APPROVED
NHS Grampian (NHSG)
Minute of the Audit Committee Meeting
Monday 29 June 2015, 1000-1230
Conference Room, Summerfield House
Present
Mr David Anderson, Non-Executive Director, NHSG (Chair)
Mrs Rhona Atkinson, Non-Executive Director, NHSG
Cllr Barney Crockett, Non-Executive Director, NHSG
Prof Mike Greaves, Non-Executive Director, NHSG
In Attendance
Prof Stephen Logan, Chairman, NHSG
Mr Malcolm Wright, Chief Executive, NHSG
Mr Alan Gray, Director of Finance, NHSG
Dr Annie Ingram, Director of Workforce, NHSG
Mr Pat Kenny, Advisory Director, Deloitte LLP
Ms Karlyn Watt, Audit Manager, Deloitte LLP
Ms Donna Berrie, Deloitte LLP,
Mr David Brown, Partner, PricewaterhouseCoopers LLP (PwC)
Ms Susan King, Manager, PricewaterhouseCoopers LLP (PwC)
Mr Adam Coldwells, Chief Officer, Aberdeenshire Shadow IJB (Items 4.4 and 4.5)
Ms Judith Proctor, Chief Officer, Aberdeen City Shadow IJB (Items 4.4 and 4.5)
Mr Andrew Wood, Risk Management Advisor, NHSG (Item 5)
Mr Garry Kidd, Assistant Director of Finance, NHSG
Ms Tracey Leete, Minuting Secretary
Observing
Ms Malgorzata Artamonow, Assistant Financial Accountant
Item / Subject / Action /1 / Apologies
Dr Lynda Lynch, Non-Executive Director, NHSG
Mrs Sharon Duncan, Employee Director, NHSG
Ms Pam Gowans, Chief Officer, Moray Shadow IJB (Items 4.4 and 4.5)
2 / Minute of Meeting Held on 17 March 2015
The Minute of the previous meeting was approved as an accurate record.
3 / Matters Arising
3.1 / Action Log of 17 March 2014
The Committee reviewed the action log from the previous meeting and noted the following point not covered elsewhere on the agenda:
17.3.15 – Item 5.3 - Audit Scotland National Studies
Professor Logan confirmed that arrangements were in place to incorporate the Supplement to the report on Scotland’s Public Finances into the formal induction material available to Non-Executive Directors.
The Committee agreed that this action was complete and should be removed from the action log.
3.2 / Any other matters arising not on the action log
None.
4 / Internal Audit
4.1
4.2 / Annual Report for Year Ended March 2015
Ms King explained that the purpose of the report was to present PWC's opinion, as internal auditors, on NHS Grampian's systems of internal control.
All identified findings arising from the audit reviews undertaken throughout the year were rated as low, medium and high and actions for improvement were identified in these areas to enhance the adequacy and/or effectiveness of governance, risk management and control. During the course of the work, two high risk recommendations were identified relating to the absence of a formal policy on Business Continuity Planning and inconsistency in the quality of information recorded on Datix for Clinical Adverse events. Management had confirmed that both of these recommendations were incorporated in the Annual Governance Statement for 2014/15.
The total number of high risk rated findings had reduced from six in 2013/14 to two in 2014/15.
The appendix to the report set out the four types of opinion available and an indication of the types of findings that may determine the opinion given. For NHS Grampian, the opinion for the year ended 31 March 2015 of “improvement required” reflected the Medium and high risk rated recommendations arising from the work conducted during the year in line with the annual internal audit plan agreed by the Committee. This level of opinion was next to top. To achieve the top level of opinion, “adequate and effective”, the findings within each of the audit reviews undertaken during the year must all be classed as low risk and this would be an unusual outcome recognising the risk profile of a large complex organisation such as NHS Grampian.
Mr Anderson asked how the Committee could be assured that the internal audit plan was targeted effectively, in light of the low number of high risk findings. Mr Gray responded by explaining that the annual operational internal audit plan was prepared based on a full risk assessment. This was informed not only by our Auditors experience of the local situation but also emerging issues nationally and within other Board areas. The Executive team and the Audit Committee were all involved in agreeing the content and scope of the internal audit plan and progress is reviewed on an ongoing basis by the Committee throughout the year. For 2015/16 all Board members have also been asked for their input to the process. The Boards key governance and financial processes are covered annually as a standard component of the internal audit plan.
The Committee noted the report.
Progress Report
Ms King presented the report which detailed progress against the internal audit programme and highlighted the following:
Key Financial Controls
The report concluded that key financial controls in place have been operating effectively and are designed suitably. No critical or high risk recommendations were identified. Two medium risk recommendations were identified relating to the maintenance of the operational scheme of delegation for electronic ordering and changes to payroll standing data. Mr Kidd reported that the authority levels within the electronic ordering system (PECOS) are now consistent with the scheme of delegation and managers have been reminded of the importance of timely notification, to the finance team, of any required changes to delegated authority levels arising from changes to key personnel.
Mr Anderson asked if the Scheme of Delegation could be simplified in any way to improve compliance. Mr Kidd responded that the Committee, two years ago, had agreed a simplified scheme of delegation. The issue is mainly one of administration and compliance relating to staff turnover in key positions. All of the required information and documentation is available on the NHSG intranet together with contact details should anyone require help with the process. One of the agreed actions arising from the audit was to remind all managers of the need to submit a change form for the scheme of delegation at the same time as they process all other appointment/change documentation.
Emergency Care Centre – Post Implementation Review
No critical or high risk recommendations were identified. One medium risk recommendation was identified relating to the absence of quantified base line data in the business case which created uncertainty over actual benefit realisation. The report recognised that the learning from this post implementation review had previously been reported to the Asset Management Group and will be used to inform future business cases.
Change Fund
No critical or high risk recommendations were identified. Two medium risk recommendations were identified relating to the requirement for all bids to clearly outline the intended exit strategy and specify the outcomes to be achieved and how these will be measured. Management have agreed all recommendations and confirmed that the learning from this report will be built in to the future arrangements for management of the integrated fund.
Working with Third Parties – Research and Development
No critical or high risk recommendations were identified. Two medium risk recommendations were identified relating to due diligence when engaging with new commercial organisations and the absence of a formal feedback process to ensure that lessons learned from commercial and non-commercial research studies are incorporated in future arrangements.
Management have accepted the findings of the report but highlighted that commercial research applications require to be processed within a 10 day timescale and the current recommended guidance on due diligence, if applied in full, would result in failure to meet this timescale. Accordingly the agreed management action for this recommendation is to develop a shortened approach that will allow basic diligence checks to be undertaken without impacting on achievement of this key target. Arrangements to request feedback on research studies will be introduced in September 2015.
Mr Anderson observed that 10 days is a tight target and asked if this was achievable. Ms King advised that the department is regularly achieving this target but management are concerned about the impact of any change to the process around due diligence. Prof Logan raised a concern that the requirement for due diligence may add a significant burden to staff who are already under pressure to meet these tight targets. Ms King confirmed that management were looking to introduce simple processes that would not impact significantly on existing workload and also ensure there is no duplication of effort.
The Committee requested that Ms King provide an update on progress at the September 2015 meeting.
Adverse Clinical Events
The review highlighted one high risk finding relating to the consistency and quality of completed Datix records and one medium risk finding relating to recording and sharing of lessons learned. Management have agreed a series of actions to address these issues including enhanced training for staff tailored to meet the specific needs within each clinical area and updated guidance material to be available on the Datix system itself, including links to key policy and guidance documents.
Prof Greaves asked why the sharing of lessons learned was only considered medium risk, if the related finding on consistency and quality of the Datix records was categorised as high risk. Ms King advised that the two findings were closely related. Mr Brown explained that the high risk categorisation reflects the issues with consistency and accuracy of data. The medium risk classification relates to the management processes designed to use this data rather than the quality of data itself.
Mr Gray advised that he had asked the Acute Sector General Manager to prioritise the implementation of the agreed action plan including dissemination of lessons learned. Dr Ingram advised that processes exist for regular Executive Review of high and very high risks recorded on Datix, in order to ensure cross sector organisation wide learning.
The Committee requested that Ms King provide an update on progress against both high and medium risk recommendations at the September 2015 meeting.
Operational Performance Management (Phase 2)
Ms King introduced the report which focused on an activity analysis of tasks performed by Lead Nurses and Senior Charge Nurses (SCNs) within the Acute Sector. Ms King explained that the content and scope of the review was jointly agreed by the Director of Workforce and the Director of Nursing. The findings, which were based on interviews with 26 SCN’s and Lead nurses, indicated that they are spending an increasing amount of time on audit related work and on other non-clinical management and administrative tasks.
Mr Anderson observed that there are two key issues arising from the review, role clarity for SCN’s and the need to ensure that their workload includes only essential tasks with no wasted effort.
Dr Ingram informed the Committee that the review was timely and helpful. The report will now be used as a key source of reference to inform the work of the Nursing Resources Group. Part of the remit of this group, which is chaired by a Board Non Executive Director and has the Director of Nursing and Director of Workforce as members, is to clarify the role of the SCN, defining those tasks which must sit with the SCN and identifying opportunitieswhere, through additional support, use of new technology or efficiency improvements, other tasks could be met in ways that reduce the administrative burden on the SCN.
Prof Greaves asked if the willingness or ability to delegate was an issue. Dr Ingram responded that this will be considered as part of the work led by the Nursing Resources Group.
Mr Wright informed the Committee that he hoped to make a permanent appointment to the Director of Nursing position in the near future. A key priority for the new appointment will be to ensure that the focus is on the change in culture necessary to support further development of the SCN’s role.
The Committee agreed the following actions :-
· Refer the audit report to the Nursing Resources Group for action;
· Dr Ingram to share the findings from the report with the Staff Governance Committee;
· Dr Ingram provide a report on progress to be available for consideration at the December meeting of the Committee / PwC
PwC
AI/GK
AI
AI
4.3 / High Priority Recommendations
Ms King introduced the report summarising progress in relation to the implementation of high priority internal audit recommendations and highlighted the following key areas:
Theatre Utilisation
Management now have access to BOXI reports with information on specialty utilisation, booking and use of sessions. Formal reporting to the Board on theatre utilisation will commence in August 2015.
The Committee noted the progress to date and requested confirmation, at the September 2015 meeting, that the Board reporting arrangements are implemented as planned in August 2015, after which this action can be considered complete.
Delayed Discharge
The actions to ensure alignment of Social Carers, attendance at MDT’s and prioritisation of Social care needs were fully implemented.
The Committee agreed this action was complete and should be removed from the list of outstanding high priority recommendations.
The action to update the Grampian Joint Adult Health and Social Care Discharge Policy and Procedure is partially complete. The policy is in draft and out for consultation. Management have advised a revised target date of August 2015.
The Committee noted the position and requested an update on progress for the September 2015 meeting.
Complaints
The remaining action to introduce reporting arrangements and improve feedback within the service was fully implemented in April 2015.
The Committee agreed this action was complete and should be removed from the list of outstanding high priority recommendations.
Business Continuity
The action to develop a Business Continuity Policy is partially complete. The policy is in draft and out for consultation. Management have advised a revised target date of September 2015.
The Committee noted the position and requested an update on progress for the September 2015 meeting. / PwC
PwC
PwC
4.4 / Delayed Discharge Action Plan
Ms Proctor and Mr Coldwells presented their paper and briefed the Committee on current arrangements for managing delayed discharges including current projections, progress against key actionsaimed at reducing numbers, performance monitoring, management arrangements and planned investment.
Ms Proctor explained that a cross system working group exists to facilitate sharing on common issues such as policies and procedures and to avoid duplication of effort and maximise benefit from planned investment through effective cross system working and consistent engagement between all three partnerships and the Acute services.