1.0 the Assurance Framework Background 3

ASSURANCE FRAMEWORK

Date: November 2007

Version: 14

CONTENTS

PAGE

1.0 The Assurance Framework – Background 3

2.0 Risk Classification Matrix 3

2.1 Potential Outcome Severity Matrix 3

2.1.1 Definitions 3

2.1.2 Likelihood 4

2.1.3 Consequence 4

2.1.4 Risk Rating And Action Plan 5

2.2 Matrix

3.0 Principal Objective One 6

Capital investment to improve;

· Patient and staff environment.

· Health and safety.

· Investment required to sustain business activity.

· Energy measures.

· Risk management.

3.1 Principal Objective Two 8

Develop and implement robust recruitment and retention measures.

3.2 Principal Objective Three 11

Effective governance arrangements that reflect current Trust business.

3.3 Principal Objective Four 13

To be an effective and efficient provider of orthopaedic and musculo-skeletal services.

3.4 Principal Objective Five 15

To achieve financial balance

3.5 Principal Objective Six 17

Develop and implement the modernisation plan – bringing about changes in clinical practice

and organisation to increase productivity. Reform the model of care.

3.6 Principal Objective Seven 19

To achieve full compliance with the national waiting list targets.

3.7 Principal Objective Eight 21

Develop and implement a cohesive and integrated IM&T Strategy.

3.8 Principal Objective Nine 23

Redevelopment of the RNOH Stanmore campus to provide a modern healthcare building.

3.9 Principal Objective Ten 25

To achieve Foundation Trust status

1.0 THE ASSURANCE FRAMEWORK - BACKGROUND

More than ever before, as the NHS embraces a culture of decentralisation, increasing local autonomy and local accountability, Boards need to be confident that the systems, policies and people they have put in place are operating in a way that is effective in driving the delivery of objectives by focusing on minimising risk. In support of that challenge, “Assurance: The Board Agenda” was issued in July 2002 and set out the principles for an assurance framework to give Boards the confidence that they need.

The Assurance Framework provides organisations with a simple but comprehensive method for the effective and focused management of the principal risks to meeting their objectives. It also provides a structure for the evidence to support the Statement On Internal Control. This simplifies Board reporting and the prioritisation of action plans, which, in turn, allow for more effective performance management.

2.0 RISK CLASSIFICATION MATRIX

The Trust accepts that in an ideal situation any level of risk is unacceptable. However, in a real healthcare work setting, this is not realistic. It is necessary therefore, to set standards to establish the level of tolerable risk. This enables the Trust to evaluate residual risk levels, which can then be prioritised and properly controlled. This is achieved by using the Trusts Risk Classification Matrix as detailed below; -

2.1 POTENTIAL OUTCOME SEVERITY MATRIX

2.1.1 DEFINITIONS

2.1.2 LIKELIHOOD

RATING /

DESCRIPTION

Rare

1 / Very unlikely.
May only occur in exceptional circumstances.

Unlikely

2 / Could occur at some time but unusual.

Possible

3 / May occur at some time, reasonable to expect at some point although infrequent.

Likely

4 / Will probably occur in most circumstances, not a surprise.
Almost Certain
5 / Is expected to occur in most circumstances.
No doubt that this event will occur frequently.

2.1.3 CONSEQUENCE

RATING

DESCRIPTION

Insignificant

1 / Negligible injury, damage or outcome.
Process delays.
Loss of production.

Minor

2 / Minor first aid injury.
Minor damage to property or equipment.
Slight delay in service provision.
An element of financial loss (between £500 and £10,000)
Low radiation dose incident (dose is a fraction of the dose limit for a member of the public)
Minor clinical incident – no immediate effect on patient safety or patient care.
Lost time.

Moderate

3 / Major injury, disabling illness, major accident.
Medical treatment required.
Significant but temporary damage to property or equipment.
Financial loss (between £10,000 and £100,000)
Temporary delay to service provision.
Clinical incident may require patient to require additional treatment or change to planned regime / care.
Significant but limited (medium) radiation dose incident (not exceeding dose limits)

Major

4 / Single avoidable death.
Extensive injuries or negative clinical outcome.
Medical treatment / intervention required.
Significant (permanent or long term) damage to property or equipment.
Major financial loss (£100,000+)
Long term delays in service provision.
Significant clinical incident where patient requires additional treatment with possible permanent effects and negative outcome.
Over exposure (high) radiation dose incident (exceeding dose limit)

Catastrophic

5 / Multiple fatalities.
Permanent loss of services, equipment and property.
Major loss of public confidence.

2.1.4 RISK RATING AND ACTION PLAN

Risk Rating

Level Of Risk

/ Action Required To Reduce Risk
Green / Very low / Accept risk.
Yellow / Low / Make every effort to minimise risk wherever possible.
Orange / Medium / Urgent action required NOW to reduce risk.
Red / High / STOP the activity until risk has been significantly lowered

2.2 MATRIX

CONSEQUENCE

/ Insignificant
1 /

Minor

2 /

Moderate

3 /

Major

4 /

Catastrophic

5
LIKELIHOOD

Almost certain

5 / Low / Low / Medium / High / High

Likely

4 / Low / Low / Medium / High / High

Possible

3 / Very low / Low / Medium / High / High

Unlikely

2 / Very low / Very low / Low / Medium / High

Rare

1 / Very low / Very low / Low / Medium / High

Acceptable Risk

A risk is considered acceptable when there are adequate control measures in place and the risk has been managed as far as is considered reasonably practicable. Risks falling in the green “very low” and yellow “low” risk section are considered “acceptable” although the Trust will still need to take action on these risks where the assessment has identified that risks can be easily minimised.

Significant Risk

All risks in the orange “moderate” or red “high” risk rating will be considered “significant”. The Risk / Clinical Risk Manager must be notified of these risks.

3.0 PRINCIPAL OBJECTIVE ONE

Principal objectives / Description of all associated risks / Key Controls / Assurances on controls / Gaps in controls / Risk rating
(L x C) / Action plan and implementation date / Board lead
Capital investment to improve; -
· Patient and staff environment.
· Health and safety.
· Investment required to sustain business activity.
· Energy measures.
· Risk management.
· Backlog maintenance.
· Fire precautions. / Insufficient funding to maintain or provide care in an environment that promotes patient and staff well-being and respect for patient’ needs and preferences in that they are designed for the effective and safe delivery of treatment, care or a specific function, provide as much privacy as possible, are well maintained and are cleaned to optimise health outcomes for patients.
Prosecution from Health And Safety Executive (HSE), due to non-compliant estate.
Increased potential for infection outbreaks. / Standards For Better Health final declaration (April 2007) / Standards For Better Healthcare (C20, C21)
Estates Risk Profile. Feb 2005
Estates Strategy (Stanmore) 2005
HSE have signed off the improvement notice. (Nov 2005)
Progress reports to Risk Management Board.
HSE action plan.
Weekly inspections of hospital cleanliness by Contract Monitoring Officer. Audit sheets are placed on the Trust’s intranet. / Standards For Better Healthcare (C20, C21, not met)
With backlog maintenance being estimated at c£50m, annual CRL limits of around £1m will do little to improve the overall condition of the estate until the redevelopment is complete.
Trust prosecuted by the HSE following the steam incident – 2005. Date of prosecution – 10th September 2007. Trust pleaded guilty. Fined £15,000 + court costs. / 3 x 4 = 12
High / The reason for non compliance relates to the inherent design of the buildings and estate, but these design issues cannot be fully addressed until the site is re-developed. (2011 – anticipated date for completion of site redevelopment)
Alternative solutions to be reviewed i.e. 2 phase development of site over 25 years. October 2006.
Updated November 2007: SHA panel have met to review options but this is currently under review regarding due process. / Director of Projects, Estates and Facilities
Director of Projects, Estates and Facilities

PRINCIPAL OBJECTIVE ONE CONTINUED

Principal objectives / Description of all associated risks / Key Controls / Assurances on controls / Gaps in controls / Risk rating
(L x C) / Action plan and implementation date / Board lead
Capital investment to improve; -
· Patient and staff environment.
· Health and safety.
· Investment required to sustain business activity.
· Energy measures.
· Risk management.
· Backlog maintenance.
· Fire precautions. / Prosecution from LFEPA, due to non-compliant estate. / Strategic overview report produced by Lawrence Webster Forrester - Fire Engineering And Fire Risk Management Consultants (LWF) (March 2006)
Health and Safety Advisor has attended a NEBOSH fire course(10th – 14th September 2007) / Board briefing paper (January 2006)
Risks have been prioritised and budget setting process completed. Capital Planning Minutes. (February 2006)
Fire management action plan (May 2007)
LFEPA inspection of Bolsover Street (6th November 2007)
E-mail form John Hawkins (LFEPA inspector) providing positive feedback on the Trusts fire risk assessment pro-forma (November 2007) / Enforcement notice from London Fire And Emergency Planning Authority (LFEPA) (Dec 2005)
Failure to recruit a Fire And Security Management Officer. Interviews held on 5th September. One applicant offered position subject to references but offer withdrawn (Oct 06) due to poor references and police checks. / 3 x 4 = 12
High / Review the Health and Safety Officers role and include Fire Officer role within her job description.
· Provide individual with suitable and sufficient training.
· Review budget allocations.
· Seek approval for job description through AFC
Completed
Continue to implement the annual LFEPA action plan
(April 2008)
Develop a fire risk assessment programme and implement
(On-going)
Inform emergency services that propane cylinders are currently stored at Bolsover Street
Completed by LFEPA Inspector – Ray Pheasant on 6.11.07
Remove propane cylinders from Bolsover Street.
(15th November 2007) / Director of Projects Estates and Facilities
Director of Projects, Estates and Facilities
Director of Corporate Affairs and Human Resources
LFEPA
Director of Projects, Estates and Facilities

3.1 PRINCIPAL OBJECTIVE TWO

Principal objectives / Description of all associated risks / Key Controls / Assurances on controls / Gaps in controls / Risk rating
(L x C) / Action plan and implementation date / Board lead
Develop and implement robust recruitment and retention measures / Failure to retain staff.
Poor working environment.
An increased reliance on bank and agency staff in areas such as ITU, theatres, spinal injuries, physiotherapy, occupational therapy and radiography can contribute to the Trusts financial overspend. (Less of a risk at the moment due to labour market changes)
Lose the flexibility to close wards and save money if vacancy rates are too low. / Human Resources (HR) Management And Development Strategy. (Updated 2005)
Provider Sustainability Plan 2006/07 to 2009/10. Page 21.
Improving Working Lives (IWL) Group
(November 2006)
Agenda For Change and the Knowledge Skills Framework.
Board papers. Monthly monitoring of vacancy rates. (August 2007) / IWL Plus Validation. (Achieved January 2006)
HR Performance Report Monthly
(September
2007 )
Diversity Analysis Recruitment 6 monthly (January 2007)
Staff survey report. (March 2006)
Workforce Planning / development of new roles as part of OBC.
Workforce Strategy Group (June 2007)
Race Equality – Demonstrating Progress. A Performance Management Framework For Race Equality Within The NHS.
(October 2004) / Poor transport links.
Uncertainty of future redevelopment.
Poor quality accommodation on-site.
Low appraisal and Performance And Development Plans (PDP) take up.
Perceived pressure on staff and high stress levels.
High level of perceived bullying and harassement.
No embedded establishment control system.
No plan for Modernising Medical Careers.
Consistent on-call rates have not been agreed across the Trust. / 3 x 3 = 9
Medium / Continue to monitor vacancy/turnover, sickness and overall number levels on a monthly basis. (Ongoing)
Develop the Workforce Plan and strategy with regards to the Clinical Model and new hospital. (May 2007)
Update September 2007: Completed but may need to be reviewed depending on outcome of independent review
Raise uptake of appraisals to 70% across all staff groups. (March 2007)
Update: Approximately 60% achieved. Aiming for 70% by March 2008
Introduce a comprehensive training programme to ensure a basic level of computer skills across the whole Trust. (January 2007)
Updated November 2007: COMPLETED. IT skills assessment undertaken at induction and training programmes in place
Continue to monitor equality data. - quarterly / Director of Human Resources and Corporate Affairs
Director of Human Resources and Corporate Affairs
Director of Human Resources and Corporate Affairs
Director of Human Resources and Corporate Affairs
Director of HR

PRINCIPAL OBJECTIVE TWO - CONTINUED