Strategic Risk Report. 16 January 2014

Transcription

1 Strategic Report 16 January 2014

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 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. 2

3 Impact HARINGEY CCG STRATEGIC OBJECTIVES: Haringey CCG Register Strategic Heat Map Likelihood 3

4 Strategic Summary Haringey CCG Register Ref Systems and processes within Continuing Health Care (CHC) are not fit for purpose. Inability to implement health economy wide strategies across Haringey, NMH and Enfield CCG Failure to effectively manage the process for handling retrospective claims for care costs. Priority 4 of CCG failing to achieve its financial targets in 2013/ Key changes since last review No significant change since last review. No significant change since last review. No significant change since last review. The Specialised Commissioning has reduced from 7m to 2m. There has been a slight improvement in month in the UCLH forecast out-turn, with the prospect that a further 0.9m could be removed. 5 Failure to deliver the CCG's agreed QIPP plan. 9 No significant change since last review. 6 Failure of Commissioning Support Unit to deliver the Service Prospectus. No significant change since last review. 7 of the CCG being unable to fulfil its responsibilities to manage Healthcare Associated Infections (HCAIs) among the local population. 8 Financial uncertainty regarding specialist commissioning funding (13/14) Failure to deliver the agreed commissioning plan and achieve performance metrics The Head of Quality and Performance has now received handover on management of infection control and the Lead Nurse, Quality has been recruited and is in post. RISK NOW CLOSED. The CCG received 5m from NHS England as a result of the third budget adjustment, leaving a 2m gap. RISK NOW CLOSED. No significant change since last review. 10 Failure to fully integrate all elements of unscheduled care within Haringey. No significant change since last review. 11 CCG inability to achieve the Better Payment Practice Code. 4 No significant change since last review. The CCG in breach of data handing and personal confidential data in accordance with Information Governance requirements. 10 No significant change since last review.

5 Haringey CCG Register 13 Personal Confidential Data held on invoices for certain services may be placed on the organisations' invoices that are processed and in turn the ledger. 4 No significant change since last review that CCG will not be able to achieve planned efficiency savings relating to integrated care and invoice validation, due to the changed legal position concerning the CCG s and CSU s ability to process Personal Confidential Data. Alerts received in relation to standards of care in nursing / care homes and capacity issues at Borough level could lead to safety / safeguarding concerns for adult resident patients. Inability to determine quality within commissioned nursing homes in the borough of Haringey. 9 No significant change since last review. closed and incorporated into The Quality Matters in Care Homes programme has now commenced and the Quality Committee will receive bimonthly reports on progress. 17 With the strategic shift from secondary to primary and community care, there is a risk that we are moving from an environment where we have robust assurance processes on quality to one where we have less assurance. closed as superseded by Quality of activity information received from UCLH is such that the CCG is not able to use it to enable it to monitor performance against the contract. Failure to fully implement and integrate the BEH Clinical Strategy and to ensure that changes become business as usual as planned. The strategic shift from secondary to primary and community care could lead to reduced quality assurance. Full scope of the palliative care service cannot be delivered and service offered is restricted. 8 9 There has been a slight improvement in month in the UCLH forecast out-turn, with the prospect that a further 0.9m could be removed. The nature of the risk has been reformulated to reflect the current position and assurances have been updated. Quality Assurance Nurse is now in post and has begun to lead on the monitoring of HCAI. Arrangements are being made between providers for approval of a new Consultant post. 5

6 Haringey CCG Register Description Owner 1 1,2 Systems and processes within Continuing Health Care (CHC) are not fit for purpose. Owner Jill Shattock Director of Commissioning (Old 1) Audit Committee Reviews of on-going operational policies and improvements not carried out Lack of key staff / resources Lack of reporting and monitoring of performance Lack of governance and failure to comply with the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care November 20 (revised) Delivery of the CHC QIPP Patient experience I = 4 L = External support secured to provide external review and advice as to on-going operational issues policies and improvements, including Team roles and functions review, high cost placement efficiency review and policy updating. 2. Improvement of process for adding any care costs onto the system to ensure consistently tight controls on any new funding added to the system. 3. Existing database cleansing and updating. 1. Monthly Programme Management Board to oversee improvement Programme, chaired by Chief Officer. 2. Two weekly Project Group to support Programme Board, chaired by Director of Commissioning. 3. Training for Caretrack system taken place. I =3 L =2 6 Planned s: Updated systems and processes to be in place and operational. owner Jill Shattock Progress on Diagnostic phase now complete and the majority of recommendations have now been implemented. Team structure reviewed, team leader appointed and team transferred to line management by Quality and Integrated Governance directorate. The final 2 sections of the Terms of Reference of the eligibility decision-making panel (concerning section 117 cases and the updated operating policies) will be agreed by the end of January. Placement efficiency project progressing. The Internal Audit report (September 2013) provided reasonable assurance that the controls in place manage this risk are suitably designed, consistently applied and effective. is being taken to address the recommendations in the report. 6

7 Haringey CCG Register Description Owner 2 1,2,3 Inability to implement health economy wide strategies across Haringey CCG, Enfield CCG and provider organisations (NMUH, Whittington Health and BEHMHT Owner Jill Shattock - Director of Commissioning (Old 4) Failure to secure sufficient engagement and collaboration across the multiple organisations Failure to negotiate QIPP scheme requirements into contracts. Impact on the underlying run rate in 13/14 and beyond Patient experience Ineffective value for money initiatives L = Monthly Joint QIPP and Transformation Boards 2. Joint workstreams to progress transformation projects and pathways. 3.Clinical workshops in place as necessary. 4. Tri-Borough Commissioning forum in place for BEH MHT, attended by Director of Commissioning. 1.Minutes of monthly meetings. 2. Workstream papers 3. Evidence of clinical workshops 4. Minutes of forum meetings. L = 4 Planned s: Progress through QIPP and Transformation Boards. owner Jill Shattock/Sarah Price Ongoing Progress on Joint Groups now in place for three main Trusts NMUH, Whittington Health and BEH-MHT. Finance Committee 3 1 Failure to effectively manage the process associated with handling retrospective claims for care costs. Owner Jill Shattock - Director of Commissioning (Old 7) Audit Committee Lack of dedicated resource to review existing open claims Unknown monetary impact Financial impacts upon CCG budget for the future Reputational damage Increased legal costs I = 4 L = Additional capacity has been secured for reviews in CHC Team, including Nurse Assessor 2.Additional capacity has been secured for reviews in CHC Team, including Nurse Assessor 3.Regular reports to CCG GB with updates on progress. 1.Establishment of Team verified by HR 2.Director of Finance confirmed financial reserve. 3.CCG GB reports, detailing progress against outstanding actions and minutes of GB meetings. I = 4 L = 3 All reviews to be completed by and outcomes enacted. owner Jill Shattock, Director of Commissioning Regular reports from CHC Team Leader with updates on progress. 7

8 Haringey CCG Register Description Owner 4 1,3 of CCG failing to achieve its financial targets in 2013/14. (The CCG is currently forecasting a 7m yearend deficit. This is a direct result of the Specialised Commissioning identified in 8 below). Owner David Maloney - (Old 8) (Old NCL 783) Finance and Performance Committee Lack of adequate budgeting and financial planning Poor financial controls Breaches in procurement rules National/government targets and initiatives distract the CCG from delivery and draw on resources. Poorly constructed contractual agreements with service providers. Poor CSU financial administration. Extreme events exceeding expectations i.e. pandemic, weather. Substantial fraud or sustained fraudulent activity. Failure to develop and deliver Quality, Innovation, Productivity, Prevention (QIPP) schemes I = 4 L = Appropriate financial governance systems in place 2.Timely financial reports from CSU,CCG into Finance and Performance Committee and CCG Governing Body 3.CCG 13/14 Financial Plan agreed with NHS England 4.Improved financial reporting processes in place 1. Internal Audit reports produced by Internal Audit which cover both financial procedures within the CCG and the CSU. 2. Papers and minutes of Finance and Performance Committee and CCG Governing Body 3. NHS England confirmation of approval of 13/14 Financial Plan. 4. Ernst & Young undertaken work on improving processes within the CSU. I = 4 L = 4 16 Planned s: Obtain update from CSU for 13/14 SLAs, with particular regards to the SLA with UCLH and RFH. owner David Maloney, CFO Mid-November Progress on Heads of Terms signed by David Cryer on and then sent to UCLH for signature. The Specialised Commissioning financial risk has fallen from 7m to 2m as a result of funding received by the CCG in period 9. The UCLH forecast overspend at M8 was 4m. The forecast out-turn at M9 is 3.6m, a slight improvement in month. In addition, the CSU Director of Finance attended the Finance and Performance Committee meeting on and confirmed that potentially 0.9m could be removed from the forecast UCLH out-turn. Compensating service cuts may be required. Reputation damage. Potential intervention from the NHS England - removal of commissioning power from the CCG. CCG administration/takeover. 8

9 Haringey CCG Register Description Owner 5 1,2,3 Failure to deliver the CCG's agreed QIPP plan Owner David Maloney - (Old 10) Finance and Performance Committee Lack of up to date financial and performance data reviewed at key meetings Lack of key staff and resources Lack of a QIPP structure QIPP plans not supported by others CCG will not achieve future financial plans Negative perception amongst other commissioners and providers L = 4 1. Local QIPP delivery group to oversee the 13/14 QIPP plan. 2. NHS England Performance Review meetings take place on a regular basis. 3. Production of monthly budget statements and monthly QIPP performance reports. 4.Discussion with account managers regarding in-year SLA performance 5. Finance reports (including acute/non-acute SLA positions), scrutiny and review by CCG Finance and Performance Committee (monthly) and Governing Body (bimonthly). 6. Monthly report produced showing QIPP financial performance. 7. Recruitment of two permanent QIPP project managers. 1. Reports and minutes of QIPP Delivery Group and Finance and Performance Committee. 2. Minutes of monthly Performance Review meetings. 3. Recipients of monthly financial reporting. 4. QIPP Delivery Group receives regular reports setting out QIPP delivery. Where risks to delivery are highlighted, schemes are the focus of subsequent meetings. 5. Reports and minutes of Finance and Performance Committee and Governing Body meetings. 6. Internal Audit report to Audit Committee on QIPP project managers recruited and in post September L = 3 9 Planned s: 1. Interim QIPP Director undertaking due diligence to assess accuracy of QIPP reporting. owner David Maloney, CFO Implementation Owner: CSU End of October QIPP Delivery Group to receive regular updates from project leads specifically where projects have blockages or slippage. owner David Maloney, CFO Implementation Owner: All project leads Progress on Ongoing. 2. Regular updates taking place as appropriate. The CCG is still on target to achieve its QIPP plan as at M9. 9

10 Haringey CCG Register Description Owner 6 1 Failure of Commissioning Support Unit to deliver the Service Prospectus Owner Jill Shattock - (Old 11) Audit Committee Lack of understanding of requirements and CCG needs Lack of CSU capacity and capability Poor levels of resilience Lack of communications and monitoring of SLA CCG does not have timely, quality data that it use to make informed decisions. CCG cannot carry out all contracting requirements as lead commissioner. Creditors not paid in a timely manner. Negative stakeholder perception as a result of poor direct third party (CSU) interaction. I = 4 L = Regular meetings between the Commissioning Support Director and Chief Officer, Chief Finance Officer and Director of Commissioning 2. Signed and agreed SLA in place with clear product lines and KPIs, monthly review meetings in place. 3.Commissioning Support, finance, contracts and analytics teams on site and increased HR visibility, leading to improved working relationships. 1.Minutes of meetings. 2. Minutes of review meetings and report from Internal Audit to Audit Committee. 3. Minutes of review meetings and report from Internal Audit to Audit Committee as above. L = 4 Planned s: Ensure CSU delivers all aspects of service offer. Implement internal auditors recommendations by due dates. Review and update the Service Level Agreement between the CCG and CSU by both parties to supersede the previous SLA. This includes adding: The total SLA cost of services in the draft revised SLA allocated to the various service lines being provided by the CSU. Flexibility for removal of elements of the service being offered during the contract period, including the cost associated with the discontinued service. The process by which any risks impacting the CCG that emerge at the CSU in the process if discharging it duties to the CCHs are flagged up and Progress on Vacancy numbers reducing as staff are appointed. Key staff members regularly on site. Open communication. Draft SLA updated July 2013 and the additions to be included in next version of SLA currently being negotitated. Received CSU pricing proposal on 1 November Jointly negotiating the updated SLA with the CCGs across NCL. Planned completion by 31 Dec

11 Haringey CCG Register Description Owner Planned s: reported to the CCG. Provision allowing the CCG to cancel any elements of the services being provided if the CSU is not meeting its performance standard. Progress on The committee that discusses monthly performance of the CSU to report to a superior committee, such as the Finance and Performance Committee. owner Jill Shattock, Director of Commissioning ,2 of the CCG being unable to fulfil its responsibilities to manage Healthcare Associated Infections (HCAIs) among the local population Owner Jennie Williams Director of Quality and Integrated Governance Lack of a designated infection control resource Patient Experience Reputational damage Performance issues Intervention L = Director of Quality and Integrated Governance (DQIG) oversees the role and wherever necessary coordinate post-infection reviews (PIRs) in accordance with Dept of Health guidance (NHSCB Planning Guidance (2013). CCG Care Homes Nurse will contribute to PIRs if a case originates in a care home. 2. DQIG receiving Public Health England (PHE) automated alerts until 1.Both local acute trusts are satisfied that DQIG can be contacted promptly for all agreed cases 2. All alerts acted on in timely fashion. 3. DQIG has developed JD and Person Specification for Lead Nurse Quality. This post will provide I = 1 L = Head of Quality and Performance to receive handover on management of infection control as part of induction. Acute Trusts to be informed of first point of contact. (C) owner Jennie Williams Director of Quality and Integrated 1. This has now been completed. The risk is therefore CLOSED. 11

12 Haringey CCG Register Description Owner (Old 13) Quality Committee RISK CLOSED further notice. 3. Haringey CCG is recruiting a lead nurse for quality to lead on harm free care (including HCAI. 4. DQIG has access to specialist advice via NHS England (London) Infection Control lead support to Director of Public Health regarding arbitration cases. 4. DQIG continues to be in regular contact with NHSE lead for HCAI Planned s: Governance 21/8/13 2. Recruit to Lead Nurse Quality which sets out arrangements for supporting arbitration process. (C) owner Cassie Williams Head of Quality and Performance Progress on 2. Quality Assurance Nurse has now started in post and is actively engaging with Trusts around HCIAs. 3. DQIG to continue brief AO on performance of HCAI at each 1-1 (A) owner Jennie Williams Director of Quality and Integrated Governance Commencing w/c Ongoing. 8 1,2,3 Financial uncertainty regarding specialist commissioning funding (13/14) Owner David Maloney - (Old 14) Lack of clarity regarding specialist commissioning split within London health economy Lack of financial and activity information CCG has a large deficit at the end of the 13/14 financial year. I = 4 L = Agreement of process to manage specialist commissioning during 1314 by NHS England and CCGs. 2. Technical finance group set up - contains representatives from NHS England and CCGs. 3. CCG Chief Officers have written to NHS England raising concerns regarding the proposed process. 4. Chief Finance Officer is NCL 1.Agreement of progress with both NHSE and CCGs 2. Chair of Technical Finance Group is shared between CCGs and NHSE. 3.CCG Chief Officer oversees communications with NHS England 4. Reports provided at Technical Group meetings. L = 5 15 Exercise at month 6 to reconcile budget changes to activity levels. owner David Maloney, CFO The CCG received 5m from NHS England as a result of the third budget adjustment, leaving a 2m gap. As there will be no further adjustments, this risk is now CLOSED.

13 Haringey CCG Register Description Owner Finance and Performance Committee Compensating service cuts may be required. Reputation damage. CCG administration/takeover. representative of the Technical Group which monitors the performance of activity during 2013/14. Planned s: Progress on At Month 6 NHS England actioned a transfer in funding from the CCG to NHS England which has created a 7m financial risk for the CCG. This risk is being reported in the CCG s Month 8 financial position and has been communicated to NHS England. It is understood that a third adjustment will be made to CCG budgets which will be based upon the reconciliation from the Specialised Commissioning Technical Group. This has not been factored into the CCG s financial position. The CCG had an assurance meeting with NHS England at the end of October 2013 where this was discussed. 9 1,2,3 Failure to deliver the agreed commissioning plan and achieve performance metrics 13 Owner Jill Shattock Director of Commissioning New Performance Poor systems and processes within provider organisations and departments. Organisational capacity and capability. Inefficiency and I = 4 L = Robust monitoring of performance of NMUH and assurance that this is in place for other local acute trusts 2. Robust monitoring of performance of NMUH ED and urgent care. 3. Director of Quality and Integrated Governance chairs NMUH CQRG and CCG representation at WH and 1. Cassie Williams, Head of Quality and Performance to work with CSU quality and performance to ensure robust and timely monitoring of performance of NMUH and oversight of other local acute Trusts. 2. Jill Shattock, Director of Commissioning, to work L = 3 9 Early identification of performance issues and clear plans to rectify. owner Jennie Williams, Director of Quality and Integrated Governance/ Jill Shattock (ED and urgent Regular performance reports daily, weekly and monthly as appropriate HCCG IPR in development and to be presented at Finance and Performance Committee on Target date for completion is end of October. Pilot

14 Haringey CCG Register Description Owner (Old NCL 717) (Old NCL 715) Finance and Performance Committee ineffectiveness, poor service for patients. Failure to achieve national KPIs (18 weeks/ A&E Performance targets etc) Poor outcomes for patients. Possible intervention from the NHS TDA. Reputational damage to CCG and Trusts. BEH CQRGs. 4. Consistent approach to the escalation of performance issues 5. Winter plans received from all NCL organisations and monitored by the Commissioning leads. 6. CSU SLA review meetings. with CSU to ensure robust monitoring of NMUH ED and urgent care via near time reporting and remedial action plans. 3. CQRG minutes are reviewed by the CCG Quality Committee. CSU generated performance reports used to inform key committees and Governing Body. Planned s: care) Ongoing Progress on during November Remedial action plans received and monitored where necessary. 4. CSU escalation framework in place. 5 Development of an integrated performance report (IPR) which is fit for purpose. Plans reviewed and monitored. 6. Minutes of CSU SLA review meetings. s plans provided by underperforming trusts and monitored by CSU team. 10 1,2,3 Failure to fully integrate and mobilise all elements of unscheduled care within Haringey Owner Jill Shattock Director of Commissioning (Old NCL 759) Poor take up of NHS 111 and GP out of hours services. No formalised operating model agreed for Urgent Care Centre at NMUH Overuse of A&E service. Clinical capacity of Out of Hours provider used inappropriately L = Continuation into third year of pilot and commissioning new UCC service at NMH in line with BEH Clinical Strategy 2. New GP Out of Hours contract in place Clinical Governance Group established and meeting monthly 1. CCG reviews progress at monthly Urgent Care Working Group meetings. 2. CCG reviews revised service model at monthly Performance and CQRG meetings. 3. Engagement with NHS 111 Clinical Governance L = 4 Revised version 2 of UCC service model agreed. Procurement timescales now awaited. owner Jill Shattock, Director of Commissioning NMH UCC service specification and procurement process in development. 14

15 Haringey CCG Register Description Owner Finance and Performance Committee Unforeseen impacts upon A&E Failure to achieve associated unscheduled care KPIs Ineffective and inefficient use of GP capacity Failure to reduce unwarranted A&E activity Contract over performance in certain areas 4. BEH Clinical Strategy Unscheduled Care Work Stream in place. 5. Urgent Care Working Group established and chaired by CCG. Participants attend from the NMH health economy and Social Services. 6. Recovery and Improvement Plan for A&E target, winter checklist and winter surge bids submitted to NHS England on Group/minutes of Governance Group meetings. 4. BEH Clinical Strategy Programme Board has oversight of workstream. Regular updates brought to Programme Board meetings. 5. Minutes of Urgent Care Working Group meetings. Planned s: Mid-October Progress on 11 1 CCG inability to achieve the Better Payment Practice Code Owner David Maloney - (Old NCL 584) Finance and Performance Committee CSU lack of capacity and capability to deliver the specified service to the appropriate timescales Failure to pay creditors in a timely and reliable manner. Negative creditor and wider stakeholder perception Potential for providers to withdraw service provision Patient care is interrupted if failure to pay is sustained L = 4 1.Daily review of Agresso to monitor payments due 2.All appropriate staff trained on Agresso to ensure any queries quickly identified and reported hour turnaround from invoice arrival to budget holders Agresso 4. System has built in mechanism to alert unpaid, unauthorised invoices to budget holder. 5.Reporting of BPPC performance to Governing Body and Finance and Performance Committee. 6. Letter from Tripartite Panel dated confirms partial assurance. 1.Management Team involved in daily reviews 2.Training records held with HR 3.Testing of the system 4.Testing of the system 5. Minutes of Governing Body and Finance and Performance Committee meetings. I = 2 L = To ensure that the CCG is able to achieve the Better Payments Practice Code. owner David Maloney, CFO. Implementation Owner: CSU To ensure that applicable invoices are backed up by a purchase order. owner 1. Communications received from CSU regarding improving the performance of invoice payments. 2. Training sessions being run for staff. Communication has been sent out to staff highlighting that invoices will no longer be paid without a 15

16 Haringey CCG Register Description Owner Planned s: David Maloney, CFO. Implementation Owner: CSU Progress on corresponding purchase order and this process is now firmly embedded among staff. Since July 2013 there has been a significant improvement in the percentage of invoices paid within target timescales. 16

17 Haringey CCG Register Description Owner 1 The CCG in breach of data handing and personal confidential data in accordance with Information Governance requirements. Owner Jennie Williams Director of Quality and Integrated Governance. (Old NCL 760) Quality Committee Lack of suitable IG Controls Staff unaware of responsibilities Lack of policy and guidance No IG Training Sub Contracted work Loss of confidentiality integrity or availability of data Poor reputation Ability to deliver business as usual Fines up to 500,000. I = 5 L = Responsibility for oversight of Information Governance has been put in place and a Caldicott Guardian Medical Director and Senior Information Owner - DQIG appointed 2. Information Governance Framework, IG Policies and high level plan in place. 3. Specialist Information Governance support is in place from NEL CSU. 4. Mandatory annual Training is an organisational priority and staff are in the process of carrying out their annual online IG Training 5. Secure technical IT solutions to access information securely (Blackberries, memory sticks, ipads, Citrix Remote Access). 6. The CCG is acting in accordance with national guidance and only accesses limited Personal Confidential Data where there is a legal basis to do so. 1.Medical Director and DQIG provide assurance that roles and responsibilities are covered 2.Evidence collated as part of 20/13 initial CCG IG return 3 CSU Information Governance Manager provides Quality Committee with quarterly Information Governance Report, including compliance with IG toolkit, issues relating to the review of HCCG systems update on implementation of national guidance. 4. Training records provided by CSU IG Team. 5. Audit carried out by RSM Tenon to cover access controls and network security. CSU has carried out data flow mapping of information security risks and mitigations are in place. 6. Review against compliance verified via IG Toolkit. I = 5 L = 2 10 Planned s: 1. CSU IG manager to lead on development of more detailed IG Plan to include on-going communications and awareness surrounding the appropriate use of Personal Confidential Data as a CCG owner Jennie Williams, Director of Commissioning. Plan approved by CCG Quality Committee on Undertake a data handling review to identify all information assets held by the CCG and the flows in and out of the organisation along with the associate controls owner Jennie Williams Implementation Owner: CSU IG Team. October December Progress on 1. Plan implemented by CSU IG team, with support from CCG IG lead. SMT receives regular HR reports from the CSU, including compliance with mandatory training. CCG aiming to achieve 100% compliance by end of January Review to be coordinated by CSU IG team in December 2013 January

18 Haringey CCG Register Description Owner Planned s: Progress on 3. NEL CSU to provide guidance on how to request disposal of IT assets and give assurance that assets are disposed of in a secure confidential manner 3. CSU has Disposal of Media Policy in place and has signed contract with ICEX. No destructions carried out to date. owner Jennie Williams, Director of Quality and Integrated Governance. Implementation Owner: CSU IT Team

19 Haringey CCG Register Description Owner 13 1 Personal Confidential Data held on invoices for certain services may be placed on the organisations' invoices that are processed and in turn the ledger. Owner Jennie Williams Director of Quality and Integrated Governance (Old NCL 410) Quality Committee Cause Lack of suitable IG Controls Staff unaware of responsibilities Lack of policy and guidance No IG Training I = 2 L = Staff aware of processes to seek consent where possible to process this information in CHC and IFR cases. 2. Providers are encouraged to minimise data shared to enable reconciliation but not identification by wider organisation. 3. Minimal access to the full ledger only key trained staff. 4. Training for all staff on their responsibilities carried out. 5. Contract with NHS SBS to minimise coding and personal confidential data on invoices. 6. Requests made under the Freedom of Information Act would be reviewed and Personal Confidential Data redacted. 1. Verified through review and testing. 2.Management verification. 3.Security controls managed by System Administrator. 4.Testing records verified by CCG Lead. 5.Contract managed and monitored by NHS England. 6.All requests made under FOI recorded and reviewed by CSU FOI team. I = 2 L = 2 4 Planned s: 1. Work with SBS and providers to limit inclusion of PID. owner Chief Finance Officer. Implementation owner: Harry Turner/CSU IT Team. Ongoing. 2. Review historic/ retrospective invoices. owner Chief Finance Officer. Implementation owner: Will Huxter/Harry Turner Progress on 1. SBS have reviewed their processes. Guidance now available from CSU on what to do if an invoice is received with PCD. Where PCD is received, the sender will be informed that PCD must not be put on invoices and invoices will need to be reissued. 2. Section 251 has been approved to support invoice validation (within controls) until 31 Oct Ongoing 19

20 Haringey CCG Register Description Owner 14 1 that CCG will not be able to achieve planned efficiency savings relating to integrated care and invoice validation, due to the changed legal position concerning the CCG s and CSU s ability to process Personal Confidential Data. Owner Jennie Williams Director of Quality and Integrated Governance Quality Committee Current confusion over approved information flows from data held at Hospitals that feed into NHS England, CSU and through to CCG On-going challenges with PCD Delays in service delivery Increase costs Potential legal implications Reputational damage L = 4 1. CSU Information Governance team, with sufficient experience, to support the CCG by providing alternative methods to enable information to be used that remain within legal requirements. 2. Engagement with NHS England, Health and Social Care Information Centre and national bodies involved in the review of potential flows of personal confidential data to support commissioning 3. Invoice validation being undertaken by the NEL CSU staff seconded to the HSCIC to ensure a lawful basis for processing exists. 4. CSU has obtained Accredited Safe Haven status which will allow some data to flow. 1. IG Activity log demonstrates the support the IG Team are providing to services and departments to demonstrate active management of issues and proactive management of potential risks. 2. CSU IG Manager liaises with NHS England on behalf of the CCG. 3. The team validating invoices operate within HSCIC protocols/ guidelines, working closely with CSU IG Manager. 4. Reviews by HSCIC (Health and Social Care Information Centre) and RSM Tenon on CSU provision, including performance and information governance. L = 3 9 Planned s: 1. CSU to maintain Accredited Safe Haven status. (C) owner Jennie Williams, DQIG Implement the Information Governance action plan to achieve level 2 in all requirements (C) owner Jennie Williams DQIG Implementation Date Progress on 1. NEL CSU is an ASH, under the interim arrangements, and is working towards the now defined ASH requirements. A s251 has now been approved by NHS England for the transfer of data from the Health and Social Care Information Centre (HSCIC) to commissioning organisation Accredited Safe Havens) until October NHS England has made separate submission to Confidentiality Advisory Group (CAG) in relation to Stratification. Awaiting further developments on this. 2. A CSU-CCG IG network has been established to provide on-going IG support, including the processing of PCD. 20

21 Haringey CCG Register Description Owner 15 Alerts received in relation to standards of care in nursing / care homes in particular Barnet, Enfield and Haringey and capacity issues at Borough level could lead to safety / safeguarding concerns for adult resident patients. Planned s: Progress on (Old NCL 660) ( closed and incorporated into 16) 21

22 Haringey CCG Register Description Owner 16 1,2,3 Inability to determine quality within commissioned nursing homes in the borough of Haringey Owner Jennie Williams Director of Quality and Integrated Governance (Old NCL 606 updated to reflect current risk ) Quality Committee Lack of cohesive approach to measuring and monitoring quality in care homes. Patients placed in Haringey nursing homes not receiving high quality personalised care. An increase in single safeguarding alerts or establishment concerns regarding standards of care delivered to adult residents in local registered care homes An increase in unnecessary acute admissions. L = 4 1. The current Care homes lead nurse has robust system for visits to quality assure local registered nursing homes. 2. Adult safeguarding lead works closely with the Continuing Health Care (CHC) team and Care Homes lead Nurse to ensure safeguarding concerns are reported and managed appropriately. 3. The Designate Nurse for Child Safeguarding provides operational support and clinical advice to the Adult Safeguarding Lead. 1. Lead Nurse Care homes escalates all concerns relating to quality and safety in timely fashion. 2. HCCG Safeguarding policy (2013) operational. Joint policy for establishment concern implemented June Adult safeguarding lead to brief Lead Haringey Local Authority. DQIG is briefed on all safeguarding issues and ensures Chief Officer is kept informed. 3. Monthly updates provided to Quality Committee by Adult and Safeguarding leads. L = 3 9 Planned s: 1. To complete and implement a revised focus for Care Homes project. owner Cassie Williams, Head of Quality and Performance delayed until launch events completed which took place in December The Continuing Health Care nurse team to transfer into the Quality and Integrated Governance Directorate 3. There is a need to ensure all staff are compliant with the safeguarding policy and procedures. owner Cassie Williams, Head of Quality and Performance. Progress on 1. Quality Matters in Care Homes programme commenced 1 January The programme applies rigour to the review and reporting of quality and safety. The Quality Committee will receive a report on a bi-monthly basis. The QIPP Delivery Group will oversee KPIs related to reduction of avoidable admissions. 2. The CHC nurse team are managed within the Quality and Integrated Governance directorate. The Head of Quality and Performance now manages the Clinical Team Manager Continuing Healthcare. 3. The Safeguarding, Care Homes and Continuing Health Care teams are compliant with safeguarding training and now meet regularly to facilitate closer joint working. 22

23 Haringey CCG Register Description Owner 17 With the strategic shift from secondary to primary and community care, there is a risk that we are moving from an environment where we have robust assurance processes on quality to one where we have less assurance. Planned s: Progress on Owner Jennie Williams Director of Quality and Integrated Governance (Old NCL 640) closed and superseded by risk

24 Haringey CCG Register Description Owner 18 1 Quality of activity information received from UCLH is such that the CCG is not able to use it to enable it to monitor performance against the contract. Owner David Maloney, Chief Finance Officer. Finance and Performance Committee Poor quality data submitted to the CSU by UCLH. Inability of the CCG to properly reflect the financial performance of the ULCH contract for 2013/14. Financial cost pressure reported by CCG is activity far beyond the budget that the CCG has set. I = 4 L = 3 1. CSU on behalf of CCG are communicating with UCLH to get to the position that the Trust can submit accurate information. 2. CSU contract lead is in post. 3. CSU Director of Finance now playing a greater role in the UCLH contract. 1. Regular reports on the UCLH position are taken to CCG Chief Officers meetings and contract performance meetings, as well as it being a standing item at meetings of the Finance and Performance Committee. Furthermore, as part of the month end financial reporting process, an assessment is made by the CSU of the financial risk for each trust. However, at present these provide limited assurance as actions being taken are not impacting on the financial position. 2. More rigorous approach to contract management. 3. CSU Director of Finance attending Finance and Performance Committee Meeting on I = 4 L = 3 Planned s: 1. CSU to agree contract with UCLH. owner David Maloney, CFO Implementation Owner: Michellle Powell, CSU Mid-November Joint working with UCLH to agree correct level of activity. owner David Maloney, CFO Implementation Owner: Michellle Powell, CSU Month 8. Progress on 1. Ongoing. 2. Ongoing. The UCLH forecast overspend at M8 was 4m. The forecast out-turn at M9 is 3.6m, a slight improvement in month. In addition, the CSU Director of Finance attended the Finance and Performance Committee meeting on and confirmed that potentially 0.9m could be removed from the forecast UCLH out-turn. 24

25 Haringey CCG Register Description Owner 19 1,2 Failure to fully implement and integrate the BEH Clinical Strategy and to ensure that changes become business as usual as planned. Owner Sarah Price Chief Officer. Finance and Performance : Unforeseen activity volumes Workforce issues Delays in or disruption to building work Impact on quality and safety in either of the local acute providers Increased financial risk as a result of unused capacity or over-performance/ activity pressures elsewhere Impact on performance attainment. I = 5 L = Contingency plans in place against key programme risks which are monitored regularly. All workstreams have specific role to manage quality and safety during transition. 2. Workforce group in place, meeting monthly. Recruitment tracker in place and being monitored on a regular basis, including at the BEH Programme Board and NCL Clinical Cabinet. 3. share agreement across North Central London CCGs agreed by all five Governing Bodies to support transitional funding. (Haringey GB approval on ). 1. Programme risk register reviewed monthly through NCL Clinical Cabinet and BEH Programme Board. External assurance by NHS England continues to monitor and assure key programme risks. 2. Final BEH Programme Board to close programme and establish handover of key workstreams. 3. Minutes of Workforce group, BEH Programme Board and NCL Clinical Cabinet. Active engagement of Chairs/Chief Officers/senior staff in BEH Clinical Strategy governance structure. I = 4 L =3 Planned s: 1. Continue to monitor progress against implementation plans and proactively address risks and issues. Urgent Care Working Group to takeover legacy workstream actions as appropriate. owner Siobhan Harrington, Programme Director, Barnet, Enfield and Haringey Clinical Strategy Programme Jill Shattock, Director of Commissioning Progress on 1. On track CCG risk register will be updated following programme close on Ownership of the residual risks will be transferred to the individual CCGs as appropriate. owner Siobhan Harrington, Programme Director, Barnet, Enfield and Haringey Clinical Strategy Programme 2. On track

26 Haringey CCG Register Description Owner Planned s: Jill Shattock, Director of Commissioning Progress on 20 1 There is a risk around moving from an environment where we have robust assurance processes on quality to one where we have less assurance. Owner Jennie Williams Director of Quality and Integrated Governance Quality Committee Strategic shift from secondary to primary and community care, Unforeseen impact on quality and safety to patients Reputational damage to CCG and providers Failure to achieve national Q&S KPIs for example HCAI and reduction of harm L = 3 9 CQRG monthly meetings in place for acute providers and 111 service Recognition that the CCG does not have a systematic approach to quality assurance of smaller providers has led to the Head of Quality asking the care homes team to undertake a baseline review of registered nursing homes. External clinical governance review by auditors Quality report to the Quality Committee (QC) and receipt of minutes of CQRGs for key acute providers Senior management team (SMT) to receive a briefing paper setting out how CCG will receive assurance on the quality and safety of care provided by local registered nursing homes. External clinical governance review report L = Determine CCG responsibilities for quality and safety in local residential homes (A) Owner Jennie Williams, Director of Quality and Integrated Governance By end of November Lack of clarity regarding role and responsibilities of CCG care home team in seeking assurance re Q&S from smaller providers and framework.(a) Owner Jennie Williams, Director of Quality and Integrated Governance By end of November and 2. Head of Quality has undertaken a review of the Care Homes team with focus development of framework (including KPIs) for use with smaller providers based on the existing CQRG model. As in 16, a paper was presented to SMT in November 2013 and this programme is in early stages of implementation. The Quality Committee will receive an update in January As set out in 7, a Quality Assurance Nurse is in post and has started leading on the monitoring of HCAI. In early 2014 the post holder will focus on overseeing a programme of work to reduce community acquired pressures and healthcare acquired infections in community settings. 26

27 Haringey CCG Register Description Owner Planned s: 3. Lack of robust approach to performance managing smaller providers on management of infection control and pressure ulcers Owner Jennie Williams, Director of Quality and Integrated Governance By end of December Progress on 27

28 Haringey CCG Register Description Owner 21 3 Full scope of the palliative care service cannot be delivered and service offered is restricted. Winter Pressure Response (to offer 7 day a week service) is not delivered. Increased pressure on service due to staff sickness and compassionate leave. Consultant locum post will not be filled in full from January Owner Jill Shattock Director of Commissioning Quality Committee Cause Provider staffing shortages: two recent retirements within the palliative care team; long term sick leave within the team and Divisional Head of Nursing post vacant. Effect Reduced staff capacity may limit the level of provision until vacancies are filled. I = 2 L= 4 8 Commissioner (AD) oversight of provider actions to increase recruitment Successful recruitment to fill vacancies No restriction to service delivery Ability to offer service 7 days per week I = 2 L= 4 8 Planned s: 1. Request formal action update from Carol Gillen, Director of Operations, Whittington Health, to include assurance of progress on recruitment and that complete service is being offered. Further urgent update requested from WH management in light of pressure to service in December 2013/January owner: Rachel Lissauer, AD, Clinical Commissioning : November 2013 Progress on 1. Update has been provided. s are being taken to recruit additional staff. 1 of 2 vacant posts has been filled. Second post advertised with upcoming interviews. Arrangements being made between providers for approval of a new Consultant post which will incorporate the 0.4PAs commissioned by Haringey for Community Palliative Care. WH has issued guidance to GPs outlining changes to the service to restrict to the core commissioned specialist palliative care service. 0.4WTE Consultant post will be vacant from January North Middlesex Hospital approaching Consultant with a view to providing PAs support for community team. 28

29 IMPACT Strategic Scoring Methodology Haringey CCG Register 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic Adverse publicity / reputation Coverage in media, little effect on public confidence / staff morale Local Media short term. Minor effect on public attitudes / staff morale Local Media long term. Impact on staff morale & public perception of organisation National media <3 days Public confidence in organisation undermined. Usage of services affected National media >3 days. MP Concern (questions in House) Business objectives / projects Insignificant cost increase/schedule slippage Less than 5 per cent over project budget. Schedule slippage. 5 to 10 per cent over project budget. Schedule slippage. Non-compliance with national per cent over project budget. Schedule slippage. Key objectives not met. Incident leading to over 25 per cent over project budget. Schedule slippage. Key objectives not met. Finance including claims Small loss. of claim remote. Loss of per cent of budget per CCG. Claim less than 10,000 GBP. Loss of per cent of budget per CCG. Claim(s) between 10,000 GBP and 100,000 GBP. Uncertain delivery of key objective/loss of per cent of budget per CCG. Claim(s) between 100,000 GBP and 1 million GBP. Purchasers failing to pay on time. Non-delivery of key objective/loss of over 0.5 per cent of budget per CCG. Failure to meet specifications /slippage. Loss of contract/payment by results. Claim(s) of over 1 million GBP. HR / organisational development / staffing / competence Short/term low staffing level that temporarily reduces service quality (less than 1 day). Low staffing level that reduces the service quality. Late delivery of key objective/service due to lack of staff. Unsafe staffing level or competence (greater than 1 day). Low staff morale. Poor staff attendance for mandatory/key training. Uncertain delivery of key objective/service due to lack of staff. Unsafe staffing level or competence (greater than 5 days). Very low staff morale. No staff attending mandatory/key training. Non-delivery of key objective/service due to lack of staff. Ongoing unsafe staffing levels or competence. Loss of several key staff. No staff attending mandatory training/key training on an ongoing basis. Impact on the safety of patients, staff or public Minimal injury requiring no/minimal intervention or treatment. No time off work. Minor injury or illness requiring minor intervention. Requiring time off work for over 3 days. Increase in length of hospital stay by 1-3 days. Major injury requiring professional intervention. Requiring time off work for 4-14 days. Increase in length of hospital stay by 4-15 days. RIDDOR/agency reportable incident. An event which impacts on a small number of patients. Major injury leading to long-term incapacity/disability. Requiring time off work for over 14 days. Increase in length of hospital stay by over 15 days. Mismanagement of patient care with long-term effects. Incident leading to death. Multiple permanent injuries or irreversible health effects. An event which impacts on a large number of patients. Quality / Complaints/ Audit Peripheral element of treatment or service suboptimal. Informal complaint/inquiry. Overall treatment or service suboptimal. Formal complaint (stage 1). Local resolution. Single failure to meet internal standards. Minor implications for patient safety if unresolved. Reduced performance rating is unresolved. Treatment or service has significantly reduced effectiveness. Formal complaint (stage 2) complaint. Local resolution (with potential to go to independent review). Repeated failure to meet internal standards. Non-compliance with national standards with significant risk to patients if unresolved. Multiple complaints/independent review. Low performance rating. Critical report. Totally unacceptable level or quality of treatment/service. Gross failure of patient safety if findings not acted on. Inquest/ombudsman inquiry. Gross failure to meet national standards. 29