report to the board of directors 2016/17 · audit fp571 re-audit - to identify and assess risks of...

Attachment 3

Report to the Board of Directors 2016/17

Date of meeting 27 May 2016

Subject Board Assurance Framework

Report of Chief Executive

Prepared by Anna Hills, Director of Governance

Purpose of report To provide the Board of Directors with assurance that the risks to achievement of the strategic aims and objectives are being appropriately mitigated and to provide detail of any actions commissioned by the sub-committees of the Board to address any gaps in control or assurance.

Previously considered by

(Committee/Date)

Executive Team individually, Board Seminar May 2016

Board Action Required Approval X Discussion

Decision Information

Executive Summary and recommendation(s)

The BAF based upon the Strategic Objectives for 2016/17 is being developed by mapping the Trust’s high and extreme risks as detailed on the Trust’s Risk Register and consideration of the controls currently in place to mitigate these risks. The BAF details where assurance is obtained regarding the effectiveness of these controls and also identifies further actions required to minimise the risks. This will be further developed with the Executive Director leads for each objective over the next few weeks. This has been cross-referenced to the Clinical Audit Forward Plan, Internal Audit Forward Plan and other forms of assurance including external reviews. The work programmes of the Board Committees have been refreshed to ensure the required controls and assurance are in place and operating effectively to ensure delivery and monitoring of the Strategic Objectives. The Board of Directors is asked to approve this report.

Reassurance Assurance

It is okay because management say it is

Strong management personalities may dominate

Track record of success Professional background or

expertise No contradictory evidence

It is okay because how management have responded to questions from the board has given me confidence

Clear and logical explanations from board members

What has happened; why it has happened and what is the response

Management explanations are consistent

It is okay because I have reviewed various reliable sources of information

Independence of information source

Evidence of historic progress, outcomes

Triangulation with other information

270516 BAF Anna Hills, Director of Governance May 2016 REP/BOD/AH1605/V1

Strategic Context/Objective(s) and Board Assurance Framework links Strategic aim(s)

To be safe X To be effective X To be caring X To be responsive X To be well-led X

Strategic objective(s) 1. Delivery of this year’s Quality priorities X 2. CQC compliance/improvement X 3. Financial control/performance requirements X 4. Workforce strategy X General - no specific link to a current year’s objective N/A

BAF reference(s) All for 2016/17

This paper provides assurance against the Trust objective(s) identified X

This paper is to close a gap in control/assurance in relation to the objective(s) X

Legal/regulatory (The relevant regulatory or legislation requirement with specific reference where appropriate)

Equality Impact/risks (Equality Delivery System 2 – EDS2 Nov 2013)

Impact

Positive Negative Neutral

Assurance process and frequency of monitoring

DEFINITIONS Information: Update to ensure Board has sufficient knowledge on subject matter and to provide assurance on progress Discussion: Seeking Board members’ views, potentially ahead of final course of action being agreedDecision: When being asked to choose between alternative courses of actionApproval: Positive resolution, to confirm paper is sufficient to assure the Board in its ongoing monitoring role, or to address a gap in control

Executive LeadLink to Risk

RegisterLink to Standards

Rating of Risk to

ObjectiveControl Gaps Assurance Gaps

What the organisation aims to deliver (outcome

required)

Board level lead responsbile

for achievement of the

objective

All Risks No. What could prevent

us from meeting this objective?

CQC, NHSLA, HSE, etc Low/Medium/High/Extreme Primary Controls Secondary Controls Tertiery Controls (includes

external audits, internal audits,

clinical audit, Royal College and

other external reviews)

Are the identifed actions being

achieved?

Report of Board where controls

and assurance around risk is

presented

Board Committee where actions

are monitored and assurance is

provided to Board

Where we are not gaining

effective evidence?

Further evidence/ actions to

address control and assurance

gaps.

Responsible Officer (to deliver

specific action)

Timescale for achievement

Medical Director 2014/26 1a Root cause analysis (RCA)

process and learning from

incidences of hospital-

associated venous

thromboembolism (HAT) is

not fully embedded.

CQC, HSE, NICE, Royal

College

MODERATE RCA/audit template developed in line with NICE

guidance and ratified by the Hospital Thrombosis

Committee. Trust Thrombosis Lead identified

(Dr Cesar Gomez). Audit of all cases reported in

2015 conducted and learning events underway

during 2016.

CCG requires quarterly

reports in line with

contractual requirements

to Quality Meeting. Clinical

Audit REG1773 Practice of

Anticoagulation in patients

with

atrial fibrillation; Clinical

Audit FP571 Re-audit - To

identify and assess risks of

venous thromboembolism

in all patients

admitted to hospital;

RCAs for cases of HAT in 2016

not commenced as at 4th April

2016.

Quality and Safety Report

to Public Board

SQG Actions in relation to

2015 audit findings to

be monitored.

Hospital Thrombosis Cttee

to review RCAs for 2016

cases of HAT and monitor

delivery of actions following

2015 audit. Rep.ort to SQG

in July

Medical Director 31/07/2016

Director of Governance 1b A means of proactive data

analysis (heat maps) as an

early warning system to

allow the Trust to detect

areas of Quality that may

need action before an

incident, complaint or

claim etc. occur is not in

place.

MODERATE Information and data can be drawn from

Safeguard system (complaints, incidents, litigation,

PALS, inquests) and from e-Roster system

(sickness absence, red flags, shift fill etc) plus other

feedback data (FFT, surveys) and clinical audits and

assurance checks etc.

Mechanism for correlating

data and presenting as

ward/dept/specilaty level heat

maps needs defining.


to Public Board

SQG

See strategic objective

2

1c/2a The ‘Requirement Notices’

issued following the Care

Quality Commission (CQC)

inspection in August 2015

- Do not attempt

cardiopulmonary

resuscitation orders

(DNACPR)

- Equipment checks

are not lifted at

reinspection

Medical Director 1d Standard 2 of 7 day

services not achieved : 90%

of in-patients to be seen by

a Consultant within 14

hours of admission.

NHS England, Monitor MODERATE Cardiology, general medicine, general surgery,

geriatric medicine, gynaecology, ICU, obstetrics,

paediatrics, trauma and orthopaedics achieve 80%

compliance with the standard.

National return October

2015 demonstrated non-

compliance. Outcome of

national return made in

March 16 awaited.

Proposed internal audit

review of the processes and

systems to test if 7 day

services are embedded in

the

Trust’s operating model.

No IT system to capture this

data. Audits of some areas

demonstrate 86%

achievement of standard but

not all areas auditted and lack

of consistency across all

specialties.

Transformation report F&P; Transformation Board Actions following

audits and national

return not yet

reported.

Medical Director 1e Standard 5 of 7 day

services not achieved :

Diagnostic services to be

available 7 days a week

NHS England, Monitor LOW Biochemistry, chemical pathology, CT,

haematology, histopathology, microbiology,

radiology, lower and upper GI endoscopy,

ultrasound and x-ray are compliant.


2015 demonstarted partial



March 16 awaited.





the


Non compliant for

bronchoscopy, echocardiology,

MRI and therapies. However

for JPUH demand is such that

bronchoscopy and echo do not

require 7 day service.

Transformation report F&P; Transformation Board Regular reporting on

progress with

achievement of

standards required

via Transformation

Plans

1. Identify all gaps to

achievement of 7 day

service for MRI and

therapies. 2.

Review job planning and

resources required.

Medical Director

Medical Director 1f Standard 8 of 7 day

services not achieved : On-

going consultant review

every 24 hours 7 days per

week

NHS England, Monitor LOW Standard allows for exceptions to 24 hour reviews

if clear documentation to support rationale.

Currently consultant ward rounds occur twice per

week on average - daily in some specialties.

Registrar reviews patients daily and escalates any

concerns to consultant for review as required.


2015 demonstarted partial



March 16 awaited.





the


Insufficient staff base to

support delivery of this

standard. Exceptions may not

be formally documented ie

where review every 24 hours is

not required

Transformation report F&P; Transformation Board Regular reporting on

progress with

achievement of

standards required

via Transformation

Plans

1. Identify all gaps to

achievement of daily

consultant ward rounds

2. Review job planning.

Medical Director

BOARD ASSURANCE FRAMEWORK MAY 2016

The quality priorities as set out in the

2015/16 Quality Report are fully achieved by

31st March 2017

1

QUALITY: 'This is what we do'

Risks Identified Identified Control Assurance Actions to Address gaps (controls and assurance)

Deliver our quality priorities as set out in the 2015/16 Quality Report

Medical Director and Director of Nursing

Safety and Quality Governance Committee

Objective:

Executive Lead:

Board Committee:

Strategic Objective 2016/17

No.



Rating of Risk to



required)

Board level lead responsbile

for achievement of the

objective


us from meeting this objective?






achieved?



presented

Board Committee where actions

are monitored and assurance is

provided to Board

Where we are not gaining

effective evidence?



gaps.


specific action)


Risks Identified Identified Control Assurance Actions to Address gaps (controls and assurance)Strategic Objective 2016/17

No.

Director of Governance 2015/16

2012/01

2014/45

1g A gap analysis has not

been conducted with

clinical specialties to

determine Trust position

on NICE Quality Standards.

LOW Operational divisions have commenced gap

analysis with support from Clinical Audit

Department. Reporting to PSEC monthly. NICE

guidance compliance mapped to NICE Quality

Standards.

Reporting to CCG re

compliance quarterly.


to Public Board

SQG

Medical Director 1h There is not a robust action

plan in response to the

NHS England publication:

Improving outcomes for

patients with sepsis

December 2015 which is

being implemented and

monitored for

effectiveness.

MODERATE Clinical Audit FP684

Neutropenic Sepsis; Clinical

Audit FP535 Severe Sepsis

and Septic Shock - care in

emergency departments

(National Audit);

Director of Finance 1i Basic Trust signage,

particularly in main areas

has not been updated to

reflect the nationality of

major users of the Trust

e.g. Portuguese.

LOW Information available regarding nationality of

service users from INTRAN and ethnicity data.

None known None known Develop plan for updating

signs as required in

languages required

Head of Patient

Experience/Head of

Estates

30/06/2016

Director of Governance 1j Actions from the NHS

England publication:

Accessible Information:

Implementation Plan, July

2015 are not being

implemented to plan

LOW Action plan developed with timescales and

responsibilities with monitoring by the Carer and

Patient Experience Committee. Small Task and

Finish Group set up by Head of Patient Experience

to take forward the work programme.

None known Quality and Safety Report

to Public Board

SQG None Known

Director of Governance 1k The Trust does not

participate in the research

opportunity to understand

how frontline staff use

patient experience data for

service improvement; and

hence improve the way we

use feedback to improve

our services.

LOW Key leads identified. Support from Information

Services to identify service users.Strong links with

research organisers. Reporting bi-monthly to CAPE

regarding progress.


to Public Board - quarterly

update regarding progress

with quality indicators.

SQG



Rating of Risk to


What the organisation aims to deliver (outcome required)

Board level lead responsbile for

achievement of the

objective

All Risks No. What could preventus from meeting this objective?

CQC, NHSLA, HSE, etc Low/Medium/High/Extreme Primary Controls Secondary Controls Tertiery Controls (includes external audits, internal audits,



Are the identifed actions being achieved?

Report of Board where controls and assurance around risk is

presented

Board Committee where actions are monitored and

assurance is provided to Board

Where we are not gaining effective evidence?

Further evidence/ actions to address control and assurance

gaps.

Responsible Officer (to deliver specific action)


2 Director of Nursing/Medical

Director

2015/38 2016/04 2a/1c The ‘Requirement Notices’ issued following the Care

Quality Commission (CQC)

inspection in August 2015

are not lifted at

reinspection in 2016

CQC MODERATE Detailed plan in place with timescales and responssibilities. Bi-weekly monitoring by EPSEC.

Director leads identified.

Proposal for internal audit review ofa sample of the

actions plans and

supporting evidence in

place for the core services

for

which the Trust was rated

as ‘Requires

Improvement’. This will

include:

- End of Life Care;

- Surgery; and

- Maternity.

Mock inspection March 2016 identified documentation gaps

particularly with DNACPR and

MCA. Some medicines storage

issues.

Quality Report monthly to Board.

SQG Report to SQG to reflect how the issues identified by

CQC mock inspection are

being addressed.

Medical Director/Director of Nursing

30/06/2016

Director of Operations 2011/67 Comms Plan for Frail Elderly

Strategy as part of

Transformation Programme

(Special Making Waves etc)

to be provided to F&P

Committee

Communications

Manager/Director of

Performance & Planning

May to August 2016

Frail Elderly Strategy to be

developed into overarching

strategy document for

presentation to Board of

Directors

Director of Operations ??

The issues causing the

areas rated as 'requires

improvement' in August

2015: Surgery have not

been addressed and

sustained.

are not lifted at

The issues causing the areas rated as 'requires


2015 : Safety have not

been addressed and

sustained.

Medical Director/Director of Nursing

30/06/2016

Mock inspection identified some issues re medicines

storage and infection conmtrol

practice in theatres

Quality Report to Board

monthly SQG

Report to SQG to reflect how the issues identified by

CQC mock inspection are

being addressed.

No.


Strategic Objective 2016/17 Risks Identified Identified Control Assurance Actions to Address gaps (controls and assurance)

CQC REGULATIONS: 'This is where we improve'

Objective: Achieve compliance with CQC Requirement Notices and work towards improving areas rated as ‘requires improvement’ at the CQC inspection in August 2015 (including development of a Frail Elderly Strategy, as detailed in the Trust-wide and Core Service CQC Action Plans).

MODERATE Detailed action plan for each core service which includes findings related to safety. Monitoring via

EPSEC fortnightly.

2b The Frail Elderly Strategy

for the Trust is not

developed and delivered

to plan.

LOW Internal Trust strategy has been articulated with

key leads identified and a detailed project plan and

timeframes; monitoring at Patient Safety

Committee (extraordinary meetings) , HMG and

Divisional Board. Strategy includes a

comprehensive geriatric assessment at the front

door (in line with British Geriatric Society

guidance); a rapid pre-screen checklist (PRISMA 7)

and access to a specialised MDT including therapist

support. Patient will be placed in the most

appropriate clinical setting.

Success will be measured utilising Frailty Outlier KPIs. Engagement with

local health and social partners and thrid sector agencies (Help the

Aged and Red Cross). Gt YW CCG have stated Elderley Frailty as a key

priority for themselves in 16/17. MOU in place with community

provider ECCH. Systemwide partnership working led by Assocaite

Director of Transformation. CQUIN in place for 16/17 which will

provide audit data and hence assurance of progress with rolling out the

strategy.

GYW HOSC undertook to

hold whole system to

account for delivery of

changes required - meeting

held in April and CEO of

CCG and JPUH required to

update on progress.

Clinical Audit REG1882

Investigation &

Management of UTI in

Older Adults (>65 years);

Clinical Audit FP491 Falls

and Fragility Fractures Audit

programme (FFFAP) -

Fracture Liaison

Service Database (National

Audit);

Admission/re-admission

prevention requires further

development to be optimally

effective. Organisational

aware ness of Frail Elderly

Strategy has yet to permeate

to all in-patient and out-

patient areas.

Quality Report monthly

(update re Frail Elderly

Strategy in April 2016) plus

updates regarding non-

achievement of CQUIN via

escalation reporting.

SQG

Executive Lead/s: Director of Governance

Board Committee: Safety and Quality Governance Committee

CQC Requirement Notices are lifted at reinspection in 2016; those areas rated as

‘requires improvement’ (Surgery and End of

Life) can demonstrate improvements and the

Trust has a fully developed Frail Elderly

Strategy recognised across the Trust, which is

being implemented in line with the plan.

Director of Nursing and

Medical Director

2c MODERATE Responsiveness relates to RTT which is achieving.

Surgery Core Service has detailed action plan with

senior leadership.

Mock' inspection in April 2016. Assurance gap related

to other waiting lists

(not elective

admission pathway)

eg diagnostics,

surveillance, out-

patients.

Address issues identified at

'mock' inspection related to

safety in theatres and

documentation.

The issues causing the areas rated as 'requires


2015: End of Life Care

have not been addressed

and sustained.

2d2015/22Director of Nursing and Medical Director

Director of Nursing and Medical Director

2e

Appointments made to leadership roles (Non-Exec director is David Ellis; Senior Doctor is Sarah

Downey and Senior Nurse is Khristina Bartlett).

End of Life Strategy signed of by SQG and progress

reviewed and monitored by Care at End of Life

Steering Group. End of Life Audit Plan developed

and being delivered to plan. Commenced inclusion

in National Care of the Dying Audit. Detailed action

plan in place to address all areas of weakness

identified in CQC report of End of Life services

which is monitored by Care at End of Life Sterring

Group.

DNACPR audits undertaken Clinical Audit FP604 Care of the Dying Audit; Clinical

Audit FP607 SPCT

Telephone Advice Line

Audit; FP606 Side Room

Access; FP683 SPCT

Documentation Audit;

FP567 Re-audit -

CAP/DNACPR Form; Clinical

audit FP662 Deaths in Acute

Hospitals: Caring to the

End? (NCEPOD 2009);

FP605 Seen by SPC team

within Time Frames;

Escalation process to

Medical Director as

required for failure to

correctly undertake

DNACPR documentation

and discussion to be

reported to SQG

Medical Director 31/05/2016

SQG

End of Life Strategy to be presented to Board of

Directors Meeting

Director of Nurisng ????

SQG

MODERATE

Quality Report to Board monthly

Audits inform us that not all

staff can articulate the

replacement for the LCP (Best

Supportive Care Plan)

Quality Report to Board

monthly

DNACPR audit results for

March 2016 indicate poor

compliance.



Rating of Risk to



required)

Board level lead

responsbile for

achievement of the

objective


us from meeting this

objective?






achieved?



presented

Board Committee where

actions are monitored and


Where we are not

gaining effective

evidence?



gaps.


specific action)


are not lifted at

3 Financial plan/control total (£2.2mil surplus at

year end) is achieved and performance

requirements to enable achievement of the

Sustainability and Transformation Fund are

delivered to trajectory.

Director of Finance 2016/11

2016/12

2016/13

2016/17

3a Delivery of Transformation

Plan and required savings

due to lack of capability,

capacity and appetite

NHS Improvement, NHS

England, CCG and other

commissioners

MODERATE Transformation planning day held in March with

good buy-in from clinical and operational staff.

2016/17 plan developed with schemes worked up

to varying degrees. Executive leadership for each

transformation programme. Enhanced governance

of Transformation Programme.

Communication Strategy developed for key stakeholders Enhanced scrutiny of plan

and performance by NHS

Improvement and CCG;

Proposal to conduct Internal

Audit review of Key Financial

Controls. Follow up internal

audit review of

Transofrmation

Governance.

Not all projects are fully

worked up with milestones,

responsibilities and deliverables

expected

Finance Report to Public

Board

F&PC

Director of Operations 2011/77

2012/64

3b Delivery of key

performance indicators

required to trajectory

(A&E)

MODERATE Performance Management Framework refreshed.

RTT: PTL meetings embedded; Waiting List

management policy;Theatretranformation

programme. Cancer:

I.S.T. recommendations developed into a detailed

action plan. Patient pathway coordinators send

reports to clinical teams alerting patients which

could potentially breach. Working to reduce

diagnostic waiting times in order to improve

efficiency of clinical pathways.

Cancer Operational Policy reviewed and updated in

line with IST and national recommendations.

Agency: Executive sign off required to go over cap

for safety/quality reasons. Monitoring of spend and

shifts over cap by F&P. Use of approved agencies

only.

Cancer: Root cause analysis conducted on every breach.

Lead Clinician reviews patient pathways to ensure in line with Anglia

Cancer Network pathways and clinically up to date.

Patient information being provided to ensure outpatient phase of the

pathway is optimal.

RCA template and process for 62 day breaches aligned to Trust process

for SIs.

Some breaches of 62 day

target however achieved in 3rd

quarter 2015/16. RTT at

risk due to Junior Doctors

strikes in 2016

Performance report;

Finance Report; HR Report

to Public Board

F&PC None Known

2012/49

2012/53

2015/42 2015/23

Delivery of key


required to trajectory (RTT)

2014/18

E41

Delivery of key



(cancer waits)

2015/43 Delivery of key



(agency cap and spend

limit)

3c Commercial strategy Plan to conduct Internal

Audit Review of partnership

and joint venture working

Director of Nursing and

Medical Director

3d Level of savings required

will adversely impact upon

quality and safety of

services

CQRA; executive leadership; regulatory indication of

percentage of savings considered to support quality

and safety; clinical directors as part of

Transformation Board and F&PC and joint

transformation board.

None Known Transformation Report and

SQG minutes. Divisional

Governance reports to SQG.

SQG None Known

FINANCE AND PERFORMANCE: 'This is where we get back on track'

No.



Objective: Achieve financial plan/control total (£2.2mil surplus at year end) and performance requirements to enable achievement of the Sustainability and Transformation Fund.

Executive Lead/s: Director of Finance

Board Committee: Finance and Performance Committee



Rating of Risk to


What the organisation aims to deliver (outcome required)

Board level lead responsbile for

achievement of the

objective

All risks No. What could preventus from meeting this objective?

CQC, NHSLA, HSE, etc Low/Medium/High/Extreme Primary Controls Secondary Controls Tertiery Controls (includes external audits, internal audits,



Are the identifed actions being achieved?

Report of Board where controls and assurance around risk is

presented

Board Committee where actions are monitored and


Where we are not gaining effective evidence?

Further evidence/ actions to address control and assurance

gaps.

Responsible Officer (to deliver specific action)


4 4a Capability and capacity to

develop Recruitment

Strategies for all staff

groups

NHS Improvement, CQC,

Royal Colleges,

MODERATE Recruitment strategies in place for nursing and

medical workforce. NPP developed and key

priorities for 16/17 agreed. AHP/Clinical others

recruitment strategy in development.

Proposal to conduct

Internal Audit review of

consultnat job planning

Workforce planning is

immature within the

organisation.

HR report to Public Board SQG

4b Capability and capacity to

develop and deliver

effective workforce

planning

MODERATE Actively wotrking with regional healthcare

providers/partner organisations to produce STP

regional workforce plan. Registered to participate

and use new e-learning workfocre planning tool

through HEEofE

Follow up internal audit

review of temporaray

staffing and e-roster

SQG

4c Capability and capacity to develop and deliver

innovative workforce

models.

MODERATE Actively wotrking with regional healthcare providers/partner organisations to produce STP

regional workforce plan. Registered to participate

and use new e-learning workfocre planning tool

through HEEofE

SQG

4d

Capability and capacity to

develop and deliver

innovative organisational

development to deliver

transformation plans

MODERATE

OD plan developed and refreshed to meet new medical

structure at end of 2015/16. Education programme developed

in an innovative way to develop the workforce. Success

measured via staff survey.

SQG

No.



Board Committee: Finance and Performance Committee

A fully developed five year Workforce

Strategy for all staff groups, encompassing

recruitment and retention, workforce

planning, flexible workforce models with

partner organisations, training and

organisational development (the strategy will

be agreed by end of September 2016 with key

deliverables during the remainder of 2016/17;

in line with the Norfolk and Waveney

Strategic Footprint and the Norfolk Provider

Partnership).

WORKFORCE: 'This is about us'

Objective: Develop a five year Workforce Strategy, encompassing recruitment and retention, workforce planning, flexible workforce models with partner organisations, training and organisational development

Executive Lead/s: Associate Director of Workforce

Associate Director of

Workforce

2013/13

2015/46

2014/48

2012/02 2012/09

2016/14

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