November NHS Rushcliffe CCG Assurance Framework

Transcription

1 November 2015 NHS Rushcliffe CCG Assurance Framework

2 ASSURANCE FRAMEWORK SUMMARY No. Lead & Sub Committee Date placed on Assurance Framework narrative Residual rating score L I rating in 19 March 2015 GB meeting rating in 19 November 2015 GB meeting Trend from last GB meeting GB35 Director Outcomes and Information Director Nursing and Quality Governing Body May-13 Failure to achieve the EMAS performance targets with a disproportionate performance between city and county. This means patients in the county may be at greater risk of harm. In addition, the nature of complaints received by EMAS demonstrate a growing concern around quality RED 5 4 HIGH HIGH GB36 Director Outcomes and Information Director Nursing and Quality 12-Nov-13 Failure to achieve the 4 hour ED performance target RED 5 4 HIGH HIGH GB16 GB39 GB40 Governing Body Director of Nursing and Quality Service Director Adult Health and Social Care Quality and Committee Director of Nursing and Quality Director of Nursing and Quality June 2012 revised May Nov Nov-15 GB41 Chief Finance Officer 19-Nov-15 Quality assurance and monitoring resources are limited and the risk is that these are targetted at some providers and not others where there are equal or greater risks. The impact would be on individual patients and also on the reputation of the CCG and confidence of the wider public. LA budget constraints: Following LA budget constraints, there is a miss-match in the resources available to fund health and social care services and the demand on those services which may affect patient experience, the quality of service provision and outcomes for patients. Home care quality monitoring: There are not currently well established processes for monitoring the quality of home care providers which means that patients may be receiving inappropriate and/or poor quality care The CCG fails to keep within the Revenue Resource Limit and is unable to pay for services it has commissioned due to higher levels of activity than expected and/ or undelivered QIPP schemes AMBER 3 3 HIGH HIGH RED 4 4 HIGH NEW AMBER/ RED AMBER/ RED 3 4 HIGH NEW 3 4 HIGH NEW GB42 Chief Finance Officer 19-Nov-15 Financial position at acute provider may affect system resilience resulting in extra costs to the CCG and other services AMBER/ RED 4 3 HIGH NEW

3 GB 35 RISK DETAIL No. GB 35 Lead & Sub Committee Director Outcomes and Information Director Quality and Patient Safety Governing Body narrative Failure to achieve the EMAS performance targets with a disproportionate performance between city and county. This means patients in the county may be at greater risk of harm. In addition, the nature of complaints received by EMAS demonstrate a growing concern around quality Initial Rating Score Residual score rating L I L I RED 5 5 RED 5 4 Assurance Domain 3 Strategic Objective 2 Delivering better outcomes for patients. Improve the quality of health services in relation to health inequalities, health outcomes, patient safety, access and patient experience. Controls Contract Review Process led by Erewash CCG on behalf of associate CCGs. Mansfiled and Ashfield lead for Nottinghamshire Nottinghamshire Divisional meetings EMAS Better Care Programme and Quality Improvement Plan following Clinical Summit (October 2013) Director of Outcomes and Information, Head of Outcomes and Information and Senior Service Improvement Manager attend regular regional monitoring meetings 01-Apr Apr Oct Sep-15 External/Internal Assurance Commissioners' Report - produced monthly by NHS Erewash CCG and shared with contract associates CQC Inspection and Report Performance reports which include the performance metrics for the EMAS response times, handover times and profile of responses including the maximum waits at Governing Body and Clinical Cabinet Deep Dive Review at Governing Body and Audit Commmittee EMAS Director of Operations attended Governing Body - outlining details of Better Patient Care Improvement Programme Better Patient Care Programme Board to monitor progress against the QIP. The formal monitoring of the QIP is by the 'Oversight Group', led by the Trust Development Authority with NHSE, Lead Commissioner and EMAS. Prolonged Wait Report - clinical audit on patients experiencing missed response times - reviewed by QRC Root Cause Analysis of missed Red 1 and Red 2 8 minute response times - reviewed by QRC Apr-14 Apr Apr-14 May 2014 January Jul Oct Jan Jan-15

4 Clinical Summit reported to Governing Bodies and EMAS recovery plan produced following Summit A harm review has been undertaken by EMAS Medical Director and Rushcliffe Governing Body GP of Red 1 breaches for Q.1. No adverse harm identified and process established for ongoing review and assurance to associate commissioners. EMAS action includes staff recruitment, fleet replacement, expansion of first responder scheme in rural areas. 01-May Oct-15 Gaps in controls and assurance and the action plans in place Action plan target date ADDITIONAL INFORMATION e.g. The considerations taken when deciding on the risk rating or information to further inform the governing body on risks which remain high despite on-going actions

5 GB 36 RISK DETAIL No. GB 36 Lead & Sub Committee Director Outcomes and Information Director Quality and Patient Safety narrative Failure to achieve 4 hour ED performance target Initial rating AMBER RED Score Residual score rating L I L I 5 3 RED 5 4 Assurance Domain Strategic Objective Delivering better outcomes for patients. Improve the quality of health services in relation to health inequalities, health outcomes, patient safety, access and patient experience. Controls Urgent Care Working Group now System Resilience Implementation Group meeting weekly across south UOP. Workstreams: admission avoidance; effective rehabilitation and discharge; demand and capacity - with comprehensive work programme and sub-groups to oversee service improvement, transformation and performance Urgent Care Daily Sit Rep to NHS England Programme Management Office has been established within NUH led by the Director of Delivery from Nottingham City CCG. Progress continues in the implementation of the individual projects including the opening of the planned additional beds within NUH. Urgent care dashboard produced on a daily basis to support daily confernece calls that include all health and social care organisations Sep-14 Sep-14 Nov-14 Sep-15 Urgent care centre opened 01/010/2015 External/Internal Assurance Performance Reports to Governing Body and Clinical Cabinet deep dive into ED performance against target Apr-14 Utilisation Report for Rushcliffe to Governing Body in January 2014, shows Rushcliffe has lowest A&E attendances in Notts and attendances have reduced over last year Friends and Family test response performance reported within Quality Premium section of Quality and Performance Report; outcome monitored through Quality Scrutiny Panel CCG Quarterly Assurance Checkpoint Meetings and Delivery Dashboard TDA/NHSE Escalation Meeting Audit Committee Deep Dive review of ED Performance McKinnsey Report - Nottinghamshire Emergency Pathway Review Apr-14 Apr-14 Sep-14 Sep-14 Sep-14 Sep-14

6 System Resilience Plan submitted A capacity investment plan has been agreed to include the opening of 71 additional substantive beds and expansion of the Emergency Department. The beds opened in a phased process which began in September Largely the beds are for the Health Care of Older People (27 beds) and Respiratory Medicine (24 beds), but there are also Oncology, General Surgery and Stroke beds scheduled CCG clinical leads planning to 'walk the walk' in the Emergency Department Performance delivered in quarter /16 was above the 95% target; quarter 2 target not met Sep-14 Oct-14 May-15 Oct-15 Gaps in controls and assurance and the action plans in place Action plan target date Date info added ADDITIONAL INFORMATION e.g. The considerations taken when deciding on the risk rating or information to further inform the governing body on risks which remain high despite on-going actions

7 No. GB 16 Lead & Sub Committee Director Quality and Patient Safety Service Director Adult Health and Social Care narrative GB 16 RISK DETAIL Quality assurance and monitoring resources are limited and the risk is that these are targetted at some providers and not others where there are equal or greater risks. The impact would be on individual patients and also on the reputation of the CCG and confidence of the wider public. Initial Rating AMBER RED Score Residual score L I rating L I 4 3 AMBER 3 3 Assurance Domain 1 Assurance Domain 3 Strategic Objective 4 Clinically commissioned, high quality services Better outcomes for patients Design, procure and monitor services to achieve the best possible clinical and patient experience outcome Controls CCG quality monitoring activities undertaken jointly with the County Council including joint visits targetted at specific care homes Monthly information sharing meetings which include health and social care commissioners and the CQC Agreed joint risk escalation protocol and process to address poor quality concerns relating to care homes Quality monitoring processes now well established and improvements being seen Jul-12 Jul-12 Nov-12 Sep-15 External/Internal Assurance Strategic Review of the care home sector across Nottingham and Nottinghamshire setting out work to date, risks and future priorities - report to Governing Body Care Homes Sub-Group reports to Governing Body via QRC Internal Audit Report on Quality and Contract Monitoring in Care Homes - significant assurance for quality monitoring - follow up Review of Quality Team capacity and Safeguarding Arrangements Quality monitoring processes now well established and improvments being seen - reduced number of care homes of concern Apr-14 Apr Dec Jan-15 Sep-15 Gaps in controls and assurance and the action plans in place Action plan target date Date info added ADDITIONAL INFORMATION e.g. The considerations taken when deciding on the risk rating or information to further inform the governing body on risks which remain high despite on-going actions

8 Redefines risk - insufficient capacity (staff resources) to manage the quality scrutiny process effectively CCGs approved additional post to shared Quality Team Implications of the Care Act on resources in the shared Quality Team Mar-15 Mar-15 Apr-15

9 No. GB 39 Lead & Sub Committee Director Quality and Patient Safety narrative GB 39 RISK DETAIL LA budget constraints: Following LA budget constraints, there is a miss-match in the resources available to fund health and social care services and the demand on those services which may affect patient experience, the quality of service provision and outcomes for patients. Initial Rating Score Residual score L I rating L I RED 4 4 Assurance Domain 1 Assurance Domain 3 Clinically commissioned, high quality services Better outcomes for patients Strategic Objective 4 Design, procure and monitor services to achieve the best possible clinical and patient experience outcome Controls Social Care Director is member of CCG Governing Bodies and presents budget proposals ahead of formal consultation. Better Care Fund programme of integration. South Notts Transformation Board working as a unit of planning with all stakeholders to ensure development of sustainable models for future health and social care. External/Internal Assurance Proposals presented to CCG GBs in January 2015 CCG repsonse to proposals submitted as part of consultation process. Gaps in controls and assurance and the action plans in place Current LA changes out to Consultation. Awaiting final details of proposals following closure of consultation. remains unchanged. Health implications of final proposals to be assessed once known. Action plan target date Date info added ADDITIONAL INFORMATION e.g. The considerations taken when deciding on the risk rating or information to further inform the governing body on risks which remain high despite on-going actions

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11 GB40 RISK DETAIL No. GB40 Lead & Sub Committee Director Quality and Patient Safety narrative Home care quality monitoring: There are not currently well established processes for monitoring the quality of home care providers which means that patients may be receiving inappropriate and/or poor quality care Initial Rating AMBER RED Score Residual score L I rating L I 3 4 Assurance Domain 1 Assurance Domain 3 Clinically commissioned, high quality services Better outcomes for patients Strategic Objective 4 Design, procure and monitor services to achieve the best possible clinical and patient experience outcome Controls Meeting regularly with new homecare providers and the County Council to mobilise the new contracts which include a quality schedule as quickly as possible. External/Internal Assurance Work continues by contracting to establish the new contracts with all providers. Annual provider audit tool in development based on health elements of the contract. Agreement reached with new CHC provider that they will undertake an annual provider audit and report to CCG quality team. Joint quality assurance processes with the LA still need to be developed. Quality Improvement Forum to be established by CityCare Gaps in controls and assurance and the action plans in place Action plan target date Date info added ADDITIONAL INFORMATION e.g. The considerations taken when deciding on the risk rating or information to further inform the governing body on risks which remain high despite on-going actions

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13 No. Lead & Sub Committee GB41 Chief Finance Officer narrative GB41 RISK DETAIL The CCG fails to keep within the Revenue Resource Limit and is unable to pay for services it has commissioned due to higher levels of activity than expected and/ or undelivered QIPP schemes Initial Rating AMBER RED Score Residual score L I rating L I 3 4 Assurance Domain 1 Assurance Domain 3 Strategic Objective 4 Clinically commissioned, high quality services Better outcomes for patients Design, procure and monitor services to achieve the best possible clinical and patient experience outcome Controls Monthly performance and financial reporting to the Governing Body Reporting to practices via the Practice Packs Specialty leads for all contracts and programmes Detailed reports to QIPP group for rigourous performance monitoring Contract monitoring meetings with providers Contract Executive Boards/ Meetings External/Internal Assurance CCGs financial plans - scenario planning CCG QIPP plans built up and to be built up in financial plan in line with good practices (i.e. identified schemes in excess of target) Clinical Lead identified for each scheme Visiting practices to review referrals and other associated costs drvers Budget reports ed to all budget holders on a monthly basis, including nominal rolls as appropriate GP practice budgets produced and reported on a monthly basis QIPP and Finance Group meet regularly in year to review QIPP schedules and Finance Performance Reports, these show the CCG is on target to deliver its required surplus (including QIPP by use of NR reserves). Chief Fiance Officer and Deputy Finance Director met with the AT 2nd November to look at the financial position of the CCG and they were happy with this and the forecast to deliver its surplus.

14 A budget manual to be produced for use by non finance managers. Gaps in controls and assurance and the action plans in place New QIPP schemes to be identified and discussed/ approved by QIPP and Finance Group. On-going management of contracts Action plan target date Date info added ADDITIONAL INFORMATION e.g. The considerations taken when deciding on the risk rating or information to further inform the governing body on risks which remain high despite on-going actions Month 7 figures show that position isn t going to change

15 GB42 RISK DETAIL No. Lead & Sub Committee GB42 Chief Finance Officer narrative Financial position at NUH may affect system resilience resulting in extra costs to the CCG and other services Initial Rating AMBER RED Score Residual score L I rating L I 4 3 Assurance Domain 1 Assurance Domain 3 Clinically commissioned, high quality services Better outcomes for patients Strategic Objective 4 Design, procure and monitor services to achieve the best possible clinical and patient experience outcome Controls Monthly performance and finance reporting to the Governing Body Detailed reports to QIPP group for rigourous performance monitoring Contract Monitoring Meetings with providers Contract Executive Boards/ Meetings External/Internal Assurance CCGs Financial Plans - scenario planning Gaps in controls and assurance and the action plans in place Action plan target date Date info added ADDITIONAL INFORMATION e.g. The considerations taken when deciding on the risk rating or information to further inform the governing body on risks which remain high despite on-going actions

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17 LIST OF RISKS ARCHIVED No. Lead narrative rating score L I Reason for removing from the assurance framework Date completed Date of removal GB37 Director of Finance QIPP 2014/15 - Expenditure will exceed budget and the CCG will not deliver its required surplus due to QIPP not delivered or not delivered recvurrently Transferred to risk register as no longer high risk Mar-15 Sep-15 GB38 Chief Officer Failure to put in place appropriate arrangements for the management of the Better Care Fund could impact on the financial position of the CCG and the services commissioned for our patients Transferred to risk register as no longer high risk Mar-15 Sep-15

18 DETERMINING THE RISK RATING Consider Table A - Likelihood, Table B - Severity and then review the matrix for a final score A - What is the likelihood that harm, loss or damage from the identified hazard will occur Likelihood score Descriptor Rare Unlikely Possible Likely Almost certain Frequency How often might it happen This probably will never happen Do not expect it to happen but it is possible it may do so Possibly may happen Highly probable that it will happen Likely Impact score Descriptor Impact should it happen Insignificant or minor No or slight impact on the CCG objectives B - What is the severity of the impact Moderate Moderate impact on the CCG objectives Significant Significant impact on the CCG objectives Very significant Impact on the CCG objectives affecting delivery over several areas Additional narrative to support identification of the severity of the impact added below Major Impact on the CCG objectives requiring radical review Injury Minor injury not requiring first aid Minor injury or illness, first aid treatment needed Over three days off sick = RIDDOR reportable. 10 days to report to the HSE. Major injuries, or long term incapacity / disability (loss of limb) Death or major permanent incapacity Patient Experience Unsatisfactory patient experience not directly related to patient care Unsatisfactory patient experience - readily resolvable Mismanagement of patient care short term effects Mismanagement of patient care long term effects Totally unsatisfactory patient outcome or experience Complaint/ Claim potential Locally resolved complaint Justified complaint peripheral to clinical care Justified complaint involving lack of appropriate care Multiple justified complaints Multiple claims or single major claim Service/ Business Interruption Human Resources/ Organisational Development Loss/interruption > 8 hours Loss/interruption > 1 day Ongoing low staffing level reduces service quality Rate as 1 Loss/interruption 1 week Late delivery of key objective/ service due to lack of staff (recruitment, retention or sickness). Minor error due to insufficient training. Ongoing unsafe staffing level Loss/interruption over a week Uncertain delivery of key objective/ service due to lack of staff. Serious error due to insufficient training Permanent loss of service or facility Non-delivery of key objective/ service due to lack of staff. Loss of key staff. Very high turnover. Critical error due to insufficient training Financial <1% of contingency Approx 45k Up to 10% of contingency Up to Approx 450k 10% of contingency Approx 450k >50% of contingency Approx 2.75m To the value of the contingency held for the financial year 13/14 Approx 4.5m Inspection/ Audit Minor recommendation s. Minor noncompliance with standards Recommendation s given. Noncompliance with standards Reduced rating. Challenging recommendations. Non-compliance with core standards Enforcement Action. Low rating. Critical report. Multiple challenging recommendations. Major noncompliance with core standards Prosecution. Zero Rating. Severely critical report Adverse Publicity/ Reputation Local Media interest Rate as 1 (significant): Local media interest for over a month National media interest < 3 days National media interest < 3 days MP

19 IMPACT RISK MATRIX SCORING A&B - Likelihood and severity RAG rating matrix Major (Very high) 5 A A/R R R R Very significant (High) 4 A A A/R R R Significant (Medium) 3 A/G A A A/R A/R Moderate (Low) 2 G A/G A/G A A Insignificant/ minor (Very Low) 1 G G G G G RARE UNLIKELY POSSIBLE LIKELY LIKELIHOOD NB The following risks go on the assurance framework - Amber/red and red The following risks go on the risk register - Amber, Amber/green and green ALMOST CERTAIN

20 Management Action Guide Committee Remit Rating Document to capture risk Governing Body Review and challenge of all strategic risks and mitigating actions provided by all the CCG Committees Red and Amber Red CCG Assurance Framework Audit Committee Interrogation of strategic risks through mechanisms such as the Internal Audit Plan and requests for full reporting to the Audit Committee by the Finance and QIPP, Quality & Committee and IGMT Commitee Red and Amber Red CCG Assurance Framework Leadership Team Finance and QIPP Quality & Committee IGMT Committee Identification and management of operational and strategic risks. Action planning to ensure mitigating factors and controls are implemented and tracked. Maintenance of the subcommittee risk register and signposting to the assurance framework All risk ratings Sub Committee registers and CCG Assurance Framework NB The following risks go on the assurance framework - Amber/red and red The following risks go on the risk register - Amber, Amber/green and green