Item: Assurance Framework Report
Purpose:
To provide the Trust Board with an update on the actions being taken to address any gaps in controls or assurances in respect of identified risks to achieving the organisation’s objectives
Summary:
The report provides:
  • Balanced scorecard
  • Assurance Framework together with action plans to address gaps
  • Increase or decrease in the risk rating.

Recommendations:
Members of the Trust Board are asked to note :
Review the Assurance Framework and consider whether further assurance is required on the actions being undertaken to mitigate significant risks to the Trust’s Strategic Objectives.
The significant risks facing the Trust are:
Ref / Page No(s) / Objective/risk – summary / Risk
Rating
1.2.1 / 3 / Maintain reduction in levels of C Diff / 20
2.4.2 / 4 / Trust fails to meet 98% within 4 hours access standard / 20
9.1.1 / 7 / Under-delivery of efficiency improvements due to a combination of internal and external factors / 20
9.2.1 / 8 / Financial pressures in local health economy / 20
9.2.3 / 9 / Emerging cost pressures have material impact on financial position / 20
Prepared by: Sheena King, Head of Risk Management & Legal Services
Presented by: Peter Mellor, Company Secretary

1

Assurance Framework/Dec 09

Balanced Scorecard Summary – Assurance Framework 2009/10

The following chart shows the breakdown of risks contained within the Assurance Framework.

LIKELIHOOD
(frequency) / CONSEQUENCE (impact/severity)
Insignificant (1) / Minor (2) / Moderate (3) / Major (4) / Serious (5)
  1. Rare

  1. Unlikely
/ 7.1.1  / 2.1.1 
7.1.3 
7.1.4 
  1. Possible
/ 5.6.1  / 2.3.1
3.1.1 / 1.3.1 
2.2.1 
3.3.1 
4.1.2 
5.2.1 
5.5.1 
9.2.2 
9.2.4  / 2.6.1
3.6.1 
5.1.1
  1. Likely
/ 1.3.2
1.3.3
1.4.1
4.1.1 
5.1.2 
6.1.1
6.2.1 / 1.1.1 
1.1.3 
2.4.1
2.5.1 
2.5.2 
9.2.5  / 1.2.1
2.4.2 
9.1.1 
9.2.1 
9.2.3
  1. Highly likely
/ 2.7.1
LIKELIHOOD / CONSEQUENCE (impact/severity)
(frequency) / Insignificant
(1) / Minor
(2) / Moderate
(3) / Major
(4) / Serious
(5)
Rare / (1) / 1 / 2 / 3 / 4 / 5
Unlikely / (2) / 2 / 4 / 6 / 8 / 10
Possible / (3) / 3 / 6 / 9 / 12 / 15
Likely / (4) / 4 / 8 / 12 / 16 / 20
Highly likely / (5) / 5 / 10 / 15 / 20 / 25
Green / Low Risk (1 – 3)
Yellow / Moderate Risk (4 – 6)
Amber / High Risk (8 – 12 )
Red / Extreme Risk (15 – 25)

Change to Risk Rating

1.1.1 / Increase in the number of Health Care associated infections e.g. MRSA, C. Difficile resulting in failure to meet objectives 1,2 & 4
Risk rating () from Amber 12 to Red 16
1.1.3 / Dirty or suboptimal public and clinical environment due to failure to implement NPSA 2007 hospital cleaning standards.
Risk rating () from Red 20 to Red 16
5.1.1 / Inability to effectively control costs associated with total workforce capacity. Potential staff shortages in key service delivery areas.
Risk rating () from Amber 12 to Red15

1

Assurance Framework/Dec 09

TRUST STRATEGIC OBJECTIVE 1: TO PROGRESS FROM BEING A ‘GOOD’ TO A GREATHOSPITAL AND TO BE ONE OF THE SAFEST IN THE WORLD

Responsible Executive: Medical Director
Principal Objectives: 1. Sustained reduction of Healthcare Associated Infections
2. To foster and enhance public confidence and perception in the delivery of safe patient care within the hospital environment.
3. To enhance and promote high quality, evidence-based care
4. To minimise the number of adverse clinical incidents through the advancement of a patient safety culture
RISKS / CONTROLS AND ASSURANCE TO MITIGATE RISK / IDENTIFIED GAPS IN CONTROLS AND ASSURANCE / ACTIONS TO CLOSE IDENTIFIED GAPS / RESIDUALRISK RATING
REF. NO
SfBH
Ref / RISKS
What could prevent the Strategic Objective from being achieved / CONTROLS IN PLACE
The specific actions being taken and or have been taken to control the risk. / POSITIVE (ACTUAL) SOURCES OF ASSURANCE
Where can we gain evidence of the effectiveness of the controls / RISK RATING
LEAD /
Resp
Cttee / GAPS IN CONTROLS
The identification of any failure to establish effective Controls. / GAPS IN ASSURANCE
The identification of any failure to gain evidence relating to the effectiveness of the Controls. / ACTION PLAN
Details of actions to address identified gaps in either Controls or Assurance, with target date for completion.
EXTREME
HIGH
Plan
GC – Gap in Controls
GA – Gap in Assurance / Target
Date / Progress Report / MOD
LOW
1.2.1
C4d / Failure to sustain improvement in antimicrobial prescribing practice may impact on Trust’s ability to maintain C.Difficile cases below trajectory with possible concomitant effect on patient safety and Trust reputation /
  • ICMC & Antimicrobial management group monitor outcomes of antibiotic (AB) audits.
  • AB prescribing rounds including C diff ward roundprovide direct clinician ward based education
  • AB prescribing policy
  • AB prescribing audits including Trust wide point prevalence audit of antimicrobial prescribing
  • Feedback via Root Cause Analysis to Div Gov by IC leads.
  • Programme of audit and clinician feedback.
  • Formal teaching of junior medical staff.
/
  • Result of Trust wide antimicrobial audit
  • Evidence of education and feedback in Trust Induction programme for medical staff and minutes of departmental meetings
  • Minutes of antimicrobial management group and ICMC
/ Clinical Lead IC DIPC
AB Pharmacist
(20) /
  • Lack of e-induction
  • Lack of electronic learning package
  • Reduced coverage of antibiotic ward rounds from Sep 09 due to resignation of consultant microbiologist
/
  • None
/ GC - Development of e learning antimicrobial prescribing package
GC – Development of E-Learning training package
GC – recruitment of replacement microbiologist / Complete
●
Apr 10
●
Feb 10
● / E Induction package produced, being finalised by educational technology.
E-Learning package in development with SUHT and Winchester.
Replacement post currently being advertised closing date 23 Oct 09. / (16)

1

Assurance Framework/Dec 09

TRUST STRATEGIC OBJECTIVE 2: DEVELOP AND STRENGTHEN OUR POSITION AS THE ‘HOSPITAL OF CHOICE’ FOR OUR PATIENTS, GPs AND COMMISSIONERS

Responsible Executive: Chief Operating Officer
Principal Objectives: 1. Develop and keep under constant review a clinical services strategy
  1. Build good effective relationships with commissioners – PCTs, PbC groups and GPS
  2. Develop a PortsmouthBrand and market the Trust effectively
  3. To meet or better all National/Care Quality Commission and Monitor targets to ensure that the Trust is highly rated by external assessors, which strengthens the organisation’s position to be ‘hospital of choice’
  4. Ensure the Trust has robust and appropriate health records management processes in place
  5. Ensure the Trust can provide a robust Blood Science Service
  6. To provide, maintain and promote an efficient direct appointment booking system

RISKS / CONTROLS AND ASSURANCE TO MITIGATE RISK / IDENTIFIED GAPS IN CONTROLS AND ASSURANCE / ACTIONS TO CLOSE IDENTIFIED GAPS / RESIDUALRISK RATING
REF. NO
SfBH
Ref / RISKS
What could prevent the Strategic Objective from being achieved? / CONTROLS IN PLACE
The specific actions being taken and or have been taken to control the risk. / POSITIVE (ACTUAL) SOURCES OF ASSURANCE
Where can we gain evidence of the effectiveness of the controls / RISK RATING
LEAD /
Resp
Cttee / GAPS IN CONTROLS
The identification of any failure to establish effective Controls. / GAPS IN ASSURANCE
The identification of any failure to gain evidence relating to the effectiveness of the Controls. / ACTION PLAN
Details of actions to address identified gaps in either Controls or Assurance, with target date for completion.
EXTREME
HIGH
Plan
GC – Gap in Controls
GA – Gap in Assurance / Target Date / Progress Report / MOD
LOW
2.4.2
C7f / C19 / Trust fails to meet 98% within 4 hours Emergency Department access standard leading to breach of national target /
  • Process and workforce redesign
  • Winter plan
  • Continued operational review and action in response to outcomes
  • Work with Local Health Community partners
  • Weekly Emergency Pathway Performance meeting
  • Weekly dashboardmonitors range of key indicators relating to patientflow.
  • Visual hospital process now implemented on medical wards and commenced in MAU
  • Implementing plan for patient boards in all clinical areas
  • The Lean transformation programme for emergency care.
  • The Weekly Emergency Care Performance Meeting will now convert once a month to a formal Steering Group for the emergency care improvements.
  • Data is being broken down to PCT and practice level so that contributing factors can be analysed and addressed.
  • Changes have been made to the ED Consultants role from 1st Nov. Increase in OOH’s cover. Locums for ED and MAU also arranged to close gap.
  • New ambulatory service commenced Jul 09.
  • Triage & transfer to speciality beds – pull model commenced Sep 09 ensuring capacity in ED.
  • GP receiving area now in use reducing demand on ED.
  • Business case for Chimera approved to support dashboard development
/
  • Reports to
EMT
HMC
TB
  • Monitored daily, weekly
  • Weekly Emergency Pathway Performance reviewusing information from the dashboard
  • Divisional performance review.
  • Discharge improvements for <48 hour stay patients now starting to be demonstrated.
/ MPu / HMC
(20) /
  • Regular real time data and early warning system
  • Electronic Bed Management EBM) system
  • A range of contributing factors need to be addressed and improvements made to smooth the patient pathways for emergency patients.
  • McKinsey LHE work has flagged issues around comparative high attendances and admissions
  • Strategic review of actions required to enable clear direction of recovery.
  • The 4 hour recovery plan has now been agreed across the WHE and is being robustly implemented. Incorporating recommendations from ECIST
/
  • The continued performance problems mean that the Trust currently remains under cumulative trajectory with partners and on a week to week basis not achieving the target. Significant improvements in performance are now being pursued.
  • The continued poor performance is increasing the risk that the end of year target may be at risk. This makes recovery actions by both PHT and LHE partners to expedite flow, crucial and urgent.
/ GC – Chimera system needed to produce regular timely data more easily. Weekly dashboard in place in the meantime together with tracking of daily position through the DHM system and the Trust Operations Board.
GC – Electronic bed management system needed to help with tracking patient actions and beds more easily.
GC – Lean projects include: discharge process redesign, establishment of the VisualHospital to track all patients through their pathway, process changes in the ED/MAU, DMOP, emergency surgery and Pharmacy.
GC - Trust activity data is being analysed to identify daily/weekly trends in attendances and admissions.
GC – A review of consultant job plans has commenced to identify ways to expand cover to weekends and evenings
GC -Strategic review underway in conjunction with Mckinsay and partners.
GC- Work has commenced to review the MAU model to identify improvements that can be identified and implemented. / Feb 10
●
2010
●
Nov 09
●
Continuing from Jun 09
●
Nov 09
●
Dec 09
●
Nov 09
● / Electronic Bed Management Steering Group convened. First meeting with agreed actions held.
All these projects are on track and being monitored against KPIs.
Reorganisation of LEA resource now agreed – further increase in resource within financial envelope. Result will include improved education and supervision of facilitators and Board/Executive education from Dan Jones
Still awaiting final details on leads and dates.
Lacking specialities have plans to pull out of MAU am post take ward rounds. / (20)

TRUST STRATEGIC OBJECTIVE 9: SUSTAIN FINANCIAL STABILITY BY REDUCING WASTE, STRIVING FOR EFFICIENCY AND IMPROVING VALUE TO ENABLE INVESTMENT IN PATIENT CARE

Responsible Executive: Director of Finance
Principal Objectives:
  1. 1. To achieve the long-term efficiency improvements as set out in the Integrated Business Plan
  2. To achieve a sustainable surplus from 2010/11 allowing scope for planned and discretionary developments in Trust’s services

RISKS / CONTROLS AND ASSURANCE TO MITIGATE RISK / IDENTIFIED GAPS IN CONTROLS AND ASSURANCE / ACTIONS TO CLOSE IDENTIFIED GAPS / RESIDUALRISK RATING
REF. NO
SfBH
Ref / RISKS
What could prevent the Strategic Objective from being achieved? / CONTROLS IN PLACE
The specific actions being taken and or have been taken to control the risk. / POSITIVE (ACTUAL) SOURCES OF ASSURANCE
Where can we gain evidence of the effectiveness of the controls / RISK RATING
LEAD /
Resp
Cttee / GAPS IN CONTROLS
The identification of any failure to establish effective Controls. / GAPS IN ASSURANCE
The identification of any failure to gain evidence relating to the effectiveness of the Controls. / ACTION PLAN
Details of actions to address identified gaps in either Controls or Assurance, with target date for completion.
EXTREME
HIGH
Plan
GC – Gap in Controls
GA – Gap in Assurance / Target Date / Progress Report / MOD
LOW
9.1.1
7d / Under-delivery of efficiency improvements due to level of savings required and continued operational and quality pressures. /
  • Programme Management Office tasked with supporting the development of schemes and monitoring progress.
  • Reinforcement of role of PMO team
  • Delivery monitored through performance management arrangements.
  • Focus through Senior Leaders Forum
  • Performance mgt meetings held fortnightly/weekly until corrective action signed off.
  • Reportingframework to SHA on monthly basis.
  • CIP process to be part of internal auditprogramme for 2009/10
  • Appointment of Turnaround Director.
  • Actions imposed on recruitment, temporary staffing & non-pay to constrain expenditure
/
  • Reports to:
Trust Board
SLF
EMT
HMC
Divisional performance meetings
SHA reviews and monitoring.
Report issued by PWC and discussed with the Director of Finance and Chief Executive and actions progressed and incorporated within PMO framework. / MD /
HMC
(20) /
  • Further controls required in divisions where shortfall identified in terms of year-to-date performance.
  • Further actions required to develop additional savings in the light of outcomes of 9.2.1
  • Recovery action plans not well established.
/
  • Continued gap in plans to meet the 2009/10 requirement of £19.8m
  • Requirement to develop plans for future years.
  • Requirement for range of contingency plans due to delivery failure.
  • Slippage against phased delivery plans.
/ GC - Divisions advised of increased targets.
GC – Expenditure continues to exceed plan despite preliminary contingency plans.
GA – Savings not delivered against phased plans / Nov 09
●
Nov 09
●
Nov 09
● / Further progress being achieved to meet target. Continuing review gap now reduced to £1.5m.
Gap filled through contingency planning to meet gap.
Continued review of impact of further controls. Further actions imposed including recruitment freeze.
The Turnaround Director appointment will focus on action plans to deliver results together with a refocus on Trust wide workstreams. / (20)
9.2.1
7d / Financial pressures in local health economy create risk of non-payment for services provided /
  • Jointly commissioned actions to support recovery plan in health economy.
  • Commitment to work with partners and SHA to evaluate extent of risks and joint recovery plan.
  • Contingency plans developed against risk of non-payment.
  • Regular monthly meeting held between FD of PHT and two PCT DoFs..
  • Meeting with contracting team
/
  • Minutes of commissioning meetings.
  • Chief Executive’s leadership meeting
  • Minutes of Exec level contract performance meetings.
  • Minutes of Board to Board meetings
  • Reports to Trust Board and HMC
  • Reports to monthly divisional performance meetings
/ MD /
HMC
(20) /
  • Further controls and analysis required to expose variances by source as they arise.
  • Clear acceptance by all parties on required action in the event of continued over performance.
/
  • Process impacted by late agreement of demand management schemes which require activity level analysis and schemes to be fully established.
  • Difficulties in delivery activity to meet 18 week waits without the need to resort to high cost waiting list initiatives.
/ GA - Further update to be provided in context of business plan 2009/10
GA- Development of activity variance reporting process.
GA- impact in respect of 10/11 has yet to be fully assessed.
GA-PCTs not linked into impact of activity for PHT and financial implication.
GA – Waiting list initiative not affordable to delivery activity. / Achieved
●
Achieved
●
Nov 09
●
Nov09
●
Nov 09
● / Income analysis and activity schedules finalised following agreement of contract. Activity schedules shared with PCTs and available to Divisions on shared drive.
Activity and financial impact in Divisional plans. Monitoring on an ongoing basis with regular meetings on a monthly basis with PCTs supported by the SHA.
Assessment as part of planning process. Review of long term financial model with TB.
.
Work being undertaken across health economy to deliver activity without incurring waiting list initiatives. Assessment being closely monitored of impact on income within forecast outturn. / (20)
9.2.3
7d / Emerging cost pressures have material impact on Trust’s financial position /
  • Creation of potential actions that can be taken in event of downside scenario
  • Development of efficiency indicator matrix to expose ongoing opportunities for further savings.
  • Efficiency Indicators available to Divisions on shared drive.
  • Summary indicators in HMC and Board report.
  • Contingency plan developed, agreed with SLF and formally issued to Divisions.
  • Appointment of Turnaround Director
/
  • Regular reporting integration with operational targets.
/ MD / HMC
(20) /
  • Divisional controls not effective in managing levels of recruitment and controlling the extent of temporary staffing
/
  • Evidence of costs exceeding budgets and continuing cost of waiting list initiatives.
/ GA – Improvement in performance evidenced.
GA- Broader review of Capacity Map across whole health economy underway. McKinsey review subject of consideration across health economy.
GA – Costs significantly at variances with plan. / Nov 09
●
Nov 09
● / 2009/10 Plan updated and advised to HMC and Board.
Further contingency action in progress with strengthened controls over recruitment, temporary staff and non-pay costs.
Range of discussions with McKinsey, PCTs & SHA underway during May & June with Board to Board discussion in June. Further discussion on implementation planning being discussed with SHA & PCTs. Ongoing discussions between SHA, PHT & PCTs on governance model & resourcing for implementation phase. / (20)
LEADS / COMMITTEE/GROUP ABBREVIATIONS / OTHER ABBREVIATIONS
JB / Jill Beckett / CSB / Clinical Standards Board / CAB / Choose and Book Appointment System
AB / Andy Burrows / CoI / Control of Infection Committee / CEO / Chief Executive Officer
BC / Brian Courtney / CoG / Council of Governors / CLIP / Complaints, Litigation, Incident, PALS
KC / Kaljit Chauhan / CPG / Clinical Priorities Group / CSL / Carillion Services Limited
JD / Julie Dawes / CWG / Clinical Workforce Group / EDM / Electronic Document Management
MD / Malcolm Dennett / CQSB / Clinical Quality and Standards Board / HCC / Healthcare Commission
BF / Bill Flatman / EMC / Executive Management Committee / HRL / Health Records Library
PG / Penelope Gordon / G&Q / Governance & Quality Committee / IBP / Integrated Business Plan
RK / Rebecca Kopecek / ICMC / Infection Control Management Committee / ICNA / Infection Control Nurses Association
JL / Jane Lowe / HMC / Hospital Management Committee / IFRS / International Financial Reporting Standards
MM / Maggie MacIsaac / PSFWS / Patient Safety Federation Work Stream / LIPS / Leading Improvement in Patient Safety Programme
FMcN / Fiona McNeight / RC / Redevelopment Committee / LTFM / Long term financial management
CM / Caroline Mitchell / SLDC / Strategic Learning & Development Committee / NRLS / National Reporting and Learning System
JP / Joanne Paul / SLF / Senior Leaders Forum / QRM / Clinical Quality Review Meeting
MP / Mark Power / TPC / Trust Planning Committee / SCSHA / South Central Strategic Health Authority
MPu / Maria Purse
RS / Robert Simpson
MS / Martin Stroud
CV / Carolyn Volker
GZ / Graeme Zaki

Symbol

/

Explanation

● / On target
▼ / Behind target
▲ / Ahead of target

1