Impact/Consequence STRATEGIC RISK PROFILE AND ASSURANCE FRAMEWORK *BMT NW 4 *Cardiac RTT *Lung RTT *Tier 1 RTT *Wheelchairs * Plastic surgery RTT (new) *Cardiac surgery for ABHB at QEH (new) 3 *Neuro rehab *BMT SW *delay cardiac referrals (new) 2 *Spinal Rehab 1 1 2 3 4 Likelihood
Strategic Objective Objective Risk Reference Cardiac Surgery CT/9 Plastic Surgery RTT CH/8 Tier 1 RTT Pl/1 Wheelchair Waiting Times NC/3 BMT (NWales) CH/ Description of risk identified Delays in admission of cardiac surgery patients from ABHB to QEH Failure of provider to deliver 26wk/ 36 wks RTT for plastic surgery Delivery of tier 1 RTT targets Waiting times for wheelchairs Bone Marrow Transplantation Service North Wales Initial Score Current Score Trend Last Review 2 2 New 16 16 New 2 16 2 16 1 1 BMT (Swales) CH/7 Bone Marrow Transplantation Service South Wales 2 12 Cardiac Surgery RTT CT/3 Delivery of cardiac surgery RTT targets 2 12 Thoracic Surgery RTT CT/4 Delivery of lung resection surgery RTT 16 12 Neuro- Rehabilitation Service NC/9 Delivery and quality of the neuro-rehabilitation service 12 12
Spinal Rehabilitation NC/1 Provision of spinal rehabilitation 6 6
Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Risk: Failure of provider (South Wales) to deliver 26wk/ 36 wks RTT for plastic surgery Date last reviewed: Executive Board 4 Initial: 4 x 4 = 16 Current: 4 x 4 = 16 Appetite: x 2 = 18 16 14 12 8 6 4 2 Risk Appetite To be confirmed To be confirmed Delivery plan provided by ABMUHB. Failure by HB to deliver against the delivery plan which has lead to correspondence between WHSSC and HB requesting revised delivery plan and assurance that 26wk will be delivered in this financial year Request weekly monitoring of waiting time DoP 31.12.14 performance and activity against delivery plan/ revised delivery plan. (How do we know if the things we are doing are having an impact?) Provider able to deliver agreed performance for plastic surgery (With these actions taken, how serious is the problem?) Current : 4 x 4 = 16 (What additional assurances should we seek?) Performance data required regularly from provider. CH/8
Aug-14 Sep-14 Oct-14 Nov-14 Risk: BMT service for North Wales does not have JACIE accreditation. This may impact on WHSSC's ability to continue to commission the service. There are also operational difficulties ongoing with Consultant staffing and inpatient facilities Date last reviewed: Executive Board 4 Initial: x 3 = 1 Current: x 3 = 1 Appetite: x 2 = 2 1 Risk Appetite WHSSC Service Specification states JACIE accreditation is essential for a commissioned service Provider timescale for submission is currently end of 21 However assurance has been given about operational difficulties BMT is a complex life-saving treatment of very sick patients. Adherence to service specification and risk management is of very high importance. Concern regarding timescale for submission for JACIE accreditation formally escalated to provider Medical by WHSSC Medical - response awaited Assurance requested from Clinical regarding operational difficulties - received Plan and timescale required from provider for Medical 31.8.14 application to JACIE Monitoring of operational difficulties through Gateway meeting DoP 3.9.14 (monthly) (How do we know if the things we are doing are having an impact?) Submission for JACIE accreditation from provider. Accreditation granted (What additional assurances should we seek?) Advice requested from WHSSC Interim of Nursing Current: x 3 = 1 CH/
Risk: Bone Marrow Transplantation (1) Inability to continue to commission the service from provider (provider for South Wales) if JACIE accreditation is not renewed; (2) Four patients have relapsed on the waiting list; (3) Provider clinician identifying that capacity is not adequate to cope with demand Date last reviewed: Executive Board 4 Initial: x 4 = 2 Appetite: x 3 = 1 2 2 1 Clinical outcome data examined up to end March 214 shows good outcomes. But concern remains as to prospective risks for the following reasons: SUI - death of a patient whilst waiting for transplant reported in July 214. Report received by WHSS Medical - capacity issues not the cause. Risk Appetite Plan requested, but not received from UHB regarding matching demand to capacity to control waiting times No response from JACIE regarding accreditation submission. BMT is a complex life-saving treatment of very sick patients. Adherence to Service Specification and risk management is of very high importance. Series of meetings held with provider to address There is no timescale given by JACIE for a DoP 31.12.14 commissioning issues 213/14 response to the UHB submission - this is awaited. UHB has addressed all issues in JACIE inspection report and responded to timescale Decision will need to be made re commissioning intentions if no response continues. Outcomes up to March 214 have been investigated and found to be within normal range Proposal for 214/1 has been received and will be considered by JC in November DoP 3.11.14 Service Specification ratified and published Request for business case to match demand and capacity sent to DoF 19.8.14 Advice requested from WHSSC Interim of Nursing regarding further risk assurance; Report re patient death has been received by Medical - capacity issues not the cause. (How do we know if the things we are doing are having an impact?) (What additional assurances should we seek?) No patients relapsing due to waiting times for BMT; JACIE accreditation given; Additional advice requested from WHSSC Interim of Nursing and Outcomes remain good (With these actions taken, how serious is the problem?) CH/7 Current : 4 x 3 = 12
Risk: The provision of thoracic surgery to undertake lung resection Date last reviewed: Executive Board 4 Initial: 4 x 4 = 16 Appetite: 3 x 3 = 9 2 1 Risk Appetite The current low rates of surgical resection are contributing to relatively poor survival for patients with lung cancer in Wales. An increased resection rate will contribute to improved survival but is not the only factor. The issue of low lung resection rates has been reviewed and a report presented to the Management Group in May 213 and September 214. JC support to develop costed proposals. Providers asked to work together to put in place a mechanism for second opinions and increasing cover for MDT meetings.. To develop commissioning intentions and DoP /12/14 proposals for Management Group/Joint Committee to increase access to recommended rates. (How do we know if the things we are doing are having an impact?) (What additional assurances should we seek?) Increased resection rates demonstrated through the annual national lung None identified. cancer audit. CT/4
Jun-13 Aug-13 Oct-13 Dec-13 Feb-14 Apr-14 Jun-14 Aug-14 Oct-14 Objective: To ensure that the specialised services provided to patients are of an appropriate quality Risk: Patients listed for cardiac surgery are not being treated within a clinically appropriate timeframe leading directly to increased morbidity, increased risk of clinical deterioration leading to emergency admission, and increased risk of mortality, while waiting for surgery. Date last reviewed: Executive Board 4 November 214 (likelihood x consequence): Initial: 4 x = 2 Appetite: 3 x 3 = 9 2 2 1 Risk Appetite Failure in this area would have a large impact on patients Whilst the impact of delayed treatment could have a major impact on patients, the aim is to substantially reduce the likelihood of this happening. Commissioning plans in place to deliver the current RTT target. Funding of further capacity through outsourcing to named centres in England agreed by Joint Committee to reduce waiting times to the current Welsh Government targets. Implementation of outsourcing plan is in progress and WHSSC are monitoring all cardiac surgery mortality on a monthly basis. Cardiac surgery project plan developed and agreed. Medical Papers presented to provide an update on progress to Management Group Joint Committee and Quality and Patient Committee (How do we know if the things we are doing are having an impact?) Implementation of weekly monitoring of waiting time performance and activity against planned delivery Implementation of weekly monitoring of waiting time performance and activity against planned delivery Continued implementation of action plan of the Cardiac Surgery Review Implementation Group and project plan. Continued engagement on taking forward plan to reduce waiting times to clinically recommended levels. To continue to provide regular updates to 1) Management Group, 2) Joint Committee and 3) Quality and Patient of Planning of Planning of Planning of Planning (What additional assurances should we seek?) Monthly monitoring reports to be received from providers To receive weekly reports on cardiac theatre utilisation 3/11/14 Monthly 3/11/14 Monthly 3/11/14 Monthly 2/11/14 11/12/14 Current : 4 x 3 = 12 None CT/3
Risk: Delays in the admission of cardiac surgery patients from ABHB to Queen Elizabeth Hospital, Birmingham Date last reviewed: Executive Board 4 Initial: x 4 = 2 Current: x 4 = 2 Appetite: 4 x 3 = 12 2 2 1 Risk Appetite To be confirmed To be confirmed Jul-14 Aug-14 Sep-14 Oct-14 Regular monitoring of outsourced patients at Queen Elizabeth Hospital, Birmingham New referrals temporarily ceased. DoP 31//14 (How do we know if the things we are doing are having an impact?) (What additional assurances should we seek?) All referrals to be admitted within agreed timescales All referrals to be admitted within agreed timescales Current: x 4 = 2 CT/9
Risk: Late referrals from cardiology services for cardiac surgery Date last reviewed: Executive Board 4 Initial: 4 x 3 = 12 Appetite: 2 x 3 = 6 1 Risk Appetite To be confirmed To be confirmed Jul-14 Aug-14 Sep-14 Oct-14 Late referrals will be monitored on a monthly basis and an exception report will be developed and shared with the referring Health Board. To monitor late referrals and confirm with DoP 31//14 referrers and providers that late referrals (in excess of 26 weeks) will count as a referral breach Referrals in excess of 26 weeks will be offered DoP 31//14 outsourcing (How do we know if the things we are doing are having an impact?) (What additional assurances should we seek?) No late referrals (in excess of 26 weeks) Referral times to be received CT/7
May-13 Jul-13 Sep-13 Nov-13 Jan-14 Mar-14 May-14 Jul-14 Sep-14 Risk: Waiting times for assessment and delivery of wheelchairs not meeting public expectations Date last reviewed: Executive Board 4 Initial: 4 x = 2 Current: 4 x 4 = 16 Appetite: 3 x 2 = 6 2 1 Risk Appetite Service is failing to meet 26 week waiting times target. As a consequence there are a number of patients who are unable to mobilise appropriately. Whilst is it not possible to meet the expectations of all service users, the achievement of a 26 week waiting will be in line with targets for other services, and such is likely to meet the needs of the majority of service users. All Wales Posture and Mobility Review recommendations to improve waiting times; DSU/NLIAH Service improvement project in progress to March 212; Partnership Board making good progress. Report submitted to JC Nov 211; Waiting time data reported to Welsh Government on a monthly basis; All Centres reporting RTT for whole pathway to WG and WHSSC; Performance against targets continues to deteriorate; WHSSC has now been asked to performance manage the three centres in Wales; A report has been requested (Oct '14) from each centre with details of they plan to improve performance (How do we know if the things we are doing are having an impact?) Monthly waiting times return and Key Performance Indicator return provide information on current service performance. Trend monitored on a monthly basis and reported to N&CC programme team WISB developing DSCN on wheelchair waiting DoP 19/11/14 times Public Health Wales Service Improvement leading DoP 19/11/14 work on development of service website including the publication of waiting times Performance Management has been further DoP 19/11/14 escalated, and meetings are now held with the three centres and Welsh Government on a quarterly basis. (What additional assurances should we seek?) Work underway as part of the ALAS project to review the current income and expenditure profile. Current: 4 x 4 = 16 NC/3
May-13 Jul-13 Sep-13 Nov-13 Jan-14 Mar-14 May-14 Jul-14 Sep-14 Risk: Spinal rehabilitation: Mid and South Wales Spinal rehabilitation service may not be sustainable, as it is currently delivered by one consultant. Date last reviewed: Executive Board 4 Initial: 3 x 4 = 12 Current: 3 x 2 = 6 Appetite: 2 x 2 = 4 14 12 8 6 4 2 Risk Sc The service is currently delivered by one consultant, and as such there are key gaps in cover which will impact on sustainability. The service is experiencing difficulties with the provision of urological support, unless all patients are monitored and managed appropriately there is a risk that they will develop renal failure This rationale needs to be updated The service cares for vulnerable adults, therefore the risk should be very low, a maximum of 4 to 6. The requirement for 2 WTE consultants has been recognised and recommended by the James Steers Neurosciences Review and the Axford Mid and South Wales Neurosciences Review New consultatn in post Service currently reviewing model and options for across spinal and rehabilitation services An SPR will be appointed to the service shortly WHSSC Medical has written to the Medical at Cardiff and Vale, to seek clarity regarding the arrangements for providing the Urology service Review response from Medical once received, and consider whether further escalation is required to resolve the issues of sustainability Review current commissioning arrangements for Spinal Cord Injury Rehabilitation, in order that we can ensure that patients are able to access a service which is able to fully meet their requirements. Medical of Planning (How do we know if the things we are doing are having an impact?) (What additional assurances should we seek?) Response from provider Medical Further assurance is required on the model for delivering spinal rehabilitation services on the current site, and with any proposed move to alternative site. Current: 3 x 2 = 6 NC/1
Sep-13 Nov-13 Jan-14 Mar-14 May-14 Jul-14 Sep-14 Risk: Email received raising concerns with the delivery and quality of neuro-rehabilitation service within a specific provider. Date last reviewed: Executive Board 4 Initial: 4 x 3 = 12 Appetite: 3 x 3 = 9 1 Risk Appetite Concerns raised about the delivery and quality of the service The service cares for vulnerable adults, therefore the risk should be very low, a maximum of 4 to 6. Meeting held between WHSSC MD and Head of Nursing and provider MD Issue highlighted at In-Committee JC on 17/9/213 Service currently participating in WHSSC multi centre audit meetings. Require final report from provider addressing all IL of the concerns raised in the initial communication. (How do we know if the things we are doing are having an impact?) Reassurance through final report that all issues have been addressed (What additional assurances should we seek?) The service should be contributing to UKROC NC/9
Risk: Delivery of tier 1 referral to treatment waiting times targets i.e. 26 weeks primarily in relation to plastic surgery, neurosurgery and cardiac surgery in Welsh Provider LHBs Phillips, DoP) Date last reviewed: Executive Board 4 Initial: 4 x = 2 Current: 4 x 4 = 16 Appetite: x 2 = 2 2 1 Services are currently failing to deliver the 26 week RTT target and the back stop 36 week target Risk Failure to receive specialised services in a timely manner (especially cardiac surgery) may have a detrimental impact on patients Waiting times monitored and reported on a monthly basis. Performance management discussions with providers based on delivery plans. Delivery of RTT is a standing agenda item for discussion at SLA meetings Outsourcing of cardiac surgery patients (How do we know if the things we are doing are having an impact?) Monitoring information showing performance in line with tracjectory and decreased waiting times Risk assess the potential for adverse outcomes DoP 31//14 on waiting list by specialty and by 26/36 weeks Update the review of delivery plans from DoP 31//14 Providers and explicitly consider in Annual Plan process Unresolved risk to be considered with alternative DoP 31//14 actions including provider/catchment realignment LHBs to produce 36 week Delivery Plan DoP 31//14 identifying actions to reduce waiting times Establish mechanism to monitor morbidity and DoP 31//14 mortality on waiting lists (What additional assurances should we seek?) None identified Current: 4 x 4 = 16 Pl/1