PUBLIC BOARD - 25 JANUARY 2018 Corporate Risk Register

Transcription

1 Agenda Item 11 PUBLIC BOARD - 25 JANUARY 2018 Corporate Register Presented for: Presented by: Author Previous Committees Assurance Julian Hartley, Chief utive Suzanne Hinchliffe, Chief Nurse and Deputy Chief utive Simon Worthington, Director of Finance Dean Royles, Director of Human Resources Yvette Oade, Chief Medical Officer Simon Neville, Director of Strategy and Planning Richard Corbridge - Chief Digital and Information Officer Craig Brigg, Director of Quality Management Committees 7 December 2017 and 4 January 2018 Trust Goals The best for patient safety, quality and experience The best place to work A centre for excellence for research, education and innovation Seamless integrated care across organisational boundaries Financial sustainability Key points 1. The Corporate Register has been reviewed. There are currently 18 material risks included in this document for the Board s consideration and oversight. 2. Members of the Board of Directors are invited to: (i) consider, challenge and confirm the correct strategy has been adopted to ensure potentially significant risks are kept under prudent control (ii) consider and approve the changes to significant risks following meetings of the Management Committees held on 7 December 2017 and 4 January 2018 (iii) advise on any further risk treatment required. Awareness Discussion and challenge - All 1

2 Agenda Item Summary 1.1 The significant risk profile provides Directors with details on all identified significant risk exposures throughout Leeds Teaching Hospitals NHS Trust. These risks are currently subject to monthly review and have been reviewed by the Management Committee on two occasions (December 2017 and January 2018) since the last meeting of the Board. This report has been updated to summarise the decisions made by the Management Committee. 1.2 The Trust has identified a range of significant risks, which are currently being mitigated, whose impact could have a direct bearing on requirements within the NHS Improvement Accountability Framework, CQC registration or the achievement of Trust policies, aims and objectives should the mitigation plans be ineffective. Currently, the significant risks relate to the following areas: National Standards 18-week RTT standard, 62-day Cancer, 6-week diagnostic wait, 28 day cancelled operations and Emergency Care target Finance Aggregate effect of income volatility, non-delivery of the Waste Reduction Programme in 2017/18, insufficient liquidity and cost pressures and equipment replacement, IT infrastructure and the risk of cyber attack Fundamental Standards of Safety & Quality Nurse staffing levels, reducing supply of doctors in training, C. difficile and MRSA targets, violence due to organic, mental health or behavioural reasons, patient flow, bed capacity and emergency admissions, unsustainable levels of medical outliers, inability to deliver a cardiac surgery service and length of time mental health patients wait in the ED Performance & Regulation Corroded pipes in Clarendon Wing, LGI, power failure at LGI and a combination of demand and capacity factors giving rise to unsustainable levels of medical outlying and delayed discharges. 1.3 A summary of the main controls and mitigating actions for the significant risks in each area is available in Appendix A. 1.4 Significant s s reviewed at the December 2017 Management Committee The December 2017 Management Committee reviewed three risks from the Corporate Register; CRR 1 Inadequate nurse staffing levels, CRR 36 Inability to deliver a cardiac surgery service and CRR38 Excessive stays in the Emergency Department (ED) for patients with Mental Health (MH) conditions. Nurse staffing levels were discussed briefly with a view to having a longer discussion at the January 2018 meeting. Improvements in some clinical areas were noted together with a recommendation to reduce the risk score from 20 to 15. The Committee noted improvements in the cardiac surgery service including an increase in the number of operations performed and a reduction in the number of cancelled sessions. It was agreed to review the risk again in February 2018 and leave the risk score at 16 until then. The risk relating to excessive stays in the ED for MH patients was reviewed in the light of the new Policing and Crime Act It was agreed that the risk score would remain at 16 until the full implications of the new Act were reviewed following implementation. 2

3 s reviewed at the January 2018 Management Committee Agenda Item 11 It was agreed that the January 2018 meeting would focus on a review of the corporate risks that were currently documented on the CRR (18 in total). Some of these risks had been reviewed at recent committee meetings and it was agreed to focus on other risks, more specifically the risks that reflected the current operational pressures across the healthcare system. It was noted that the risks relating to the achievement and delivery of waiting time performance standards were largely a consequence of these operational pressures and these risks would therefore be reviewed in more detail through the scheduled work programme. The purpose of the more focused discussion was to consider those specific risks relating to patient flow across the healthcare system in light of the very significant capacity pressures on our hospitals, reflecting the local and national position. The Committee concentrated their discussion on four corporate risks; CRR1 Inadequate nurse staffing, CRR 12 failure to achieve emergency care standard, CRR 31 Patient flow and capacity for emergency admissions and CRR 32 Medical Outliers and patients waiting in non-designated bed areas. The Committee noted the previous months nurse staffing update and the recommended reduction in the risk score from 20 to 16. Further updates were received on the enhanced staffing incentives to provide additional support to wards and the plans regarding overseas recruitment. The Committee noted the additional support for the two Emergency Departments by redeploying doctors from other clinical areas. There was no recommended change to the risk score of 20, acknowledging the extremely high levels of activity being experienced. The most recent measures to help mitigate the patient flow risks were reported to the Committee and included; admission avoidance through an enhanced Frailty Service, the provision of additional capacity, the cancellation of routine operations and the possibility of opening community EMI beds commissioned by CCG s and the local authority. Again current pressures mitigated against any change to the risk score of 20. In relation to the risks posed through medical outliers and patients in non-designated bed areas, the Committee was briefed on the additional capacity which had been opened up and the use of social media by Trust doctors advising patients to contact their GP if possible before contemplating presenting at a hospital. There was no recommended change to the risk score of 20. The Committee were briefed on the potential risk relating to loss of electrical supply to LGI and potential to exceed supply capability of the main system feeding this site. This related to a delay in the implementation of the construction programme set by the contractor, which had required the LGI site to remain on the old incoming electrical supply for longer than planned. MT advised the committee that two temporary emergency generators had been established which would ensure that there was no loss of power to critical patient areas. MT advised the committee that the LGI will switch over to the new incoming electrical supply in February/ March The risk therefore related to this short period of time. The committee considered the risk and were assured by the mitigating actions that had been put in place and the impact that this would have on reducing the likelihood of power failure. This would continue to be overseen by the estates team. 2. Background See previous reports to the Board of Directors. 3. Financial Implications and See specific risks for details (where applicable). 3

4 Agenda Item Communication and Involvement The Corporate Register is made available for review executive directors, corporate teams and CSUs at the monthly Management Committee. 5. Equality Analysis No adverse implications identified under equality and diversity legislation. 6. Publication Under Freedom of Information Act This paper is made available under the Freedom of Information Act Recommendations Members of the Trust Board are invited to: consider, challenge and confirm the correct strategy has been adopted to keep potential significant risk under prudent control consider and approve the changes to significant risks following the meeting of the Management Committee; and advise on any further risk treatment required. 8. Supporting Information Corporate Register - Appendix A. Craig Brigg Director of Quality January

5 Agenda Item 11 Appendix A CORPORATE RISK REGISTER JANUARY

6 Summary Corporate Register January 2018 Agenda Item 11 No. Nature of utive Lead Current Score Last Reviewed By Safety and Quality CRR 1 Inadequate nurse staffing levels Chief Nurse/Deputy CEO 15 Apr 16, Mar 17, Dec17, Jan 18 CRR 2 Exposure to Healthcare Associated Infection- C.difficile and MRSA Chief Medical Officer 15 Jan 16, Dec 16, Sept 17 CRR 33 Violence due to organic, mental health or behavioural reasons Chief Nurse/Deputy CEO 16 Aug 15, Nov 15 Apr 16, Jul 17 CRR 36 Inability to deliver a cardiac surgery service Chief Nurse/Deputy CEO 16 Jul 16, Feb 17, Dec 17 CRR 38 Excessive stays in the Emergency Department for patients with Mental Health conditions Chief Nurse/Deputy CEO 16 Dec 16, Jul 17, Dec 18 Financial CRR 9 Failure to deliver the financial plan (aggregate effect of income volatility, CIP shortfall and cost pressures Director of Finance 20 Sept 15,May 16 Sept 16, Jan 17, Jul 17, Aug 17 CRR 6 Unserviceable critical I/T infrastructure and resilience Chief Medical Officer 20 Dec 15, Jan 17 CRR 39 Loss of data or system outage as a result of a cyber attack Chief Medical Officer 16 Jul 2017 People CRR18 Reducing supply of doctors in training Chief Medical Officer 16 Jul 14,Oct 15 Nov 15,Aug 16, May 17 Performance and Regulation CRR 12 Failure to achieve Emergency Care Standard Chief Nurse/Deputy CEO 20 Nov 16, Nov 17, Jan 18 CRR week RTT target non-compliance Chief Nurse/Deputy CEO 20 Feb 15, Aug 15 Jun 16, Apr 17 CRR day cancer target Chief Nurse/Deputy CEO 20 Feb 15, Sept 15, Mar 17 CRR 22 Patients waiting longer than 6 weeks following referral for diagnostic tests Chief Nurse/Deputy CEO 15 Nov 14, Aug 16, May 17, Jun 17 CRR 23 Failure to achieve 28 day cancelled operations target Chief Nurse/Deputy CEO 16 Nov 16 CRR 31 Patient flow and capacity for emergency admissions (health economy) Chief Nurse/Deputy CEO 20 Feb 16, May 16, Dec 16, Jun 17, Nov 17, Jan 18 CRR 32 Unsustainable levels of medical outliers Chief Nurse/Deputy CEO 20 Feb 16, Jul 16, Apr 17, Jun 17, Sept 17, Nov 17, Jan 18 CRR 34 Corroded heating pipes in Clarendon Wing, LGI - potential disruption to services Director of Strategy and Planning 16 Jun 16, Apr 17 CRR 35 Power failure/lack of IPS/UPS resilience due to electrical infrastructure Director of Strategy and Planning 16 Dec 15, Jun 16, Nov 16, Oct 17 Symbols used in this report Inherent and Unmitigated Score Residual Score (Current Exposure) Target / Appetite Threshold 6

7 Agenda Item 11 NATURE OF EXPOSURE S=5 CRR1: Inadequate Nurse Staffing Levels L=3 Potential Insufficient nurse staffing levels. Caused by inability to recruit to registered nurse vacancies, (particularly in the Emergency and Specialty Medicine, Cardio-respiratory (CSU current risk score 9), Trauma and Related Services and Neurosciences CSU s) inefficient staff deployment through rosters. May result in an inadequate patient experience; a failure to protect patients or staff from serious harm (including death); loss of stakeholder confidence; and/or a material breach of CQC conditions of registration. Suzanne Hinchliffe Treatment Controls Roster management Actions to be taken when the numbers of nurses or midwives per shift falls short of the agreed roster template - Guidance- updated November 2017 Annual nurse recruitment plan in place Use of temporary workforce (bank and agency) Review of skill mix including new roles for Advanced Practitioner and Nursing Apprentice from January 2017 Additional RN school from January 2017 Gaps in controls Budget and roster templates do not always align Lack of performance management regarding sign off of rosters Availability of registered nurses nationally Timeliness of supply related to new roles following skill mix review Work on going between Corporate Nursing and CSU s to update their annual budget establishment Consideration of global recruitment- Paper to Team Dec 17 Increase in student nurse preregistration numbers Leeds wide integrated nursing group in place from January 2017 reviewing opportunities for integrated education and training, practice and deployment Leeds Wide Group and LTHT consulting on total rewards package of recruitment incentives Establishment of Local Academic Health Partnership (LAHP) Nurse Planning Group from Nov 17 to ensure strategic approach to maximising recruitment of students Areas of high risk in relation to staffing are monitored and supported Sanctioned payment above agency cap Additional RN apprentice cohort from 2018 Consideration of staff incentives to provide additional cover Clinical Practice Review Frequency Monthly at 7

8 Agenda Item 11 NATURE OF EXPOSURE S=5 CRR2: Exposure to HCAI C. difficile & MRSA Potential Effective management systems are not in place or sufficient to protect people from the risk of hospital acquired C. difficile or MRSA. Caused by insufficient compliance with infection prevention procedures, including hand hygiene, decontamination, environmental cleaning and insufficient training May result in serious harm or death to a patient, prolonged LOS, unsatisfactory patient experience; significant financial loss; loss of stakeholder confidence; and/or a material breach of CQC conditions of registration. Yvette Oade Treatment L=3 Assessment Assessment; Patient level assessment of risk on admission/arrival /transfer(filed in patient care record) IPC/Microbiology risk assessment completed electronically in PPM+ Training, Policies and Guidelines Mandatory Infection Prevention and Control training to all staff, with an over-arching Infection Prevention and Control policy and a suite of Guidelines and SOP s. Environmental Controls Environmental decontamination programme and standards, segregation and safe disposal of waste process, programme of water safety and IPC design incorporated into refurbishments and new builds Antimicrobial Stewardship Policies and Standards, City wide Group, Ward rounds and day 3 IV antimicrobial review Detection Monthly ward health check Twice yearly MRSA screening and IV device management audit Surveillance through Catheter related blood stream infection in critical care and paediatric haematology, alert organism, surgical site and ward based Recovery and lessons learned Management of outbreak guidance - ward closures, Outbreak Control Group meetings and citywide response Incident investigation with city wide involvement if required to identify lessons learned for implementation IPC alert mechanism to be incorporated into electronic patient record PPM+ (March 2018) Implementation of the ACED (Apyrexial, clinically improving, eating and not deep seated infection) tool to support IV to oral switch will be embedded across the Trust by Dec 2017 IA new national ambition to reduce healthcare Gram - negative blood stream infection by 50% by March 2021 across the whole health and social care sector has been launched. The development of a HCAI Faculty and Collaborative, utilising a quality improvement approach in 10 wards will be in place by Dec 2017 Clinical practice Monthly at 8

9 NATURE OF EXPOSURE CRR06: Unserviceable critical IT infrastructure and resilience. Potential The identified most critical IT systems and access to archived medical information may fail without warning, caused by critical systems being held on old platforms and insufficient data storage, system outage or damage, environmental factors, unauthorised access or failed backup arrangements. This may result in errors or delays in diagnoses, a need to repeat tests, invoice failures, reporting failures, and/or unsatisfactory patient experience. Yvette Oade Treatment S=5 Agenda Item 11 L=4 Access to server rooms and servers is restricted to authorised personnel only and strictly controlled to eliminate risk of contamination, damage, misuse or sabotage Control of computer room environment (cooling, security, UPS backup, fire prevention Back up computer rooms with sufficient redundancy to operate a full service in the event of failure of 2 out of 3 rooms Routine scheduled maintenance of servers in accordance with manufacturers specifications and relevant guidelines/alerts All computer rooms occupied daily to verify the operating environment Computer room temperatures are monitored and will alarm if control parameters breached Fire detection equipment in situ in main computer rooms Nagios System alerts are generated in the event of failure Critical IT systems on the old platform are being migrated to new IT platform to reduce exposure and maintain resilience Optimised power, performance and stability of old IT platform following migration of workload to new platform. Expansion of new platform has provided additional stability Out of hours alert notices are escalated to IT personnel or on-call team for immediate action and Senior Informatics Management notified Gaps in Control Issues highlighted by the Telepath outage in 2016 Trust reviewing capital requirements and producing Strategic Outline Case (SOC) to support I/T Infrastructure, Assessment Task and Finish Group established in January A complete risk assessment of all key critical systems is being undertaken to assess assurance levels July 2017 Implementation of the recommendations from the internal and external reviews carried out following the Telepath system outage. January to July 2017 Mersey Internal Audit Agency has carried out a system resilience review of cyber security. Recommendations to be considered by the utive Team for implementation. May 2017 IT Assessment Review Frequency Monthly at 9

10 NATURE OF EXPOSURE CRR9: Failure to deliver the financial plan for 2017/18 (aggregate effect of income volatility, Waste Reduction Programme shortfall and cost pressures) Potential There is a risk that the Trust does not achieve its financial targets in 2017/18 Due to the inability to deliver the Waste Reduction Programme and planned activity levels and continued expenditure pressures May result in the possible loss of Sustainability and Transformation funding from the DH, the Trust entering special administration and extreme external scrutiny Simon Worthingto n Treatment S=5 Agenda Item 11 L=4 Board owned financial plans. Establishment of realistic CSU budgets and plans. Finance supports the process and works with budget holders to ensure ownership. CSU s requested not to commit expenditure for non-essential items Monthly board/budget reporting and outturn forecasts Monthly Integrated Accountability meetings with CSU s and Assistant Director of Planning Negotiation with NHS improvement on surplus or deficit Maintaining good relationships with NHS Improvement and Commissioners Targeted patient level costing reviews Monitoring activity on a weekly basis to maximise income Robustly verify data completeness, accuracy and income coding to enhance income position Review of SFI s to strengthen core financial governance (March 2017) CSU s requested to increase the value of their current Waste Reduction Programme delivery (e.g. by removing vacant posts rather than offering them as non-recurrent savings) Integrated Accountability Framework - Finance and Financial Improvement Plan in place from July 2017 Gaps in Control CSU s have identified limited available time and insufficient support from finance, information, change management and project management to deliver Waste Reduction Programmes Waste Reduction Programmes not fully linked to Leeds Improvement Method CSU s experience difficulty delivering savings from cross cutting initiatives Joint cost based review with Commissioners to be concluded in 2017/18 Implementation of the Leeds Improvement Method - Rapid Improvement Workshop outcomes, during 2017/18 Ensure CSU s make use of the recommendations from the Lord Carter report on Expenditure in the NHGS - The model hospital. Reporting during 2017/18 on progress to Finance and Performance Committee and to the DH Establish exactly what corporate support individual CSU s need to deliver their Waste Reduction Programmes June 2017 Establish stronger links between the Leeds Improvement Methodology and the Waste Reduction Programmes during 2017/18 utive Directors have been identified to sponsor CSU cross cutting schemes (Theatres and Productivity/Cancer MDT s/planned Care and Outpatients/Paperless 2020) during 2017/18 Complete the NHSI baseline assessment for financial governance arrangements August 2017 Internal audit to carry out a piece of work into the processes for identifying waste reduction Assessment Monthly at 10

11 Agenda Item 11 NATURE OF EXPOSURE CRR12: Emergency Care Standard noncompliance Potential Failure to achieve the maximum waiting time of four hours from arrival to admission, transfer or discharge (95% threshold). Caused by an increase in demand and/ or inability to discharge, insufficient social care provision, inadequate patient flow, insufficient staffing levels, delayed transfers of care and repatriation delays. This may contribute to a poor patient experience or potential fatality, deterioration in performance across LTHT s access standards, multiple cancellations and rework as well as affecting LTHTs overall governance rating. Suzanne Hinchliffe S=4 L=5 Treatment CSM status reports Bronze, silver and command escalation process Capacity plan and escalation process Daily monitoring report - 4 hour emergency care performance A dedicated non-elective dashboard to help focus attention on internal performance areas which support service/standard delivery Weekly report and escalation of repatriation delays to acute Trusts across West Yorkshire Weekly review including CMO and CNO - all potential serious incidents and harm caused by long delays in ED, to identify cause and learning to be shared Focus on ambulatory care. Reduced admissions via A/E and CDU and reduced length of stay for non-electives Patient streaming in place to most appropriate route - GP, assessment, minor injuries, JAMA etc. to maintain non-admitted performance Board to Board meetings with city partners Deployment of doctors from other clinical areas at times of extreme demand Internal flow support plans being developed in CSU s Discharges by 12 mid-day Use of discharge lounge Critical care step down in 4 and 24 hours Output report from Perfect Week (w/c 2 Oct 2017) and actions to be agreed internally and externally Amendment to ECS performance inclusions Gold table top exercise 20 October 2017 Performance Management Review Frequency Monthly at 11

12 Agenda Item 11 NATURE OF EXPOSURE S=5 CRR13: 18-week RTT target non-compliance L=4 Potential Failure to achieve the revised referral to treatment time reporting standards at specialty level with effect from March 2016 (92% of patients waiting on an incomplete pathway less than 18 weeks). Caused by demand exceeding planned levels of activity, insufficient capacity at specialty level In key areas and impact of acute flows on elective capacity May result in poor patient experience, poor quality care, deterioration in LTHT s governance rating, increased external scrutiny and adverse financial position through high cost capacity and/or breach sanctions Suzanne Hinchliffe Treatment Maximising the use of elective capacity and flow due to non-elective impact through: - Focus on reducing all 1st Outpatient waits over 18 weeks to a wait time that would support 18 week RTT delivery for all patients - Daily Bed management / operational processes to optimise bed availability and elective surgical flow - Opening of Bilberry, Heather and Chapel Allerton beds for TRS use to allow some surgical ring fencing at each site to mitigate against impact of non-elective pressures - Theatres Programme Board focussed on maximising utilisation of inpatient and day case theatre capacity - Use of independent sector capacity and additional weekend lists/clinics - Formal escalation of constraints to Commissioners re; paediatrics, oral surgery and spines, with support to manage demand from primary care and identify alternative choice for patients and/ or alternative surgical capacity outside LTHT. - Implementation of revised referral management arrangements in Oral Surgery and Pain - Access policy and procedures are in place and up to date with on-going review to ensure policy is applied consistently at CSU level Routine Oversight - Suite of daily waiting time reports and tools showing key risks - CSU s review position weekly through standard access meeting agenda - Position monitored corporately as part of weekly utive Directors performance briefing and weekly Deputy CEO meeting Any area with an over 18 week problem as recovery plan monitored through; - All CSU s and specialties with significant backlogs of patients > 18 weeks have developed OP focussed recovery plans. - Non-compliant specialty teams review progress against recovery plans with Deputy CEO team at least monthly although more frequently by exception - Bi-monthly review of individual consultant booking order and waiting list management practice Contingency/recovery controls - Escalation system to relevant Assistant Directors of Operations, Medical Director for Operations and/or Deputy CEO if agreed progress not achieved. - Enactment of Special Measures - intensive monitoring and support in the event of continued performance risk Rollout of Outpatient Programme board projects in 2017/18 that support better use of OP capacity: - Full and Partial booking - Clinic template management - Use of the utilisation tool - E referral and E triage Renewed focus on day case throughput during Q1 2017/18 Just one more theatre and OP clinic initiative in Q1 / year of improvement to support increased throughput Explore opportunities for successful Wharfedale pilot in 2017/18 to support RTT position Continued focus on plans to reduced 1st OP waits over 18 weeks Continued use of Harrogate and IS surgical capacity where appropriate. Performance Management Review Frequency Monthly at 12

13 Agenda Item 11 NATURE OF EXPOSURE S=5 CRR15: 62-Day Cancer Target Potential Treatment Effective management systems are not in place or sufficiently resilient to ensure treatment within 62 days following receipt of urgent referral by a GP for suspected cancer. Caused by late referral from other providers, ineffective access policies or waiting list management, insufficient critical care capacity, insufficient control over pathways of care, higher than expected urgent care demand, or insufficient theatre utilisation. May result in poor quality care, unsatisfactory patient experience, unacceptable delays for patients, and/or deterioration in LTHT s governance rating. Suzanne Hinchliffe L=4 Access policy and procedures, waiting list management and referral procedures on Patient Pathway Manager Daily procedure to govern cancellations to ensure clinical priority Application of cancer waiting time guidance MDT process patient oversight weekly Developed Patient Pathway Manager (PPM) system function to support reporting of internal and pre-day 37 performance Regular escalation to referring organisations for patients referred after day 38 Any team with an over 62 day performance issue - recovery plan monitored through; Weekly performance sent to CSU senior leadership and relevant corporate leads Weekly 1st Line Performance Trigger Meetings Performance reviewed by each CSU as part of their weekly access meeting (supported by a member of the performance team) Root Cause Analysis for breaches Monitored via Integrated Quality & Performance Report All CSU S have established target waiting times for key elements of pathways and are provided with data to monitor position weekly CSU s review position weekly through standard access meeting agenda Non-compliant specialty teams review progress against recovery plans with deputy CEO team at least monthly although more frequently by exception Position monitored corporately as part of weekly utive Directors performance briefing, fortnightly activity review and weekly deputy CEO m Discretionary use of Bank/Agency/Locum to address shortfalls in staffing levels Escalation system to Medical Director for Operations, Associate Directors of Operations and Deputy CEO Enactment of Special Measures intensive monitoring and support in the event of significant performance dip Ongoing work with external partners (referring Trusts, Lead Clinicians) in Cancer Network to reduce the impact of late referrals to patient care and achieve a shared NHS Constitutional responsibility Further Actions Planned Focus on internal pathways and hold a series of pathway specific events with MDT s to issue the challenge to get performance back to 90% internally. Support the IPT work across West Yorkshire to implement a clinically driven solution through. Support the West Yorkshire discussions on agreeing to implement the Breach allocation national guidance from April

14 Agenda Item 11 NATURE OF EXPOSURE S=4 CRR18: Reducing supply of doctors in training Potential There is a risk that medical staffing may not meet the safest possible levels Caused by reductions in trainee placements and funding which lead to noncomplaint or non-feasible rotas and a failure to ameliorate the reduction in junior doctors entering the workforce May result in severe pressure to deliver safe and effective clinical services; delays in responding to the deteriorating patient; and/or poor experience in training for junior doctors resulting in a further reduction in posts. Yvette Oade Treatment L=4 Workforce planning The Trust lobbies the Deanery and Health Education England to secure sufficient trainee placements to meet expected service demands Compliant duty rotas and shift patterns Extending and developing roles of Nursing and AHP practitioners and Physicians Associates Improving the trainee experience as evidenced by the GMC trainee survey 2016 DatixWeb Attendance Management Use of locum doctors and breach of agency capping rules in extreme circumstances Merging of rotas leading to less specialist input Consultant delivered care (consultants in place of trainees) Diversification of the workforce MTI schemes (overseas recruitment) Empowering junior doctors (Junior Doctor Body) Guardians of safe working in place from July 2016 Continuous communication updates using contemporary social media (what s app/twitter) impressing the Trust s values and reporting good news stories from May 2016 Review and develop workforce plans alongside activity forecasts in order to anticipate future workforce requirements and any adjustments required to adapt to reducing numbers of junior doctors and/or retirements (Chief Medical Officer & Director of Human Resources) Implementation of the new junior doctor contract in a sensitive way alongside improving clinical processes through the Lord Carter work and the Leeds Improvement Method (Virginia Mason) work Assessment Review Frequency Monthly at 14

15 Agenda Item 11 NATURE OF EXPOSURE CRR22: Patients waiting longer than 6 weeks following referral for diagnostic tests Potential Patients waiting longer than 6 weeks following referral for diagnostic tests (in particular Ultrasound, MRI and Endoscopy) Caused by either insufficient capacity at specialty level, demand exceeding planned levels of activity, insufficient control over pathways of care or ineffective waiting list management. May result in unacceptable delays for patients, and/or deterioration in LTHT s governance rating as well as poor quality care, an unsatisfactory patient experience and possible failure to retain JAG accreditation in Endoscopy Suzanne Hinchliffe Treatment S=5 L=3 Access policy and procedures in place. Waiting List management processes including acceptance criteria and validation. Management of Annual Leave Capacity & Demand modelling Effective KPIs in place to monitor performance Selective but limited use of the independent sector and in-reach services where required JAG accreditation Use of Wharfedale Endoscopy service with a partner Trust E-booking in place from July 2016 Formal capacity review with CCG s (capacity 9,000, demand 17,000) completed Q2 2016/17 Weekly performance update to CSU leadership and relevant corporate leads Weekly access meeting held by every CSU with escalation to DCE where required. Routine monitoring of referral demand. Root Cause Analysis for breaches. Monitoring at Board level via Integrated Quality & Performance Report Discretionary use of bank/agency/locum staff to address shortfalls in capacity Discretionary use of additional independent sector capacity to address shortfalls. Performed against this national standard since Sept 2016 but monitoring continues s with MRI, Ultrasound and Endoscopy continue to be managed/mitigated in line with rising demand profiles Assessment Review Frequency Monthly at 15

16 NATURE OF EXPOSURE CRR23: Failure to achieve 28 days cancelled operations target Potential There is a risk that the Trust does not achieve the 28 day cancelled operations target Due to acute activity pressures, critical care capacity, availability of theatre time, patient flow and the impact on elective bed availability Resulting in delays to patient treatment and possible harm and financial penalties Suzanne Hinchliffe Treatment S=4 Agenda Item 11 L=4 Quarterly Root Cause Analysis undertaken to ensure underlying causes are addressed where possible Core process to for notification of cancellation and re-booking procedure in place Weekly meeting to identify available theatre capacity for additional sessions, manage risks and review cancellations and discharge and theatres KPI s Daily meeting to allocate demand for critical care capacity Monitoring at Board level via Integrated Quality and Performance Report Discretionary use of bank/agency/locum staff to address shortfalls in capacity Maximisation of day case capacity and identification of patients who would normally be treated as inpatients. CSU/Senior Ops oversight and Trust internal accountability process and escalation Continue to balance daily pressures of delivering elective care for patients in constrained bed/flow conditions 16

17 NATURE OF EXPOSURE CRR31: Insufficient capacity and patient flow across the health care system for emergency admissions Potential There is a risk of insufficient capacity in the Trust and across the health care system for emergency admissions due to demand for inpatient capacity out-stripping capacity, greater numbers of older patients with 3 or more co-morbidities and more patients requiring on-going or social care input This may result in (i) (ii) (iii) (iv) (v) (vi) (vii) High numbers of patients in the bed base who are medically fit for discharge as services not available in the community and social care Failure to deliver 4 hr emergency care standard Elective admission cancellations and cancelled operations Failure to transfer patients out of critical care (step down)and provide capacity for patients who require high dependency or critical care Failure to respond to peaks in emergency care demand Poor patient experience, high number of outliers and potential harm to patients Poor staff morale and well-being at work Suzanne Hinchliffe Treatment S=5 Agenda Item 11 L=4 Internal Pathways for rapid referral to specialty services Clinical Site Managers - out of hours support and co-ordination Processes for collation and capture of Delayed Transfers of Care Board rounds in place on every ward linked to GP surgery s; EDD Escalation process and full capacity plans by CSU - bronze, silver and gold command; DOP, on-call rota assessment and escalation procedure in place for patients waiting on a trolley Monitoring trolley waits between 8 and 12 hours and development of a risk assessment and escalation procedure including RCA review for addressing bed pressure issues Cancellation of routine operations and outpatients appointments and relaxing the directive on mixed sex wards, in times of extreme demand External Regional escalation process and system wide REAP agreement Development of a Trusted Assessor model to support discharge processes and reduce delays across the health system System Resilience Group and plan (with partner organisations System-wide Early Discharge Assessment Team (MDT - OT, physio, social worker, geriatrician, discharge nurse) Admission avoidance schemes including expansion of the Frailty Service Additional capacity in partnership with Villa care to provide a ward on Beckett Wing in times of extreme demand Other See Treatment for Emergency Care Standard risk CRR12 Development of MoFD patient data Tender for the provision of Community Intermediate Care concluded Sept 2017, outcome for LTHT to be assessed Winter Plan 2017/18 Assessment Decision Making Tool developed for in extremis decision support Perfect Week (Oct 2017) outcome CSU s Assessment Review Frequency Monthly at 17

18 NATURE OF EXPOSURE CRR32: Unsustainable levels of medical outliers and patients waiting in non-designated areas Potential Current high volume of medical outliers and patients in non-designated bed areas. Caused by demand outstripping capacity and reduced outflow, resulting in reduced quality of care, increased out of hours transfers, patients waiting on trolleys and reduced patient experience Impact on non-delivery of the Emergency Care Standard and hospital surgery cancelations which could cause potential harm to patients. (Cross Reference Acute Medicine 9070) Suzanne Hinchliffe Treatment S=4 Agenda Item 11 L=5 Programme of work on patient flows agreed, led by ADO with supporting team and reporting through the Unplanned Care Improvement Programme. Increased assessment services and ambulatory care capacity colocated within ED footprint to support increased ambulatory care pathways, use of virtual ward and hot clinics to reduce admissions and therefore medical outliers. Resilience plan in the CSU aligned to REAP/OPEL levels across Leeds Health System Surge actions in place including additional beds Agreed approach for the management of outliers by consultants and relevant specialties including timeliness of review, escalation, and which team covers what ward Recruit junior doctors to cover outliers to increase cover at the weekends Regularly review trajectories relating to delayed transfers of care with partner organisations Two wards at Wharfedale Hospital (56 beds) to remain in place to help alleviate the acute pressure on the main sites Support from Corporate Nursing Team for problem areas See Treatment for Emergency Care Standard risk CRR12 Social Media messages from Trust Doctors to patients encouraging them to seek support from their GP initially LIM (Virginia Mason) Value Stream 5 - Programme looking at DOH 7 day standards in particular consultant review within 14-hours of acute admission. Perfect Week (Oct 2017) outcome Winter Plan 2017/18 Assessment Decision Making Tool developed for in extremis decision support CSU Assessment Review Frequency Monthly at 18

19 NATURE OF EXPOSURE S=4 CRR33: Violence due to organic, mental health or behavioural reasons VERY LOW RISK LOW RISK MEDIUM RISK HIGH RISK SIGNIFICANT RISK Agenda Item 11 L=4 Potential There is a risk of violence towards patients, visitors and staff due to organic, mental health or other behavioural reasons, resulting in the potential for a fatality, serious harm or litigation against the Trust Suzanne Hinchliffe Treatment Emergency Specialty Medicine CSU Procedure in place for the management of violence in clinical areas Training provided for staff on the management of violence in high risk areas, including acute medicine, admission areas and urgent care Procedure for obtaining urgent psychiatric assessments 24/7 support from Acute Liaison Psychiatry Service (ALPS) and escalation; links to Crisis Assessment Service (Becklin Centre) Out of hours on-call psychiatry staff located at St James s hospital Daily nurse staffing reviews, support from Matron and CSM Collaborative working with partners in health and social care CROMA risk assessment tool implemented, which determines when external expertise is required CROMA vigilant staff provide 1:1 supervision Monitoring of incidents (datix-web) Potential Serious Incident notifications Weekly review meeting with Chief Nurse/Chief Medical Officer Clinical Site Manager reports Staff survey results Escalation process for urgent psychiatric review Independent investigation and review being undertaken to share learning and inform further improvements KPI in place for referral and assessment within 3 hours agreed with CCG s Strategic partnership group established with LYPFT to oversee implementation and governance of the Mental Health Crisis Care Concordat and support staff working with patients at risk of violent behaviour Clinical Support staff appointed to wards to assist in the care of patients at risk of violent behaviour Personal safety training Shorter stays in ED to reduce exposure Symphony system flags identify known aggressors Links with security staff and police to respond ALP s team based in ED giving quicker psychiatric assessment Security routes changed to give greater presence in ED Trust wide Established a strategic partnership with LYPFT and a team of MH nurses to provide a 24 hour inreach patient assessment service to nursing teams SLA with LYPFT in place for Liaison Psychiatry and a range of DoL s policies and procedures in place Security patrols over all zones at StJUH and LGI increased Increased WY Police profile in ED s and office now accessible by Trust Security staff Remote lockdown capability at both LGI and StJUH in place CROMA contract review group established - new Assessment Tool in place from April Usage of CROMA has reduced and can only be engaged through CARPS facilities booking system Increased reporting to better understand the extent and type of incident and the balance of usage between CROMA and specialist nurses Emergency Specialty Medicine Develop care plans in conjunction with LYPFT - Respond to the outcomes of reports relating to SI s (J19 - Feb/Mar 2015 and suicide - Mar 2016) Security cameras being considered for each of the ED s Trust wide Reviewing MH/MHA/Deprivations of Liberty Team (DoL s) requirements and developing a case for investment in the team with expert resources following a change in legislation. Approval to create a new multi-skilled First Responder role for more vulnerable areas of the Trust. HR process/consultation in place To be advertised in July 2017 Encourage more comprehensive reporting of incidents by wider promotion of actions taken in response to untoward events Each CSU is producing a Training Needs Assessment for conflict resolution training by April 2018 Acute Medicine and Urgent Care CSU s Assessment Review Frequency Monthly at 19

20 NATURE OF EXPOSURE CRR34: Corroded heating pipes, Clarendon Wing LGI - potential risk of disruption to clinical services Potential There is a risk of disruption to clinical services on Clarendon Wing, LGI, due to corroded heating pipes resulting in delayed treatment and a poor patient experience Simon Neville Treatment S=4 Agenda Item 11 L=4 A programme for renewal of distribution pipe work commenced in With expenditure of 80,000 replacing infrastructure above neo-natal. The Trust spent 350,000 from capital resources in 2016/17 on a number of high risk areas including Neonatal Services, I/T hubs and where leaks had occurred in the previous year. To minimise the impact when leaks occur, the response receives a high priority with repairs undertaken and services restored as quickly as possible. The Trust has commissioned a report from DSSR, Mechanical Engineering Consultants on the project who have recommended a systematic quadrant by quadrant approach to repairs. The initial view is that the 350,000 annual capital allocation for this work would be insufficient for this type of approach. A further risk assessment is to be carried out Estates and Facilities Monthly at 20

21 NATURE OF EXPOSURE CRR 35: Power Failure due to Electrical Infrastructure/lack of IPS/UPS resilience Potential There is a risk of power failure at a Trust site (ward or clinical area) Due to failure to comply with HTM caused by outdated electrical infrastructure and the absence of a complete IPS/UPS resilience May result in a poor patient experience; a failure to protect patients or staff from serious harm or fatality; loss of stakeholder confidence; and/or a material breach of CQC conditions of registration or HSE prosecution Simon Neville Treatment S=4 Agenda Item 11 L=4 Emergency generator power provision across all sites. The sites typically benefit from n+1 power resilience in terms of emergency generator power provision across all sites Independent battery back-up in clinical areas and use of battery operated equipment Estates staff escalate high level concerns/incidents out-of-hours to Clinical Site Manager/Oncall Management Team as per the Estates Major Incident Handbook updated for emergency plans (June 2017) Comprehensive review across the Trust completed which documents precise location of all electrical equipment Business Continuity Plans reviewed and updated with every CSU (Sept 2016) and a comprehensive review of electrical resilience has been compiled and is located in both Gold Command Rooms Increased interleaving of circuits on Clarendon Wing i.e. there is now more flexibility as to the where power to wards/depts. Is directed from, increasing resilience (Sept 2016) Full emergency power resilience to whole of LGI and phase 3 emergency generator work completed. Additional switching in place (Nov 2016) Golden Boxes have been identified and returned to Medical Physics and Theatres and Anaesthetics CSU advised accordingly The electrical autonomy on J54 Critical Care has been increased from 10 minutes to 1 hour from June 2017 Infrastructure to support Geoffrey Giles theatre and J54 (ICU) has been installed. This will include enabling works to 2 theatres at StJUH allowing Ophthalmology to move to one of those theatres and the current Ophthalmology theatre to be used for decant. Gap in Control: Awaiting capital resources for final connection Theatre review Programme - 1million a year built into capital programme from 2016 to 2031 Completion of the Geoffrey Giles Theatre capital scheme when resources are available Estates and facilities Review Frequency Monthly at 21

22 NATURE OF EXPOSURE CRR 36: Inability to deliver a cardiac surgery service Potential There is a risk that the CSU can no longer provide an adult cardiac surgery service sufficient to meet Commissioner requirements or the needs of the Cardiology and Cardiology Intervention Services Due to; lack of dedicated theatre capacity, insufficient cardiac theatre staff (nursing/odp), critical care capacity/flow, and the continued necessity to undertake all the least complex cases in the private sector (Nuffield). Resulting in; damaged reputation, poor patient experience and outcome (e.g. cancelled operations), a decreasing range of cardiac surgery available in LGI, only the most complex electives and all acute cases are performed at LGI (suboptimal case mix), severely restricted service development in Cardiac Surgery and interdependent services such as Cardiology (including development of clinical expertise). Suzanne Hinchliffe S=4 Treatment (Controls) Agenda Item 11 L=4 Even out demand for critical care across the working week to enable improved access. Clear clinical pathways across CSU's and monitored compliance through audit. Agree 2 first cases to start at 8am prior crit care bed confirmation. CSU participating in TPOT and 642 Monday meetings with other LGI Surgical CSU's to identify and reallocate theatre capacity and improve service delivery. HoN working with HoN for Critical Care to develop High Observation Beds (HOB's) on ward L16. General manager in place to review pathway, make recommendations and implement changes. Clear escalation processes to line manager prior any cancellation of patients. SOP for HObs beds approved. Additional Staff being recruited. Planned start from October 2016 Action plan developed to be agreed by stakeholder CSUs. Key elements; Waiting list management, recruitment and retention, service specific related actions, cardiac surgery pathway review, communications. Clinical practice Review Frequency Monthly at 22

23 Agenda Item 11 NATURE OF EXPOSURE CRR 38: Excessive stays in the Emergency Department for patients with Mental Health conditions Potential There is a risk that patients with mental health issues who present to the ED may spend excessive periods of time in the ED due to lack of suitable MH treatment options and time taken to access appropriate MH services, changes to the Mental Health Act 1983 (s135/136 MHA) through the Policing and Crime Act 2017 (place of safety), December 2017 resulting in a poor patient experience with potential impact on the patients long term condition Suzanne Hinchliffe Treatment S=4 L=4 Identification of high risk patients on assessment and move to Room 3 (distant from exits) Delivery of 1:1 care during patients stay in ED where demand allows although this impacts on care of other patients and performance of the department LYPFT encouraged to develop alternative arrangements for a more rapid review of mental health patients presenting to ED LYPFT to be asked to ensure that patients requiring mental health inpatient care are allocated appropriate beds quickly and that transport is provided within an hour Lockdown capability now possible at both LGI and SJUH. Identified local health based places of safety - S136 suite at Becklin Centre; ED department at SJUH (although not legally designated) CAMHS S136 procedure (flow chart) - Police to liaise with CAMHS or on-call consultant prior to S136 Inter-agency guidance - consultation with street triage team or defined professional prior to S136 Patient Information leaflet and rights of patients document Escalation procedure (S136) Multi-agency group meetings (monthly) - review use of S136, impact on capacity, flow, waiting times and emerging risks See also Controls for CRR 33 Mental Health Specials can be requested National CQUIN is focussing on reducing attendances to the ED. This is a partnership with LYPFT, YAS, Commissioners and local stakeholders Respond to the changes to the Mental Health Act 1983 (s135/136 MHA) through the Policing and Crime Act 2017 (place of safety), December 2017, working with multi-agency partners to agree plan to meet the potential demands for local health based places of safety- January Review local health based place of safety for people < 18 years - January 2018 assessment 23