Board Assurance Framework and Corporate Risk Register Report

Transcription

1 Trust Board Meeting in Public: Wednesday 9 th November 20 Title Board Assurance Framework and Corporate Risk Register Report Status History For discussion The full BAF and CRR was reported to the: Audit Committee in April and September 2015, February and April 20. Trust Board in November 2015 and May 20. Trust Management Executive on 9 July and 12 November 2015 and 28 January, April 20, 25 August and 26 October 20. Extracts of relevant risks from the CRR and the BAF were reported to: Quality Committee in June, October and December 2014; February CRR: June and August 2015, CRR and BAF: December 2015, February 20 and April 20 Finance & Performance Committee in June, October and December 2014; February CRR: June and August 2015, CRR and BAF: December 2015, February 20 and April 20 Updates of relevant risks from the CRR were reported to Trust Management Executive on 2 and 7 August, 24 September and 8 October 2015 Board Lead(s) Eileen Walsh, Director of Assurance Key purpose Strategy Assurance Policy Performance Board Assurance Framework and Corporate Risk Register Report Page 1 of 7

2 Executive Summary 1. This paper provides a summary of the developments to the Board Assurance Framework made during 20/17 and following the approval of the Trust s Strategic Objectives. 2. It also provides the results of the Quarter two review of the Corporate Risk Register and a summary of changes to the risk register for the Board s review and discussion. 3. The Trust Board is asked to: Note the continued development of a new Board Assurance Framework Approve the changes to the CRR, risk scores, and escalated risks. Board Assurance Framework and Corporate Risk Register Report Page 2 of 7

3 1. Introduction 1.1. This paper provides an opportunity for the Trust Board to review the Board Assurance Framework (BAF) and Corporate Risk Register (CRR) following the Quarter two review results as presented to the Trust Management Executive on 27 th October The development of the new strategic themes provided the Assurance Directorate with an opportunity to develop a new version of the Board Assurance Framework This paper provides the following: A summary of the development of the BAF for 20/17, Ongoing changes to risks held in the current version of the CRR, following consultations with the risk leads and approval by Trust Management Executive in October. 2. Board Assurance Framework 2.1. The existing Board Assurance Framework has been in place from April 20 until September 20, aligned to the Trust s strategic objectives in place for that time period Aligned to the Sustainability and Transformation Plan (STP) for Oxfordshire; there has been a review of the Trust strategy which has identified the following strategic themes: 2.3. Following the development of the strategic themes, a new set of strategic objectives were formally approved by the Trust Board on 14th September 20. These new objectives now form the basis of the new BAF The Trust has used the opportunity of the new objectives to launch a new approach to the presentation of the BAF going forward. As part of this research conducted to inform this new approach, the Trust considered the findings of a KPMG study in 2015, which reviewed various approaches to best practice for Board Assurance Framework and Corporate Risk Register Report Page 3 of 7

4 Board Assurance Frameworks. The report reviewed areas of weakness within organisations, the quality of information and sources of assurance contained within a range of Board Assurance Frameworks As a result, the Trust has developed a digital BAF tool that is designed to streamline resources and reflect the new strategic themes. The new BAF uses strong assurance mapping methodology, presented in a clear and visual format using the principles of mapping the existing risks on the CRR to the new themes The updated BAF is currently a work in progress. The aim is that it should act as a more effective tool to provide assurance to the Board on plans to deliver the Trust s new Strategic Objectives over the next 3-5 years The following provides a brief summary of developments to the Board Assurance Framework: Existing BAF was remapped to the new Strategic themes / strategic objectives as approved by the Board in September 20. Each theme has a page in the new BAF. Current risks were mapped to the revised BAF, albeit there are some themes that are new and demonstrate a different focus for the trust. These have fewer risks mapped to them. The Assurance Team are working with the relevant Theme Lead to review and populate each page. A new BAF template was developed to more clearly map risk, control and assurance, also to bring in a direct link to the Key Performance Indicators (KPIs) that help demonstrate that performance is on track or moving towards the strategic goals. These will be further developed through Board subcommittees and Trust Management Executive review over time. This will include a link to the operational Corporate Risk Register as part of the risk map. A feedback loop was added to capture queries in relation to gaps in control and gaps in assurance, with a cross reference between risk owners (where they are different from the overarching theme owner) A draft outline of the proposed Board Assurance Framework has been shared with the chairs of the Board sub-committees. Their feedback is helping to shape the final framework which will be discussed in detail by the Trust Board at its next seminar meeting in late November The Assurance Directorate is working with the theme owners to continue to populate the BAF as plans and KPIs are developed. It is proposed that a revised version of the new BAF is presented to the Board in January Board Assurance Framework and Corporate Risk Register Report Page 4 of 7

5 3. Review of the Existing Corporate Risk Register 3.1. This quarterly review was completed with the help and support of Divisional Governance Leads and Executive Directors or nominated representatives. A full copy of the detailed register is available at the following hyperlink. a Corporate Risk Register Update v2.docx 3.2. From this review, the TME were asked to discuss two key areas. New risks for escalation on to the CRR Changes in risk scores and risks proposed for archive Changes to the CRR 3.3. This review of the CRR for 20/17 was conducted with all the risk leads. Full list of all risks on the CRR is provided as Appendix 1. New risks / risks for escalation 3.4. The following risks were accepted as new risks or for escalation to the CRR by the Divisions and Risk Leads. Escalated by CD CD MRC Risk Description Failure to implement actions following the CQC Improvement Notice which could result in the contravention of IRMER Regulations It was noted that there were issues with documentation controls with incomplete training records and monitoring compliance. Risk of lower quality care for patients as some policies and Standard Operating Policies are not updated in accordance with the Trust Policy. This may result in staff potentially following out of date policies Potentially unable to sustain Emergency Department (both JR and HGH)middle grade rota due to recruitment difficulties Changes to Risk Scores Board Assurance Framework and Corporate Risk Register Report Page 5 of 7 Risk Score 3 x 3 4 x 3 4 x 3 Table 1: Risks for inclusion onto CRR 3.5. TME accepted to risk scores as a result of the review, with one having met target. The changes are presented in table 2. The red italics in the risk descriptions summarise the reasons for change. New Risk Risk Description ID 4.1 Unsuitable outpatient accommodation in Clinical Genetics Department at the Churchill A solution has been found for the Genetics Service to relocate to the ACE building on the NOC site. Refurbishments of the area are in the process of being planned to come on line during October. It is likely that the relocation will take place towards the end of November estates works permitting. 5.1 Patients experience indicators show a decline in quality. Improved results from patient experience indicators 5.5 Inability to continue to supply stock medicines to wards and Trust dispensaries Sep- Oct- Trend Distanc e from Plan to improve staff accommodation is in progress and the space created will need to be converted to medicines storage 7.1 Insufficient provision of appropriate education and

6 New Risk ID Risk Description learning development opportunities Sep- Oct- Trend Distanc e from Controls in place are working to reduce the risk 8.4 Potential risk of failing to respond to the results of diagnostic tests Results show improvements and actions monitored through Clinical Governance Committee monthly 8.5 Potential risks to handover of treatment through poor communication of discharge summaries Results show improvements and actions monitored through Clinical Governance Committee monthly Impact of changes to specialist services tariff Two year tariff proposals published along with a note from NHSI that they are not considering introducing a marginal rate for specialised services for 2017 to ** to be considered for archive** Excessive use of agency staff may pose a risk to the quality of service delivered reviewed and reduced from 3 to to archive 8-2 Change to target 2 2 Table 2: Changes to risk scores 3.6. TME discussed the current situation with ED performance regarding the national standard for 4 hours. The Trust performance has dropped and following detailed discussions it was agreed that the risk score for this risk should be increased to 20, based on the fact that likelihood had increased from a score of 4 to now being a score of 5. It was agreed that a series of actions would be implemented to reestablish control and to improve the performance in a sustained manner. 4. The Trust Board is asked to: Note the continued development of a new Board Assurance Framework Approve the changes to the CRR, risk scores, and escalated risks. Eileen Walsh, Director of Assurance November 20 Report prepared by: Clare Winch Deputy Director of Assurance and Catherine Pearson Assurance Manager Board Assurance Framework and Corporate Risk Register Report Page 6 of 7

7 Appendix 1 Corporate Risk Register in order of Highest Rank Old New Risk ID Risk ID Risk Description Proximity Mar- (Y/E) Sep- Oct- Trend Distance f rom Movement to since y/e 15/ Failure to deliver National A&E targets and increasing level of delay impacting on patient flow 3-12 mth Lack of robust plans across healthcare systems / Failure to reduce activity through robust demand management plans 3-12 mth Potential failure to deliver the required levels of CIP 3-12 mth Risk of not hitting Trajectories to access Sustainability and Transformation Fund 3-12 mth new Capacity of AICU/CICU does not meet demand Difficulty recruiting and retaining high-quality staff in certain areas Inability to continue to supply stock medicines to wards and Trust despensaries 3-12 mth new risk Loss of funding if contractual CQUIN targets not met 3-12 mth new Building issues in the Women's Centre could lead to patient safety issues Potential for reduced staffing levels in maternity service 3-12 mth CAS Alert NPSA 2011/PSA001 Part b Implementation of the Horton contingency plan results in potential adverse outcomes now new 10 n/a TBC #VALUE! tbc Inability to meet the Trust needs for capital investment 3-12 mth Access to hospital site and current car parking constraints across the trust Failure to deliver National Access targets 18 weeks incompletes, failure to deliver 1% or less for diagnostic waits within 6 weeks 3-12 mth Failure to deliver National Access targets Cancer - (62 day cancer standard) 3-12 mth Potential failure to effectively control pay and agency costs mth Failure to Generate hot water and heat in retained parts of the Churchill estate Potential failure to obtain the clinical advantages from EPR 3-12 mth Potential risk of failing to respond to the results of diagnostic tests Potential risks to handover of treatment through poor communication of discharge summaries Poor clinical records management processes have a potential impact in quality and safety Potential failure of accurate reporting and poor data quality due to implementation of the EPR 3-12 mth Unsuitable outpatient accommodation in Clinical Genetics Department at the Churchill Failure to meet the Trust s Quality Strategy goals Services display poor cost-effectiveness 3-12 mth Insufficient provision of appropriate education and learning development opportunities 3-12 mth Out of hours care (Care 24/7) 3-12 mth TIE failure between EPR and CRIS poses a risk to accurate data recording and reporting 3-12 mth Failure to comply with NICE Quality Standard 13 End of Life Care (now a CQUIN) Low levels of staff satisfaction 3-12 mth Aspects of Medicine Management identified as needing improvement 3-12 mth Patients experience indicators show a decline in quality CAS Alert NPSA 2011/PSA001 Part A 3-12 mth Excessive use of agency staff may pose a risk to the quality of service delivered n/a 8.15 Failure to implement actions arising from CQC Improvement Notice n/a 8. Risk that outdated Trust Policies may have an impact upon the quality of care n/a 8.17 Emergency Department (both JR and HGH) risk to middle grade rota as insufficient permanent team new 9 new 12 new 12 new ris k 3 new ris k 3 new ris k 2 6 new risk 9 new risk 10 new risk Link to the Full Corporate Risk Register is here Board Assurance Framework and Corporate Risk Register Report Page 7 of 7