalties as outlined in contract are routinely imposed and this is reported to the Governing Body
External/Internal Assurance
Remedial Action Plan has an agreed date for recovery which is 1st April 2016
ADDITIONAL INFORMATION e.g. The considerations taken when deciding on the risk rating or information to further inform the governing body on risks which remain
high despite on-going actions
Deep dive planned for Audit Committee on 30th March 2016
Gaps in controls and assurance and the action plans in place
L I L I
5 4AMBER/
GREEN3 2
Action
plan target
date
Date info
added
GB43 RISK DETAIL
Risk Score Residual
Risk
rating
Risk score
Nottingham City CCG lead commissioner hold fortnightly discussion with NUH cancer leads and attend the Patient Target List meeting Ongoing
Clinically commissioned, high quality services
Better outcomes for patients
Design, procure and monitor services to achieve the best possible clinical and patient experience outcome
Controls Date
The Contract Executive Board and the Quality and Performance Committee will monitor performance against the Remedial Action Plan. The CCG will have oversight Ongoing
Quality Team has undertaken harm reviews which has identified a low level of clinical risk associated with the delays Feb-16
Three Remedial Action Plans have been agreed and implemented Feb-16
OngoingCancer performance forms part of regular discussions with NHS England Locallity Team as part of regular assurance meetings
Remedial Action Plan includes financial consequences of non-delivery
Financial penalties as outlined in contract are routinely imposed and this is reported to the Governing Body
Feb-16
Ongoing
External/Internal Assurance Date
Remedial Action Plan has an agreed date for recovery which is 1st April 2016 Feb-16
ADDITIONAL INFORMATION e.g. The considerations taken when deciding on the risk rating or information to further inform the governing body on risks which remain
high despite on-going actionsDate info added
Deep dive planned for Audit Committee on 30th March 2016 Feb-16
Gaps in controls and assurance and the action plans in place
LIST OF RISKS ARCHIVED
L I
GB37Director of
Finance
QIPP 2014/15 - Expenditure will exceed budget and
the CCG will not deliver its required surplus due to
QIPP not delivered or not delivered recurrently
2 1 1
Transferred to risk
register as no longer high
risk
Mar-15 Sep-15
GB38 Chief Officer
Failure to put in place appropriate arrangements for
the management of the Better Care Fund could impact
on the financial position of the CCG and the services
commissioned for our patients
4 2 2
Transferred to risk
register as no longer high
risk
Mar-15 Sep-15
GB16
Director of
Nursing and
Quality
Quality assurance and monitoring resources are
limited and the risk it that these are targeted at some
providers and not others where there are equal or
greater risks. The impact would be on individual
patients and also on the reputation of the CCG and
confidence in the wider public
9 3 3
Transferred to risk
register as no longer high
riskNov-15 Jan-16
GB41Chief Finance
Officer
The CCG fails to keep within the Revenue Resource
Limit and is unable to pay for services it has
commissioned due to higher levels of activity than
expected and/ or undelivered QIPP schemes
9 3 3
Transferred to risk
register as no longer high
riskJan-16 Mar-16
Date of
removal
Risk
No.Lead Risk narrative
Risk
rating
Risk scoreReason for removing
from the assurance
framework
Date
completed
Likelihood
score1 2 3 4 5
Descriptor Rare Unlikely Possible LikelyAlmost
certain
Frequency
How often
might it
happen
Impact
score1 2 3 4 5
DescriptorInsignificant
or minorModerate Significant
Very
significantMajor
Impact
should it
happen
No or slight
impact on the
CCG objectives
Moderate impact
on the CCG
objectives
Significant impact
on the CCG
objectives
Impact on the
CCG objectives
affecting delivery
over several areas
Impact on the
CCG
objectives
requiring
radical review
InjuryMinor injury not
requiring first aid
Minor injury or
illness, first aid
treatment needed
Over three days
off “sick” =
RIDDOR
reportable. 10
days to report to
the HSE.
Major injuries, or
long term
incapacity /
disability (loss of
limb)
Death or major
permanent
incapacity
Patient
Experience
Unsatisfactory
patient
experience not
directly related to
patient care
Unsatisfactory
patient experience
- readily
resolvable
Mismanagement
of patient care –
short term effects
Mismanagement
of patient care –
long term effects
Totally
unsatisfactory
patient
outcome or
experience
Service/
Business
Interruption
Loss/interruption
> 8 hours
Loss/interruption >
1 day
Loss/interruption
1 week
Loss/interruption
over a week
Permanent
loss of service
or facility
Late delivery of
key objective/
service due to
lack of staff
(recruitment,
retention or
sickness). Minor
error due to
insufficient
training. Ongoing
unsafe staffing
level
Inspection/
Audit
Minor
recommendation
s. Minor non-
compliance with
standards
Recommendation
s given. Non-
compliance with
standards
Reduced rating.
Challenging
recommendations.
Non-compliance
with core
standards
Enforcement
Action. Low
rating. Critical
report. Multiple
challenging
recommendations.
Major non-
compliance with
core standards
Prosecution.
Zero Rating.
Severely
critical report
DETERMINING THE RISK RATING
Ongoing low staffing level reduces
service quality
Local Media interest
Financial
Adverse
Publicity/
Reputation
Non-delivery of
key objective/
service due to
lack of staff.
Loss of key
staff. Very
high turnover.
Critical error
due to
insufficient
training
B - What is the severity of the impact
Complaint/
Claim
potential
Locally resolved
complaint
Justified
complaint
peripheral to
clinical care
Justified complaint
involving lack of
appropriate care
Multiple justified
complaints
Multiple claims
or single major
claim
Human
Resources/
Organis-
ational
Development
Rate as 1
(significant): Local
media interest for
over a month
National media
interest < 3
days MP
To the value of
the
contingency
held for the
financial year
13/14
Approx £4.5m
>50% of
contingency
Approx £2.75m
Up to 10% of
contingency
Up to Approx
£450k
<1% of
contingency
Approx £45k
10% of
contingency
Approx £450k
National media
interest < 3 days
Rate as 1
Uncertain delivery
of key objective/
service due to
lack of staff.
Serious error due
to insufficient
training
Additional narrative to support identification of the severity of the impact added below
Consider Table A - Likelihood, Table B - Severity and then review the matrix for a final score
A - What is the likelihood that harm, loss or damage from the identified hazard will
occur
This probably
will never
happen
Do not expect it
to happen but it
is possible it
may do so
Possibly may
happen
Highly probable
that it will
happen
Likely
Major
Very
significant
(High)
Significant
Moderate
Insignificant/
minor
1 2 3 4 5
RARE UNLIKELY POSSIBLE LIKELYALMOST
CERTAIN
NB
The following risks go on the assurance framework - Amber/red and red
The following risks go on the risk register - Amber, Amber/green and green
A&B - Likelihood and severity RAG rating matrix
IMP
AC
T
5 A R R R
(Very high)
4 R
3 A
R
AA/G
A/R
A/RA
G
A
A/G
A/G
LIKELIHOOD
A/R A/R
RISK MATRIX SCORING
A(Low)
1 G G G G G
(Very Low)
(Medium)
2
A
Risk Management Action Guide
Governing
Body
Review and challenge of all
strategic risks and mitigating
actions provided by all the CCG
Committees
Red and Amber
Red
CCG Assurance
Framework
Audit
Committee
Interrogation of strategic risks
through mechanisms such as
the Internal Audit Plan and
requests for full reporting to the
Audit Committee by the Finance
and QIPP, Quality & Risk
Committee and IGMT Commitee
Red and Amber
Red
CCG Assurance
Framework
Leadership
TeamSub Committee
Finance and
QIPP
Risk registers and CCG
Assurance Framework
Quality &
Risk
Committee
IGMT
Committee
NB
The following risks go on the assurance framework - Amber/red and red
The following risks go on the risk register - Amber, Amber/green and green
Committee Risk RatingDocument to capture
risk
Identification and management
of operational and strategic
risks. Action planning to ensure
mitigating factors and controls
are implemented and tracked.
Maintenance of the sub-
committee risk register and
signposting to the assurance
framework
All risk ratings
Remit