Public Board 28 July 2016 Corporate Risk Register

Transcription

1 Agenda Item 11 Public Board 28 July 2016 Corporate Register Presented for: Presented by: Author Previous Committees Assurance Julian Hartley, Chief utive Suzanne Hinchliffe, Chief Nurse and Deputy Chief utive Jonathan Wood, Interim Director of Finance Dean Royles, Director of Human Resources Yvette Oade, Chief Medical Officer Simon Neville, Director of Strategy and Planning Craig Brigg, Director of Quality Management Committees 2 June 2016 and 7 July 2016 Trust Goals The best for patient safety, quality and experience The best place to work A centre for excellence for research, education and innovation Seamless integrated care across organisational boundaries Financial sustainability Key points 1. The Corporate Register has been reviewed. There are currently 16 material risks included in this document for the Board s consideration and oversight. 2. Members of the Board of Directors are invited to: (i) consider, challenge and confirm the correct strategy has been adopted to ensure potentially significant risks are kept under prudent control (ii) consider and approve the changes to significant risks following meetings of the Management Committee held on 2 June and 7 July 2016 (iii) advise on any further risk treatment required. Awareness Discussion and challenge - All

2 1. Summary 1.1 The significant risk profile provides Directors with details on all identified significant risk exposures throughout Leeds Teaching Hospitals NHS Trust. These risks are currently subject to monthly review and have been reviewed by the Management Committee on two occasions (June and July) since the last meeting of the Board. This report has been updated to capture the decisions made by the Management Committee. 1.2 The Trust has identified a range of significant risks, which are currently being mitigated, whose impact could have a direct bearing on requirements within the TDA s Accountability Framework, CQC registration or the achievement of Trust policies, aims and objectives should the mitigation plans be ineffective. Currently, the significant risks relate to the following areas: National Standards 18-week RTT standard, 62-day Cancer, 6-week diagnostic wait targets and waiting times for endoscopy Finance Aggregate effect of income volatility, non-delivery of CIP in 2016/17, insufficient liquidity and cost pressures, and equipment replacement, IT infrastructure Fundamental Standards of Safety & Quality Nurse staffing levels, medical staffing, C. difficile and MRSA targets, failure to rescue a deteriorating patient, endoscopy accreditation/decontamination, violence due to organic, mental health or behavioural reasons in the Acute Medicine CSU, patient flow, bed capacity and emergency admissions and the inability to deliver a cardiac surgery service Performance & Regulation Corroded pipes in Clarendon Wing, LGI, power failure at LGI and a combination of demand and capacity factors giving rise to unsustainable levels of medical outlying and delayed discharges 1.3 A summary of the main controls and mitigating actions for the significant risks in each area is available in Appendix Significant s Corporate s reviewed at the June Management Committee The corporate risks relating to 18 week RTT Target non-compliance (CRR13) and Corroded heating pipes in Clarendon Wing, LGI - potential disruption to services (CRR34) were discussed in detail at the meeting. Controls and actions were updated but there was no change to the current scores of 20 and 16 respectively. Corporate s reviewed at the July Management Committee The corporate risk relating to Unsustainable levels of medical outliers in Acute Medicine CSU (CRR32) was discussed in detail at the meeting. The Committee agreed that this was a much broader issue than just delayed transfers of care and that it also included patients who are medically fit for discharge. It was agreed that the score should remain at 20 however the Chief Nurse/deputy Chief executive and the Director of Quality would revisit the risk description prior to the August meeting of the Management Committee. The Committee also received an update from the Clinical Director and Head of Nursing of the Cardio-Respiratory CSU in relation to the theatre capacity and overall staffing difficulties faced by the cardiac surgery service. It was agreed that the risk score should be elevated from a 12 on the CSU s risk register to a 16 which would designate it a corporate risk. This has been added to the Corporate Register as CRR 36. 2

3 Potential significant risks identified within CSU risk registers remain subject to review and are challenged at the Management Committee. Significant risks relating to staffing levels, infection prevention, delivery of 62-day cancers, 18-week RTT and delivery of financial plans are frequently cited within CSU risk registers. For the purpose of Corporate Register these risks are aligned to the aggregate corporate risk ratings and reflected in CRR1, CRR2, CRR9, CRR13 and CRR Background See previous reports to the Board of Directors. 3. Proposal Not applicable. 4. Financial Implications and See specific risks for details (where applicable). 5. Communication and Involvement The Corporate Register is made available for review executive directors, corporate teams and CSUs at the monthly Management Committee. 6. Equality Analysis No adverse implications identified under equality and diversity legislation. 7. Publication Under Freedom of Information Act This paper is made available under the Freedom of Information Act Recommendations Members of the Board of Directors are invited to: consider, challenge and confirm the correct strategy has been adopted to keep potential significant risk under prudent control consider and approve the changes to significant risks following the two meetings of the Management Committee; and advise on any further risk treatment required. 9. Supporting Information Corporate Register - Appendix 1. Craig Brigg Director of Quality July

4 CORPORATE RISK REGISTER JULY

5 Appendix 1: Corporate Register JULY 2016 Nature of Current Score & Change Within Tolerance? Safety & Quality CRR1 Inadequate Nurse Staffing Levels Chief Nurse/Deputy CEO 20 No CRR2 Exposure to Healthcare Associated Infection - Clostridium difficile & MRSA Chief Medical Officer 20 No CRR28 Failure to Rescue a Deteriorating Patient Chief Medical Officer 16 No CRR33 Violence due to organic, mental health or behavioural reasons in the Acute Medicine CSU Chief Nurse/Deputy CEO 16 No CRR36 Inability to deliver a cardiac surgery service Chief Nurse/Deputy CEO 16 No Financial CRR9 Failure to deliver the financial plan (aggregate effect of income volatility, CIP shortfall and Director of Finance cost pressures) 20 No CRR6 Unserviceable critical IT infrastructure and resilience Director of Finance 20 No People CRR18 Reducing supply of doctors in training Chief Medical Officer 16 No Performance & Regulation CRR13 18-week RTT Target non-compliance Chief Nurse/Deputy CEO 20 No CRR15 62-Day Cancer Target Chief Nurse/Deputy CEO 20 No CRR22 Patients waiting longer than 6 weeks following referral for diagnostic tests Chief Nurse/Deputy CEO 15 No CRR27 Delays in endoscopy procedures; failure to achieve JAG accreditation Chief Nurse/Deputy CEO 16 No CRR31 Patient flow and capacity for emergency admissions (health economy) Chief Nurse/Deputy CEO 20 No CRR32 Unsustainable levels of medical outlying in Acute Medicine CSU Chief Nurse/Deputy CEO 20 No CRR34 Corroded heating pipes in Clarendon Wing, LGI - potential disruption to services Director of Strategy 16 No CRR35 Power failure/lack of IPS/UPS resilience due to electrical infrastructure Director of Strategy 16 No Symbols used in this report Inherent and Unmitigated Score Residual Score (Current Exposure) Target / Appetite Threshold No change since last report < > increased (since last report) reduced (since last report) 5

6 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 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 - Sept 2016) Differential risk rating identified for CSUs with most significant recruitment challenges (April 2016): Medicine & Older People Critical Care Cardio-respiratory Trauma Chief Nurse - progress reported to Board (Hard Truths) Clinical Practice ANTICIPATED EFFECT ON CONTROL / COMMENT 6

7 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=4 Core Prevention Controls Patient level assessment of risk on admission/arrival (filed in patient care record) Use of Standard Precautions 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 Prescribing Policy and Standards Antimicrobial Stewardship Rounds led by Microbiologist Mandatory Infection Prevention & Control Training to all staff Overarching Infection Prevention Policy and suite of Guidelines and SOPs MRSA decolonisation for specific patients Provision and use of hand hygiene materials and washing facilities Provision and use of Personal Protective Clothing (gloves, aprons, masks, eye protection etc) Side room facilities Increased the number of hand hygiene basins (at strategic locations within or adjacent to specified clinical areas) Ensured all staff undertake and complete mandatory training HPV terminal clean to side rooms after CDI occupancy Whole ward decant HPV programme Core Detection Control Ward health check monthly MRSA Screening Procedure Catheter-related blood stream infection surveillance in critical care Safety thermometer - catheter-relates UTI Alert organism surveillance Ward-based surveillance (viral gastroenteritis) Protocol for [C. difficile] Cell Cytotoxin Assay testing Daily IPC Team of cases with Microbiological support Root Cause Analysis of identified cases Hand hygiene and source isolation audits Audit of compliance with High Impact Interventions at Ward level Surgical site infection surveillance Contingency/Recovery Controls Management of Outbreak Guideline Enhanced IPC Team intervention & support Cohort isolation practices (ring-fenced CDI cohort facility) Closure of Ward(s) to new admissions (where necessary) Complete planned programme of whole ward decant HPV fogging (Director of Estates & Facilities remains in progress) the business case for UV decontamination treatment (in view of the fact that HPV cannot be reliably applied) April 2016 ANTICIPATED EFFECT ON CONTROL / COMMENT Recommendation/Decision Required: continue to acknowledge the level of risk remains unacceptable and maintain efforts to further reduce exposure by improving control effectiveness and delivering the action plan. 7

8 CRR06: Unserviceable critical IT infrastructure and resilience. Potential 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. Tony Whitfield 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 ANTICIPATED EFFECT ON CONTROL / COMMENT IT Assessment Contingency/Recovery Controls 90% of critical IT systems on the old platform have been migrated to new IT platform to reduce exposure and maintain resilience Optimised power, performance and stability of old IT platform following migration of 90% 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 8

9 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 Director of Finance 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 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 Core Detection Controls Monthly board/budget reporting and outturn forecasts Liquidity score calculated and reported monthly Performance 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 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 Joint cost based review with Commissioners to take place in spring/summer 2016 Implementation of the Virginia Mason/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 ANTICIPATED EFFECT ON CONTROL / COMMENT Assessment 9

10 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 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 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 Continued management of the discharge of patients medically fit for discharge Implement the productive operating theatre (TPOT) programme across the Trust to maximise productivity and capacity available Performance Management ANTICIPATED EFFECT ON CONTROL / COMMENT Recommendation/Decision Required: 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 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 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 significant performance risk 10

11 S=5 CRR15: 62-Day Cancer Target Potential 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 Treatment L=4 Core Prevention Controls Access policy and procedures Waiting list management and referral procedures on Patient Pathway Manager Efficient use of critical care beds Procedure to govern cancellations Application of cancer waiting time guidance Yorkshire Cancer Network guidelines for each tumour group 54-day pathway mapped out for each tumour group MDT Meetings Capacity and demand modelling is in place for priority 62-day specialties with quarterly review process commenced by Performance team Theatre utilisation weekly process now in place, with weekly prioritisation for key 62 day specialties Assessment against 8 point Cancer Tsar Plan Core Detection Controls 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 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 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 Performance /Deputy CEO ANTICIPATED EFFECT ON CONTROL / COMMENT 11

12 S=4 CRR18: Reducing supply of doctors in training Potential Insufficient numbers of trainee medical staff on a scale likely to disrupt normal operations 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 Core Prevention Controls 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 Improving the trainee experience Core Detection Control DatixWeb Attendance Management Contingency/Recovery Controls Use of locum doctors Merging of rotas leading to less specialist input Use of consultants in place of trainees 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) Continuous communication updates using contemporary social media (whatsapp/twitter) impressing the Trust s values and reporting good news stories - May 2016 ANTICIPATED EFFECT ON CONTROL / COMMENT Assessment Recommendation/Decision Required: to acknowledge the level of risk exposure remains unacceptable and continue reducing exposure by improving control effectiveness and delivering the action plan. 12

13 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. Effective management of Annual Leave Capacity & Demand modelling Effective KPIs in place to monitor performance Supported use of the Independent sector 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 COO 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 independent sector capacity to address shortfalls. Endoscopy Recovery Group established, chaired by ADOP Endoscopy Turnaround Manager in place Endoscopy and Audiology Recovery Plans agreed and delivery begun Continued support by Service Improvement Team ANTICIPATED EFFECT ON CONTROL / COMMENT Assessment 13

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 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 from beginning of to reduce LTHT demand. Detect Controls 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. of clinic template and development of sustainable requirements Replacement of temporary administrative staff with substantive appointments with a view to growing local workforce Regular nurse recruitment programme in place Programme of nurse recruitment continues with aim to appoint to all vacant posts by May 2016 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 (To be submitted by 12 September 2016) Following this the National JAG Administration Team will review the service s accreditation status, which is currently Assessed: Improvements Required ANTICIPATED EFFECT ON CONTROL / COMMENT Assessment 14

15 CRR28: Failure to Rescue a Deteriorating Patient Potential Insufficient staff out of hours to respond to deteriorating patients. Caused by lack of 24/7 Outreach provision. Resulting in potential deterioration of, and harm to, patients. Yvette Oade Treatment S=4 L=4 Prevention Control Taking and recording of observations at a frequency determined by clinical need Use and Early Warning Scoring System (with escalation as appropriate) Mandatory Training (Resuscitation) Advanced life support training (as required by role) Implementation of Quality Improvement programme (deteriorating patient) Quality Improvement programme (deteriorating patient) - interventions agreed and tested in 15 pilot wards Detect Controls Emergency Medical Response/Cardiac Arrest Call System Contingency/Recovery Controls Deployment of Critical Care Outreach Tests of change completed October spread care bundle to all wards in the Trust, supported by Faculty - May 2016 Intervention package agreed and launched - piloted on 15 wards in programme - May 2016 CSU roll out to commence Feb /7 Outreach Team to be provided at St James s - May 2016 and LGI - August 2016 Ward L39 to transfer from Clarendon Wing at LGI to L08 on Jubilee Wing - April 2016 Increased staffing ANTICIPATED EFFECT ON CONTROL / COMMENT Assessment 15

16 CRR31: Insufficient capacity and patient flow across the health care system for emergency admissions Potential Failure to provide sufficient capacity in the Trust and across the health care system for emergency admissions. This may result in (i) High numbers of patients in the bed base who are medically fit for discharge as services not available in the community and social care (ii) Failure to deliver 4 hr emergency care standard (iii) (iv) (v) (vi) (vii) Elective admission cancellations and cancelled operations Failure to transfer patients out of critical care (step down)and provide capacity for patients who require high dependency or critical care Failure to respond to peaks in emergency care demand Poor patient experience, high number of outliers and potential harm to patients Poor staff morale and well-being at work Suzanne Hinchliffe Treatment S=5 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 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 System wide winter plan and 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 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) LTHT has arranged a meeting in July 2016 with key partners to discuss the governance and delivery of the Sustainable Transformation Plan (STP) and have already undertaken a nonelective workshop to determine opportunities Trust. LTHT to develop a clear strategy and implementation plan for robust assessment for ambulatory care (Mar 2017) System wide (SRG) 20% of nonelective attendances could be managed by Primary care. System wide plan to be developed to determine if there should be GP s in A/E or that patients should be diverted to alternative providers (Aug 2016) WYAT Regional re-patriation process developed. Final sign off by WYAT (Aug 2016) CSU s Assessment ANTICIPATED EFFECT ON CONTROL / COMMENT 16

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 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 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 Agreed approach for the management of outliers by consultants and relevant specialties including timeliness of review, escalation, and which team covers what ward 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 Recruit junior doctors to cover outliers including at the weekends Management of discharge processes and reduced length of stay trajectories relating to delayed transfers of care with partner organisations (July 2016) ANTICIPATED EFFECT ON CONTROL / COMMENT CSU Assessment 17

18 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 S=4 L=4 Prevention Control Procedure in place for the management of violence in clinical areas Training provided for staff on the management of violence in high risk areas, including acute medicine, admission areas and urgent care Procedure for obtaining urgent psychiatric assessments 24/7 support from Acute Liaison Psychiatry Service (ALPS) and escalation; links to Crisis Assessment Service (Becklin Centre) Out of hours on-call psychiatry staff located at St James s hospital Daily nurse staffing reviews, support from Matron and CSM Collaborative working with partners in health and social care CHROMA risk assessment tool implemented, which determines when external expertise is required Detect Controls 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 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 - May 2016 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 ANTICIPATED EFFECT ON CONTROL / COMMENT Acute Medicine CSU Assessment Contingency/Recovery Controls 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 18

19 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 to be deployed to minimise period of drying out - May 2016 Estates and Facilities Simon Neville 19

20 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/Oncall Management Team Estates Handbook updated for emergency plans (March 2016) Comprehensive review across the Trust completed which documents precise location of all electrical equipment Golden Box - Introduction of an interim engineering solution for procedures which rely solely on an electrical supply to deliver patient care (From Sept 2016) Theatre review Programme - 1million a year built into capital programme from 2016 to 2031 Clinical Practice ANTICIPATED EFFECT ON CONTROL / COMMENT 20

21 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; severely damaged reputation, poor patient experience and outcome (e.g. cancelled operations), a decreasing range of cardiac surgery available in LGI, only the most complex electives and all acute cases are performed at LGI (suboptimal case mix), severely restricted service development in Cardiac Surgery and interdependent services such as Cardiology (including development of clinical expertise). 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. ANTICIPATED EFFECT ON CONTROL / COMMENT 21