CORPORATE RISK REGISTER JANUARY2017

Transcription

1 Agenda Item 11.1 CORPORATE RISK REGISTER JANUARY2017 G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx

2 Summary Corporate Register January 2017 No. Nature of utive Lead Current Score Safety and Quality Last Reviewed By CRR 1 Inadequate nurse staffing levels Chief Nurse/Deputy CEO 20 Apr 16 CRR 2 Exposure to Healthcare Associated Infection- C.difficile and MRSA Chief Medical Officer 15 Jan 16, Dec 16 CRR 28 Failure to rescue a deteriorating patient Chief Medical Officer 16 Feb 16, Nov 16 CRR 33 Violence due to organic, mental health or behavioural reasons Chief Nurse/Deputy CEO 16 Aug 15, Nov 15 Apr 16,Sept 16 CRR 36 Inability to deliver a cardiac surgery service Chief Nurse/Deputy CEO 16 Jul 16 CRR 38 Excessive stays in the Emergency Department for Mental Health patients Chief Nurse/Deputy CEO 16 Dec 16 Financial CRR 9 Failure to deliver the financial plan (aggregate effect of income volatility, CIP shortfall and cost pressures Interim Director of Finance 20 Sept 15,May 16 Sept 16, Jan 17 CRR 6 Unserviceable critical I/T infrastructure and resilience Chief Medical Officer 20 Dec 15, Jan 17 CRR 37 Failure to achieve a satisfactory termination agreement for the pathology services SLA Director of Strategy and 16 Sept 16 with Bradford Teaching Hospitals, by 31 December 2016 Planning People CRR18 Reducing supply of doctors in training Chief Medical Officer 16 Jul 14,Oct 15 Nov 15,Aug 16 Performance and Regulation CRR 12 Failure to achieve Emergency Care Standard Chief Nurse/Deputy CEO 20 Nov 16 CRR week RTT target non-compliance Chief Nurse/Deputy CEO 20 Feb 15, Aug 15 Jun 16 CRR day cancer target Chief Nurse/Deputy CEO 20 Feb 15, Sept 15 CRR 22 Patients waiting longer than 6 weeks following referral for diagnostic tests Chief Nurse/Deputy CEO 15 Nov 14, Aug 16 CRR 23 Failure to achieve 28 day cancelled operations target Chief Nurse/Deputy CEO 16 Nov 16 CRR 27 Delays in Endoscopy procedures; failure to retain JAG accreditation Chief Nurse/Deputy CEO 16 Aug 15,May 16, Sept 16 CRR 31 Patient flow and capacity for emergency admissions (health economy) Chief Nurse/Deputy CEO 20 Feb 16, May 16, Dec 16 CRR 32 Unsustainable levels of medical outliers in Acute Medicine CSU Chief Nurse/Deputy CEO 20 Feb 16, Jul 16 CRR 34 Corroded heating pipes in Clarendon Wing, LGI - potential disruption to services Director of Strategy and 16 Jun 16 Planning 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 Symbols used in this report Inherent and Unmitigated Score Residual Score (Current Exposure) Target / Appetite Threshold G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx

3 S=5 CRR1: Inadequate Nurse Staffing Levels L=4 Potential Insufficient nurse staffing levels. Caused by high levels of sickness/absence; insufficient investment in nurse staffing; high vacancy factor; insufficient workforce planning or adjustment for case-mix; or insufficient supply qualified staff. May result in an inadequate patient experience; a failure to protect patients or staff from serious harm; loss of stakeholder confidence; and/or a material breach of CQC conditions of registration. Suzanne Hinchliffe Treatment Core Prevention Controls Duty Rotas prepared and communicated in advance Agreed minimum staffing thresholds (numbers and skill mix) in all clinical areas - blue print for the Trust (informed by AUKUH Safe Staffing Tool, with 1:8 roster tool undertaken from October 2013) All annual, special or study leave is booked and agreed at least 6 weeks in advance to allow sufficient planning to take place (except where required in an emergency) Flu Jab uptake for front line colleagues Proposal for 30 month transitional investment plan identified Review of commissions undertaken Regular discussions held with LETB and HEI Expansion of Band 4 Assistant Practitioners - cohorts have commenced Core Detection Control Non-attendance is notified to direct line manager as per sickness procedures Duty Managers report 4 times per day identifying staff gaps and planned actions Direct observation - Patient Safety Walkrounds Adverse event reports - incidents or complaints Responsive visits where concerns have been identified Monthly Workforce Health Check Contingency/Recovery Controls Bed numbers within wards are reduced to reflect nurse staffing levels in association with redirecting activity to private sector in light of staffing levels Operating Procedure: Actions to be taken when the numbers of nurses or midwives per shift falls short of the agreed roster template(currently being updated) Discretionary use of bank or agency cover in the event of an identified shortfall Redeployment of colleagues on duty where staffing levels permit Contract with NHSP who also are the agent for agency progression Block booking of flexible labour is supported in required circumstances Specialist and corporate nursing colleagues are required to work clinical shifts where required Shorter term supply management - recruitment process over next 12 months commenced (Chief Nurse remains in progress) Deliver plan to meet requirements of agency cap (Chief Nurse discussions continue regarding this - April 2016) Deliver agreed priority investments in staffing as per acuity tool (see investment plan - Chief Nurse remains in progress - Dec 2016) Differential risk rating identified for CSUs with most significant recruitment challenges (Dec 2016): Medicine & Older People Critical Care Cardio-respiratory Trauma Abdominal Medicine and Surgery (Endoscopy) Chief Nurse - progress reported to Board (Hard Truths) Clinical Practice Review Frequency G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx

4 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 others; 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 Core Prevention Controls Assessment; Patient level assessment of risk on admission/arrival (filed in patient care record) Standard Precautions; provision and use of HH materials and washing facilities and use of personal protective equipment Environmental decontamination including; Implementation of National Specification for cleaning, rolling programme of HPV Fogging, segregation and safe disposal of contaminated waste Specific measures to reduce contamination (environmental cleaning, decontamination of equipment, single use items, rolling programme of HPV Fogging, segregation and safe disposal of contaminated waste) Environmental cleaning in accordance with National Specification Antimicrobial Stewardship including; Rounds led by Microbiologist, Anti-microbial prescribing policy and standards, topical decolonisation for MRSA positive patients and prophylaxis Training; Mandatory, Infection Prevention & Control Training to all staff Overarching Infection Prevention Policy and suite of Guidelines and SOPs IPC design in the built environment including; increased side room facilities, increased number of HH basins (at strategic locations within or adjacent to specified clinical areas) Core Detection Control Ward health check monthly MRSA Screening Procedure Catheter-related blood stream infection surveillance in critical care Alert organism surveillance Ward-based surveillance (viral gastroenteritis) Root Cause Analysis of identified cases Hand hygiene and source isolation audits Surgical site infection surveillance Contingency/Recovery Controls Management of Outbreak Guideline Cohort isolation practices (ring-fenced CDI cohort facility) Closure of Ward(s) to new admissions (where necessary) IPC advice to be incorporated into electronic patient record (Dec 2016) HCAI Improvement Group across Leeds health economy to review lessons learned (commenced June 2016) IPC resilience system wide group to be formed in response to increasing number of MRSA incidents (Output by Dec 2017) Anti-Microbial Stewardship Group chaired by Director of Public Health (From July 2016) Vessel health and preservation programme (commenced Dec 2015) Clinical practice G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx

5 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 and compute. 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 L=4 Prevention Control 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 Detect Control 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 Contingency/Recovery Controls 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 Trust reviewing capital requirements and producing Strategic Outline Case (SOC) to support I/T Infrastructure, by end of January 2017 A complete risk assessment of all key critical systems is being undertaken to assess assurance levels Jan/Feb 2017 Internal Audit is carrying out a system resilience review in the event of a cyber attack. Q4 2016/17 IT Assessment Review Frequency G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx

6 CRR9: Failure to deliver the financial plan (aggregate effect of income volatility, CIP shortfall and cost pressures) Potential There is a risk that the Trust does not achieve its financial targets in 2016/17 Due to the inability to deliver the Cost Improvement Programme, reduced social care funding and changes in the provision of secondary care by other local DGH s May result in the possible loss of Sustainability and Transformation funding from the DH, the Trust entering special administration and extreme external scrutiny Jonathan Wood Treatment S=5 L=4 Core Prevention Controls Board owned recovery and financial plans. Establishment of realistic CSU budgets and plans. Finance supports the process and works with budget holders to ensure ownership. Close working between Finance and CSUs to identify threats to plan delivery and formulate mitigations and develop stretch targets for CIP 13-Week rolling cash forecast anchored to long term plans Weekly review of cash position and payables due Weekly payment values determined by Senior Finance staff Project Management Office C-I-P lead in place from May 2016 CSU s requested not to commit expenditure for non-essential items for remainder of 2016/17 Core Detection Controls Monthly board/budget reporting and outturn forecasts Liquidity score calculated and reported monthly Performance Review Meetings with Finance/COO Contingency/Recovery Controls Corporate approach to problem resolution Negotiation with TDA on surplus or deficit In-year review and revision of capital commitments Renegotiation with Commissioners to minimise threat of penalties Other Controls Establish Working Capital Loan Facility Establish I&E accounts for service lines Develop and improve capacity planning to enhance income position Robustly verify data completeness, accuracy and income coding to enhance income position Review of SFI s taking whatever action is necessary to strengthen core financial governance. Delivery of training on MyFIT to all budget holders Implementation of Knowing the business Stage 2 Regulators escalation process CSU s requested to increase the value of their current CIP delivery (e.g. by removing vacant posts rather than offering them as non-recurrent savings) Joint cost based review with Commissioners to be concluded in Q1 2017/18 Implementation of the Leeds Improvement Method - Rapid Improvement Workshop outcomes, during 2016/17 Ensure CSU s have an Action Plan in place to implement the recommendations from the Lord Carter report on Expenditure in the NHGS - The model hospital. Reporting quarterly in 2016/17 on progress to Finance and Performance Committee and to the DH Re-brand CIP as Waste Reduction Programme (to fit with the Leeds Improvement Methodology) From January 2017 Assessment G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx

7 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, waiting on trolley outside a ward area, deterioration in performance across LTHT s access standards, multiple cancellations 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 Strengthened ED medical rota s through recruitment of 11 substantive doctors reducing the reliance on agency/locum staff and allowing for better shift fill rates from August 2016 onwards Ensuring the robust delivery of the green stream at both sites to allow the streaming of the less complex patients in ED GP and patient advisor in ED at St James s and LGI from Nov 16 Creation of a dedicated non-elective dashboard to help focus attention on internal performance areas which support service/standard delivery Joint Acute Medical Assessment (JAMA) improvements through the creation of a dedicated assessment area (6 trolleys) to avoid inpatient admissions Analysis of areas of for improvement on the paediatric/ed pathway 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 and increased usage of CDU. Reduced admissions via A/E and CDU and reduced length of stay for non-electives assessment and monitoring process for patients waiting on a trolley outside a ward area Urgent Care CSU has set an internal target of 100% compliance against non-admitted breaches in two phases - firstly 100% of patients seen by GP by Q3 2016/17 and secondly 100% of non-admitted patients by Q4 2016/17 Roll out Safer Care Bundle and incorporate into internal plans: Better use of discharge lounge Home by lunch Reducing the number of critical care patients delayed by more than 24 hours Implementation of WYAS funded action plan to support the flow of patients out of hospital and prevention of ED attendances by Jan 17 Performance Management Review Frequency G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx

8 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 October (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, ineffectual waiting list management practice, or inefficient pathways of care and late referral from neighbouring providers 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 System capacity and demand Maximising the use of limited capacity and non-elective flow through; Capacity and demand modelling is in place for priority RTT specialties with monthly review of demand by corporate team to ensure that capacity is aligned to forecast demand Formal escalation of constraints to Commissioners re; oral surgery and spines, requesting support to manage demand from primary care and identify alternative choice for patients Bed management and discretionary (limited) use of ring fencing to mitigate against impact of non-elective pressures Theatres Programme Board focussed on increasing utilisation of inpatient and day case theatre capacity Use of bank/agency/locum to address shortfalls in staffing levels Use of independent sector capacity and additional weekend lists/clinics Additional validation of waiting lists Performance management Any area with an over 18 week problem gas recovery plan monitored through; 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 meeting Escalation system to Medical Director for Operations, Associate Directors of Enactment of Special Measures - intensive monitoring and support in the event of significant performance risk Plans and trajectories revised to achieve incomplete performance compliance at specialty level. Five CSU s to implement revised plans. Lead CSU General Managers TRS, AM&S, Neuro, LDI and Chapel Allerton. Plans include expediting capacity increases and improved referral management Further validation and review across all non-compliant specialty pathways to increase non-admitted capacity, reduce pathways and mitigate breach volumes. Performance managers Implementation of revised referral management arrangements in Oral Surgery and Pain All CSU s and specialties with significant backlogs of patients > 18 weeks have had their recovery plans assessed and refreshed, recognising on-going constraints with workforce and bed capacity. A supportive process is in place where the Corporate Operations Team are supporting CSU s with a RTT health check, refreshed capacity and demand analysis and back to basics access process review and refreshed validation training (Oct 2016) Waiting list management practices and referral triage procedures reviewed as part of RTT specialty level action plans Bi-monthly review of individual consultant booking order and waiting list management practice Administration and pathway management Access policy and procedures are in place and up to date with on-going review to ensure policy is applied consistently at CSU level Contingency/recovery controls Escalation system to Medical Director for Operations, Associate Directors of Operations, Deputy CEO. Enactment of Special Measures - intensive monitoring and support in the event of performance risk Continued management of the discharge of patients medically fit for discharge Capacity and identified and in use at Harrogate Trust from 1 Nov 2016 indefinitely. (c 40 patients a month) Working with L&D to prioritise RTT training for Admin staff (complete Q4 2016/17) Performance Management Review Frequency G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx

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10 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 Core Prevention Controls 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 Core Detection Controls 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 meeting Contingency 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 Q3 2016/17. Support the West Yorkshire discussions on agreeing to implement the Breach allocation national guidance from April 2017 G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx

11 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 G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx

12 CRR22: Patients waiting longer than 6 weeks following referral for diagnostic tests Potential Patients waiting longer than 6 weeks following referral for diagnostic tests Caused by ineffective waiting list management, insufficient capacity at specialty level, insufficient control over pathways of care, demand exceeding planned levels of activity. May result in poor quality care, unsatisfactory patient experience, unacceptable delays for patients, and/or deterioration in LTHT s governance rating. Suzanne Hinchliffe Treatment S=5 L=3 Prevention Control 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 Supported use of the Independent sector and in-reach services in Endoscopy (CSU / ADOP) Extended use of Wharfedale Endoscopy service with a partner Trust (CSU/ ADOP) Detect Control 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 Contingency/Recovery Controls Discretionary use of bank/agency/locum staff to address shortfalls in capacity Discretionary use of additional independent sector capacity to address shortfalls. Endoscopy Recovery Group established, chaired by ADOP Endoscopy and Audiology Recovery Plans agreed and delivery begun Continued support by Performance Team E-booking in place from 4 July 2016 Partial transfer of patient booking from Endoscopy to RBS from 4 July 2016 Further recruitment to nurse staffing complete Formal capacity review with CCG s triggered in quarter /16 (capacity 9,000, demand 17,000) Completion in quarter /17 Reducing use of Medinet through wider use of independent sector procured by Commissioners (April 2017) Assessment Review Frequency G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx

13 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 L=4 Full Root Cause Analysis undertaken for every breach 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 Bed management systems and discretionary (limited) use of ring fencing Theatre utilisation KPIs in place Use of medical outlying restricted to minimum Capacity and demand modelling progress in place for priority RTT specialties Weekly meeting to smooth demand for critical care capacity Monthly reporting to CSU leadership and escalation to Chief Nurse where required Weekly access meeting held by every CSU with escalation to Chief Nurse where required Monitoring at Board level via Integrated Quality and Performance Report Discretionary use of bank/agency/locum staff to address shortfalls in capacity Discretionary use of independent sector to address capacity shortfalls Process - cancellation, daily operations prioritisation to balance elective/non-elective flows and escalation through CSU team and then Corporate Ops for inter CSU decision making re cancellations Performance management - RCA s, KPI s/utilisation and outlying utilisation Work on-going to maximise day case capacity and identify suitable additional patients who would normally be treated as inpatients to move to day case and reduce cancellations and assist with throughput during the coming winter period. G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx

14 CRR27: Patients waiting for endoscopy procedures: failure to retain Joint Accreditation (JAG) in endoscopy Potential Failure to retain National Endoscopy Programme Joint Accreditation Group (JAG) accreditation, due limited capacity to address demand and/or booking process inhibiting the delivery of a timely service. This may result in: (i) loss of accreditation with negative consequences for the Trust s participation in the National Bowel Screening Programme; (ii) potential loss of income: and/or (III) breach of conditions of CQC registration Suzanne Hinchliffe Treatment Prevention Control Detect Controls S=4 L=4 Access policy and procedures in place. Waiting List management processes including acceptance criteria and validation. Capacity and demand modelling Additional sessions provided over extended period, including service agreement with Harrogate FT and Medinet to provide additional capacity (staff) to undertake endoscopy procedures Triaging of referrals to optimise use of resources Accreditation achieved Roll out of Booking Bug scheduling system Additional directly commissioned Upper GI 2ww capacity in place to reduce LTHT demand. D/W JAG officers - Acknowledgement of demand for service access across UK. Content with progress subject to reduction Alternative arrangements for nursing staff for endoscopy support agreed with Medinet Proposal for MRI management raised at F&P Committee with narrative paper Booking bug system introduced for endoscopy via Outpatient services Opportunities for expanding scoping skills for nursing staff progressed Programme of nurse recruitment continues with aim to appoint to all vacant posts. Reduce waiting times in line with national waiting time requirements and submission of monthly waits data for the 3 month period May, June and July (Submitted 12 September 2016) Following this the National JAG Administration Team will review the service s accreditation status, which is currently Assessed: Improvements Required Assessment Review Frequency Weekly monitoring of performance through CSU and Trust performance structures Contingency/Recovery Controls. Additional sessions provided over extended period, including service agreement with Harrogate FT and a wide range of Independent sector providers (5) to provide additional capacity to undertake endoscopy procedures. Review of clinic template and development of sustainable requirements Replacement of temporary administrative staff with substantive appointments with a view to growing local workforce Nurse recruitment programme in place G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx

15 CRR28: Failure to Rescue a Deteriorating Patient Potential There is a risk that patient deterioration is not identified, due to the failure to recognise and respond appropriately to deterioration and to monitor patients appropriately, resulting in potential fatality or serious harm to patients Yvette Oade Treatment S=4 L=4 Prevention Control Minimum standard for taking and recording of observations, increased frequency determined by clinical need. All wards monitored by the Ward Health Check Use of the National Early Warning Scoring System (NEWS) with escalation as appropriate Mandatory Training (Resuscitation) Advanced life support training (as required by role) Quality Improvement programme (deteriorating patient) - intervention bundles delivered a 50% reduction in cardiac arrests Quality Improvement roll-out programme across the Trust 24/7 outreach provision cross site (LGI and SJUH) Learning Bulletin and communications to staff on detection and prevention of Deteriorating Patients Capacity plan and escalation for the safe management of patients requiring admission to acute hospital wards, including risk assessment and management of patients waiting on trolleys for an inpatient bed Detect Controls Emergency Medical Response/Cardiac Arrest Call System Incident reports - potential serious incident notifications Ward health check Trust deteriorating patient dashboard - cardiac arrest (2222) calls - CSU level (acute medicine, surgery and cardio-respiratory Trust heat map - cardiac arrest calls by location and time of day Deployment of Critical Care Outreach CSU roll out of QI programme from April 2016 Develop Trust deteriorating patient dashboard - cardiac arrest (2222) calls and extend to all CSU s Ensure adequate staffing appropriate to patient need, across all inpatient areas Assessment Review Frequency G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx

16 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 comorbidities and more patients requiring on-going or social care input This may result in 1 High numbers of patients in the bed base who are medically fit for discharge as services not available in the community and social care (i) Failure to deliver 4 hr emergency care standard (ii) Elective admission cancellations and cancelled operations (iii) Failure to transfer patients out of critical care (step down)and provide capacity for patients who require high dependency or critical care (iv) Failure to respond to peaks in emergency care demand (v) Poor patient experience, high number of outliers and potential harm to patients (vi) Poor staff morale and well-being at work Suzanne Hinchliffe Treatment S=5 L=4 Prevention Control Agreed staffing levels and rotas aligned to seasonal variation and anticipated peaks in demand 24 hour consultant presence in A&E Consultant led rapid assessment, triage process and route to GP Pathways for rapid referral to specialty services Admission avoidance schemes and pathway redesign (transformation); ambulatory care models Discharge planning team, led by Head of Nursing System-wide Early Discharge Assessment Team (MDT - OT, physio, social worker, geriatrician, discharge nurse) Advanced Practitioners and discharge facilitators Clinical Site Managers - out of hours support and co-ordination 24 hr assessment services in medicine, surgery, children s services Processes for collation and capture of Delayed Transfers of Care Board rounds in place on every ward linked to GP surgery s; EDD Winter plan 2016/17and risk log Outlier plan; repatriation process Escalation process and capacity plans by CSU - bronze, silver and gold command; DOP, on-call rota System Resilience Group and plan (with partner organisation) Regional escalation process and system wide REAP agreement Joint work with Commissioners to increase available capacity and with provider partners to improve patient flows to Care Homes Discharge team infrastructure strengthened (corporately) - appointed Head of Nursing to lead the team; development of a fully integrated discharge team with partner organisations. Development of a Trusted Assessor model to support discharge processes and reduce delays across the health system Trust wide Recovery Plan in place from April 2016 which involves every CSU identified in the delivery of the Emergency Care Standard. Managed by the Corporate Performance Team assessment and escalation procedure in place for patients waiting on a trolley WYAAT regional re-patriation process developed and in place Detect Controls Clinical Site Manager reports; delayed discharge and outlier reports Daily operational report Quarterly bed census undertaken Breach review and RCA process (4hr standard) Quality and Performance report Incident reports and complaints Reports on number of delayed transfers of care (DTOC) and medically fit for discharge patients Trust. LTHT to develop a clear strategy and implementation plan for robust assessment for ambulatory care (Mar 2017) Agree Winter Plan 2016/17 with partners/stakeholders and get Trust Board sign-off (Nov/Dec 2016) Implement revised triage process and referral to GP s (Nov 2016) Monitoring of trolley waits between 8 and 12 hours and developing a risk assessment and escalation procedure (Nov/Dec 2016) CSU s Assessment Review Frequency G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx

17 CRR32: unsustainable levels of medical outlying in Acute Medicine CSU Potential Current high occupancy levels and high volume of medical outliers caused by demand outstripping capacity resulting in reduced quality of care, out of hours transfers, patients waiting on trolleys and reduced patient experience and non-delivery of ECS in addition to hospital surgery cancelations causing potential harm to patients. (Cross Reference Acute Medicine 14) Suzanne Hinchliffe Treatment S=4 L=5 Prevention Control Use statistical expertise to right size the bed base and redesign the service delivery to maximise medical input and decision making in the right place at the right time Discharge team infrastructure strengthened (corporately) - appointed head of Nursing to lead the team. Programme of work on patient flows agreed, led by ADO with supporting team Plans are in place to increase assessment services, increase ambulatory care pathways and reduce admissions and therefore medical outliers Agreed approach for the management of outliers by consultants and relevant specialties including timeliness of review, escalation, and which team covers each ward Contingency/Recovery Controls Resilience plan in the CSU aligned to REAP levels across Leeds Health System Surge actions in place including additional beds Implement a revised SOP for transfer of patients in and out of the CSU Additional managers to support the CSU Review of patients that are not placed in the correct speciality and defaulted to medicine and agree alternative pathways Pharmacy to provide additional cover to the Top Floor 7 days a week including prescribing and technicians to support rapid EDANs Clinical Director to work and agree with other Clinical Director shared management of outliers so as to reduce impact on patient care and elective performance Management of discharge processes and reduced length of stay CSU Assessment Review Frequency G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx

18 Recruit junior doctors to cover outliers including at the weekends Review trajectories relating to delayed transfers of care with partner organisations G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx

19 S=4 CRR33: Violence due to organic, mental health or behavioural reasons 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 VERY LOW RISK LOW RISK MEDIUM RISK HIGH RISK SIGNIFICANT RISK L=4 Acute 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 (MH Practitioners) 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 Enhanced supervision procedure Urgent Care CSU 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 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 from July 2016 Increase WY Police profile in ED s and office now accessible by Trust Security staff Acute Medicine Clinical support staff to be appointed to wards to assist in the care of patients at risk of violent behaviour - May 2016 Develop care plans in conjunction with LYPFT - May 2016 Respond to the outcomes of reports relating to SI s (J19 - Feb/Mar 2015 and suicide - Mar 2016) - May 2016 Urgent Care After a serious incident at the SJUH site in July 2016, including an assault on 3 members of staff, a police and Trust security review has taken place. Option appraisal is being carried by Peter Aldridge, Head of Security - Oct Security cameras and improved security presence being added to each of the ED s Trust wide Implementing changes to enhanced care across the Trust (risk assessment tool to direct staff to appropriate enhanced care for patients with different needs - possibly violent patients) From end Sept 2016 Reviewing MH/MHA/Deprivations of Liberty Team (DoL s) requirements and developing a case for investment in the team with expert resources. End Nov 2016 Agreed care plans including risk assessment for correct level of supervision pilot completed in a number of high risk clinical areas. Awaiting documentation for full roll out. End Sept 2016 Approval in principle to create a new multi-skilled First Responder role for more vulnerable areas of the Trust. HR process/consultation in place Improve conflict resolution training for clinical staff using DATIX intelligence from December 2016 Encourage more comprehensive reporting of incidents by wider promotion of actions taken in response to untoward events Commission remote lockdown capability at StJUH (to be consistent with LGI) Order to be raised following tender Nov 2016 Minimise the inappropriate use of CROMA staff through training and responsiveness to incidents Acute Medicine and Urgent Care CSU s Assessment Review Frequency G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx

20 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 Treatment S=4 L=4 A programme for renewal of distribution pipe work has been implemented. The Trust has spent 80K in June 2015 replacing infrastructure above neonatal. 250 was allocated from B&E capital in 2015/16 for further replacement of more of the infrastructure. A request to consider allocating a further 350K B&E capital in 2016/17 has been made. To minimise the impact when leaks occur, the response receives a high priority with repairs undertaken and services restored as quickly as possible. Additional equipment t deployed to minimise period of drying out Estates and Facilities Simon Neville G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx

21 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 Emergency generator power provision across all sites Dual electrical supplies to most clinical areas Independent battery back-up in clinical areas Use of battery operated equipment L=4 Completed assessment of Telephony Switchboard resilience in terms of UPS protection and autonomy (up to 4 hours) Estates staff escalate high level concerns/incidents out-of-hours to Clinical Site Manager/On-call Management Team Estates Handbook updated for emergency plans (March 2016) 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) Levels of electrical resilience throughout the Trust have been risk assessed in line with the HTM (Sept 2016) Golden Box - Introduction of an interim engineering solution for procedures which rely solely on an electrical supply to deliver patient care (From Dec 2016) Theatre review Programme - 1million a year built into capital programme from 2016 to 2031 A capital scheme is being developed to improve the resistance to electrical failure through the introduction of 2 x 2.5 KVA generator sets to replace the 2 existing 800 KVA sets There is a current plan to increase the electrical autonomy on J54 Critical Care from 10 minutes to 1 hour before 31 March 2017 Estates and facilities Review Frequency 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) Infrastructure to support Geoffrey Giles theatre and J54 (ICU) will be installed by March 2017 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 G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx

22 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 S=4 Treatment (Controls) 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 G:\s_Support_Team\General\Trust Board\ \BoD\Formal Board Meetings\05 26 January 2017\Public\Final\11.1 Corporate Register January 2017.docx