Strategic Risk Report 12 September 2016

Transcription

1 Strategic Report September 20

2 Haringey CCG Register Introduction The Strategic Report (historically known as the Board Assurance Framework) evidences Haringey Clinical Commissioning Group s control over the delivery of its strategic objectives listed above. This report directly underpins the Annual Governance Statement (AGS) and is the subject of annual enquiry by Internal and External Audit. Function of the Strategic Report This report is a tool for the Governing Body corporately to assure itself (gain confidence, based on evidence) about successful delivery of the organisation s strategic objectives. The framework is designed to focus the Governing Body on controlling principal risks threatening the delivery of those objectives. It aligns principal risks, key controls and assurances on controls alongside each objective. Oversight of the management of individual risks is assigned to relevant Governing Body Committees. Where gaps are identified and key controls and assurances are insufficient to reduce the risk of non-delivery of objectives, action plans will be created where appropriate and overseen by the responsible committee. The Senior Management Team and the Audit Committee routinely review all risk on the Register, whereas the Governing Body receives a more high-level Strategic Report, containing risks rated and above. The purpose of the Strategic Report may be summarised as: To provide: a comprehensive method for the effective and focused management of the principal risks to achieving strategic objectives; and a basis for the preparation of a fair and representative Annual Governance Statement. Governing Body responsibility for the Strategic Report It is the responsibility of the Governing Body as the corporate head of the CCG to: Establish strategic objectives. Identify the principal risks that threaten the achievement of these objectives. Identify and evaluate the design of key controls intended to manage these principal risks. Set out the arrangement for obtaining assurance on the effectiveness of key controls across all areas of principal risk Evaluate the assurance across all areas of principal risk. Identify positive assurances and areas where there are gaps in controls and / or assurances Ensure that plans are put in place to take corrective action where gaps have been identified in relation to principal risks and receive assurance Maintain dynamic risk management arrangements including, crucially, a well-founded risk register. Open risks and recently closed risks are set out in pages

3 Haringey CCG Register Strategic Heat Map Impact Likelihood 3.9.

4 Strategic Summary Open s Haringey CCG Register Ref Priority Key changes since last review 10 There is a risk of continued poor performance against the A&E target at NMUH. Planned actions and progress on actions have been updated. 26 There is a risk that BEHMHT will fail to deliver the required must do and should do improvements required, after the Trust was rated as requires improvement following an inspection by the CQC in December Progress on actions has been updated. There is a risk of failing to ensure effective systems and processes are in place to support, monitor and challenge NMUH to deliver: Progress on actions has been updated the NHS Constitution targets improvements to the A&E department as detailed by the CQC in the section 29A Warning Notice issued on 27 April 20 the Health Education England (HEE) improvement plan agreed following the Trust-wide MDT visit in March 20. There is a risk that the CCG is unable to demonstrate, for all providers, that it has delivered its duty under the NHS Constitution to ensure patients have the right to access services within maximum waiting times. 9 Progress on actions has been updated. 34 There is a risk of failing to deliver a balanced Financial Plan in 20/17. A new action has been added. Progress on actions has been updated. 35 NEW RISK added to cover failure of NMUH to achieve the 62 cancer target. Progress on actions has been updated. 4.9.

5 Haringey CCG Register Description Owner 10 1,2,3 There is a risk that the performance against the A&E target at NMUH will not improve in line with the agreed trajectory to achieve the target of 95% of patients being seen within 4 hours by the end of March 2017 and continue to show sustained target attainment thereafter. Owner Jill Shattock Director of Performance (Old NCL 759) Committee Causes Poor patient flow throughout the Trust. Too much reliance on inpatient beds and admitting patients. Not enough assessment capacity. Lack of clinical leadership within the Emergency Department (ED). Consultant and middle grade vacancies leading to inconsistent senior cover for ED. Effects Too many patients waiting an unacceptably long time for assessment and treatment within the department. Potential for unforeseen patient harm caused by extended waits in ED. Unforeseen pressure on nursing resource in ED caused by department congestion. Failure to achieve associated unscheduled care Key Performance Indicators (KPIs) L = The Trust is acting on the findings of the full diagnostic report commissioned from North West Utilisation Management Unit to achieve agreed clinical outcomes. 2. Report and recommendations now incorporated as part of the Safer, Faster Better (SFB) work programme to implement recommended actions via four workstreams. 1. Full diagnostic report and recommendations presented and agreed by System Resilience Group May 20. 1/2. CCG (and partners) to review SFB programme progress at monthly SRG meetings. 1/2. Bespoke programme governance created to oversee the programme and link to wider Trust improvement programme. 1/2. Weekly SFB Programme reports circulated (as part of above). 1/2. Dedicated Programme Director resource in place. 1/2. Weekly workstream meetings in place, progress reports produced weekly. L = 3 Actions 1. CCG acting as convenor and lead for Out of Hospital workstream. Weekly project team meetings to be set up and partner organisation membership agreed. Action owner Karen Baggaley, Assistant Director of Quality Existing SRG became A&E Delivery Board with effect from 1.9. to oversee performance improvement and target recovery. 3. Recovery target to be proposed and managed as part of the STF (Sustainability and Transformation Fund) arrangements for 20/17. Action owner 1. Out of hospital workstream now set up and weekly project meetings in place. Membership agreed and the Integrated Discharge Function (IDF) is being developed as a key part of the workstream. All integrated resilience schemes as part of this OOH group have now been agreed for funding. Plans in place for implementation. 2. The updated terms of reference have been agreed and enacted from STF trajectory agreed by NHS England and applied from April 20. Target achieved in three of four months since April 20 (July position of 88.9% against a target of 86%) 5.9.

6 Haringey CCG Register Description Owner Ineffective and inefficient use of GP capacity Failure to reduce unwarranted A&E activity Damage to CCG reputation Impact on waiting times for planned treatment. Jill Shattock, Director of Performance ,2 There is a risk that BEHMHT will fail to deliver the required must do and should do improvements required, after the Trust was rated as requires improvement following an inspection by the CQC in December Owner Jennie Williams Executive Nurse and Director of Quality and Integrated Governance Quality Committee Causes Effect Lack of capacity/ capability to deliver the required improvements The Trust is unable to make the necessary improvements to services provided out of the St Anne s site due to unsatisfactory environment. There will be a further deterioration in the quality and safety of services and BEHMHT will be deemed not to meet regulatory standards in respect of CQC outcomes. L = 4 1. The delivery of the BEHMHT CQC improvement action plan will be overseen by the Joint Performance and Quality Group (JPQG) from June Haringey CCG will ensure the CQC improvement plan gives appropriate focus to improved outcomes for patients accessing services in Haringey. 1. JPQG minutes will provide evidence of review of the Trust s quality and delivery plan and the quality and safety dashboard, with specific focus on safeguarding, patient complaints and serious incidents. 2. The performance against key patient safety and experience metrics for services delivered in Haringey will demonstrate month on month improvements. L = 3 Action 1. Enfield CCG lead for quality to meet the Trust Director of Quality to review the draft Trust CQC improvement plan on and then brief the Executive Nurse and Director of Quality and Integrated Governance, Haringey CCG. Jennie Williams By end of June To ensure the CCG senior management team and CCG Quality Committee are kept briefed on the progress made by the Trust to deliver the CQC improvement plan and the Chief Officer and Chair are informed of any emerging concerns relating to quality and safety. (C) 1. The Trust has published the 2015/ Quality Accounts. The priorities are aligned with the findings of the CQC inspection conducted in December Update (15.08.) 1. The BEH CQC improvement action plan - v10 was presented to the meeting of the Joint Quality and Performance Group on The CQC has confirmed it is satisfied with the plan. The Trust has submitted a request for additional funding to deliver the CQC improvement plan; the Trust and Mental Health commissioners are working together to ensure the Trust provides the necessary evidence to support this. A deadline of has been agreed for completion of this work. Discussions with commissioners regarding request for additional funding are ongoing. Quality leads are meeting with the Trust on

7 Description Owner 32 1, 2 There is a risk of failing to ensure effective systems and processes are in place to support, monitor and challenge NMUH to deliver sustained improvements required by : Owner The NHS Constitution targets The CQC which issued a section 29A Warning Notice on 27 April 20 Health Education England (HEE) which as a result of the Trust-wide visit in March 20 The GMC in respect of the Trust meeting the GMC Standards for Medical Education (20) Jennie Williams Executive Nurse and Causes Lack of capacity and capability within the Trust to deliver quality and safety improvements Inability of the Trust to appoint substantively to consultant and middle grade posts in emergency medicine. Effects Deterioration in key quality and safety metrics Further deterioration of A&E performance leading to increased likelihood of poor quality, poor patient experience and delivery of poor clinical outcomes Increased likelihood that the Trust will fail to meet the GMC requirements which could result in the suspension of medical trainee placements in the A&E department. L = 4 1. NHS Improvement is supporting the Trust to strengthen leadership at executive level. 2. The monthly Clinical Quality Review (CQRG) and Contract Review Group (CRG) meetings led by commissioners ensure close scrutiny of key quality and safety metrics and performance against the national targets for A&E 3. A monthly Programme Oversight Group (POG) implemented by NHS Improvement (NHSI) following the ED Summit on is overseeing delivery of the medium and longer-term improvements required by the CQC and HEE and ensure short term actions lead to sustainable improvements. Haringey and Enfield CCG Chief Officers are members of this group. 4. An Operational Delivery Group (ODG) chaired by NHS England (NHSE) continues to hold the Trust and system to account for delivery of the required operational actions to support the Trust to meet the HEE requirements. 5. CCG staff have been assigned to support the Trust transformation programme Safer Faster Better to 1. An interim Chief Executive was appointed in July 20 with the Chief Executive of the Royal Free NHS Foundation Trust, providing support as the Trust s Interim Accountable Officer in July 20. The CE has been joined by an experienced interim Director of Nursing who started at the beginning of August 20. An Improvement Director commenced at the Trust in July 20 with oversight of preparation for the CQC inspection in September and A&E improvement. NHS Improvement is continuing to support the Trust to establish how to further strengthen leadership 2a CQRG minutes provide evidence that appropriate challenge and support and, where appropriate, escalation of quality and safety risks. 2b CRG minutes demonstrate appropriate challenge and robust use of Haringey CCG Register 7.9. L = 3 Jennie Williams From June December 20 (Update ) 1. The CCG Accountable Officer (AO) and Executive Director of Nursing to continue with regular 1-1s with the interim Trust CEO and interim Director of Nursing. Jennie Williams, Executive Nurse and Director of Quality and Integrated Governance August There is a coordinated approach to communication to ensure robust and consistent communication and engagement with stakeholders Jennie Williams, Executive Nurse and Director of Quality and Integrated Governance August 20 2a The CCG to request assurance that the Trust has acted on the findings of a Trust-wide programme 1. Chief Executive, NMUH has confirmed that substantial resource is in place to prepare for the CQC inspection commencing The Improvement Board is now in place. 2. Fortnightly system -wide teleconferences established in August to ensure consistent approach around the NMUH to ensure robust and consistent communication and engagement with the Trust staff, the public, stakeholders and local MPs. System communications calls are continuing. NHS England are leading on the co-ordination of briefings for stakeholders prior to the CQC inspection.

8 Haringey CCG Register Description Owner Director of Quality and Integrated Governance Quality Committee (NOTE: this risk should also be cross-referenced with 10, where the risk relating to the Trust not meeting the agreed trajectory to achieve its 95% A&E target is described in detail). improve patient flow and reduce delayed discharges. contractual levers where NHS Constitution standards are breached. 3. The minutes of the monthly POG meeting demonstrates that the CQC and HEE is satisfied that the Trust plans to address the areas of concern are progressing. HEE have confirmed the Trust is delivering improved supervision and education for medical trainees, robust medical rotas. There has been an improvement in feedback from trainees in A&E and evidence of substantive medical appointments. 3. Minutes of the monthly ODG demonstrates delivery of the HEE action plan continues to progress within the agreed timeframe. of mock CQC inspections between June - August 20. 2b Member of CRG will attend CQRG meetings to assure appropriate challenge and avoid duplication of requests for assurance. Jennie Williams, Executive Nurse and Director of Quality and Integrated Governance Ongoing 3. The Executive Nurse and Director of Quality and Chief Officer to attend ODG to maintain close oversight of Trust delivery of CQC Warning Notice actions and HEE action plan. Jennie Williams, Executive Nurse and Director of Quality and Integrated Governance Ongoing 2a August CQRG will request an update on the outcome of the mock inspections and actions in place to address quality concerns. The Trust weekly ED dashboard continues to be reviewed internally by the senior ED team and presented to commissioners at the monthly CQRG. The Executive Nurse and Director of Quality and Integrated Governance has requested a meeting with the Trust Director of Nursing to discuss a recent mockinspection of maternity and the actions taken post mockinspections to other areas. 3. The CCG Chief Officer and Executive Nurse and Director of Quality attends the weekly and monthly oversight meetings. Commissioners have been invited to provide feedback to the CQC in advance of the Comprehensive CQC Inspection in September 20. The Trust is currently meeting the GMC conditions placed on A&E regarding medical rotas, training and education of medical trainees, provision of equipment and senior Paediatric supervision. HEE plan to conduct a formal review on behalf of GMC on

9 Haringey CCG Register Description Owner 33 1,2,3 There is a risk that the CCG is unable to demonstrate, for all providers, that it has delivered its duty under the NHS Constitution to ensure patients have the right to access services within maximum waiting times. Owner Jill Shattock Director of Performance New Performance (Old NCL 717) (Old NCL 715) (Old HCCG 24) Committee Causes Effects NCL acute providers failing to consistently achieve cancer, RTT or diagnostic standards. Inefficiency and ineffectiveness and poor experiences and outcomes for patients Increased risk of clinical harm due to longer waits of failure of Quality Premium relating to the constitutional standards. Currently 2 of the 4 Quality Premium constitutional targets will not be achieved. Reputational damage to the CCG due to failure to achieve standards at individual provider and borough level. L = 4 1. The Director of Performance is working closely with the CSU to ensure robust monitoring of constitutional standards for all providers. 2. Remedial action plans (RAP) have been agreed by host commissioners and are monitored at regular review meetings and all CCGs updated. 3. HCCG is assured that plans are in place for agreed trajectories to deliver compliance. 1. Ongoing performance is monitored through the Integrated Contract Monitoring Report and other performance reports. 2. Contract/Performance Query Notices are issued by the lead commissioner, in line with the NHS Standard contract, to Trusts who report target failures. 3. Remedial Action Plans (RAP) are required from underperforming trusts and monitored by the lead CCG team. 4. RAP review meetings minutes detail agreed action updates and improvement compliance. I = 3 L = Weekly cancer Patient Tracking Lists (PTL) supplied by RFL and monitored by lead CCG (Barnet) to ensure improvement with 62 day cancer standard. 2. To monitor recovery against compliance with the national standards for Diagnostics at UCLH from quarter two 20, (lead commissioner Camden CCG) 3. To ensure a robust action plan is in place to ensure recovery of the diagnostic target attainment by Inhealth, independent sector diagnostic provider (lead commissioner Camden CCG). 4. To monitor improvement of the cancer target attainment at UCLH. Actions owner Jill Shattock, Director of Performance Quarter RFL provide a weekly PTL and progress report. 62 day cancer standard now achieved. HCCG is working with the lead commissioners to ensure that performance is closely monitored. The RFL achieved the standard in June Trajectories are regularly reviewed at the RAP review meeting. UCLH is now planned to be compliant with the Diagnostics standard by the end of July 20, although the standard was not achieved in June InHealth achieved the standard in June 20. The Remedial Action Plan continues to be monitored. 4. UCLH are currently exceeding their Strategic Transformation Fund trajectory and plan compliance with the 62 day cancer Standard for October

10 Haringey CCG Register Description Owner 34 1 There is a risk of failing to deliver a balanced Financial Plan in 20/17. Owner David Maloney Chief Finance Officer Committee Cause 1. Failure to control acute activity during 20/ Failure to deliver 20/17 QIPP Plan. 3. Financial pressures in nonacute CCG budgets. 4. Requirement to set aside 1% of the CCG budget. Effect 1. Failure to fulfil the CCG s statutory financial duties. 2. Insufficient resources across North Central London to fund transformation agenda. L= 4 1.Appropriate financial governance systems in place 2. Review and ongoing scrutiny of the CCG s financial performance by Committee and Governing Body. 3. Review of 20/17 QIPP Plan at QIPP Delivery Group and Finance and Performance Committee meetings /17 budget setting process. 5. Approval of Financial Plan by Committee and Governing Body. 6. Rigorous contract management processes undertaken during 20/ Internal Audit reports produced by Internal Audit which cover financial procedures within the CCG. 2. Papers and minutes of Committee and CCG Governing Body. 3. Papers and minutes of QIPP Delivery Group and Committee. 4. Budget holders have signed off their 20/17 budgets which were uploaded onto the ledger in May Financial Plan was reviewed by the Finance and Performance Committee on and then approved by the Governing Body on Monthly contract meetings with NMH. Similar process in place for other contracts where the CCG has significant expenditure. Thorough discussion of the monthly financial position at the working day 6 meeting with CSU colleagues. L= 4 1. Identification of additional areas for 20/17 QIPP. (C) Action owner: David Maloney Chief Finance Officer : First half of 20/ Monthly monitoring of expenditure against budget (C) Action owner: David Maloney Chief Finance Officer : Ongoing during 20/ Implementation of Recovery Plans for all acute contracts in NCL (A) Action owner: David Maloney Chief Finance Officer : September The 2015/ QIPP Plan is a key focus of the fortnightly QIPP Delivery Group meetings and is also scrutinised monthly by the Senior Management Team. In addition to working up new QIPP areas for implementation in year, the reviews will also identify where planned savings are not being achieved and monitor the impact of any resulting mitigations. Monthly meetings are being held between NMUH and CCG clinicians to discuss and deliver inyear QIPP projects. In addition, work is being undertaken with Haringey Council to identify joint savings. 2. Monthly finance reports, including in-depth monitoring of variances and supporting lead CCGs rigorous challenges of activity. Agreement that all expenditure commitments are subject to approval at Senior Management Team meetings. 3. Draft of Recovery Plans developed for implementation in September 20. Development of pan-ncl financial strategy for 20/

11 Haringey CCG Register Description Owner 4. Reach agreement with providers regarding 20/17 expenditure. Action owner: David Maloney Chief Finance Officer : Mid-October Strategy agreed with CCG/CSU colleagues for each provider. Aim to reach agreement with providers by mid-october NEW RISK Added ,2,3 There is a risk that NMUH will fail to achieve the NHS Constitution performance target for the 62 day cancer pathway. owner Jill Shattock, Director of Performance. Committee Causes Effects Poor external pathway processes for cancer standards. Inefficiency and ineffectiveness of internal pathway processes. Poor experiences and outcomes for patients Increased risk of clinical harm due to longer waits of failure of Quality Premium relating to the constitutional standards. Constitutional targets will not be achieved. Reputational damage to the CCG due to failure to achieve standards at key local provider and borough level. L= 4 1. Contract Performance Notice issued via the NHS standard contract process. 2. Remedial Action Plan required from (1) to detail improvement and target recovery. 1. Correspondence and minutes from Contract Review Group meetings. 2. Remedial action plan produced and reviewed, monitored and updated at fortnightly RAP meetings. L= 4 1. Weekly Patient Tracking List (PTL) monitoring for all patients waiting longer than 62 days, via teleconference. 2. RAP update as no recovery in performance. Action owner: Jill Shattock, Director of Performance : Target achievement from Q3 20/ PTL weekly reviews continue. 2. Revised and updated RAP has been submitted to NHS England and more detail has been requested by the CRG. An improvement trajectory has now been agreed which delivers compliance for quarter 3 in 20/