Appendix 1: Croydon Clinical Register and Board Assurance Framework - 9th April 2013 Principal to Delivery Key Assurance on we have in in our are 1. To achieve financial sustainability in three years (2013-2014 to 2015-2016) Lead: Director of Finance and Recovery 1.1 To ensure contracts perform within their financial envelope Patient demand and supplie4r induce4d demand exceeds contract volumes Contracts have been negotiated based on maximised efficiency and minimised risk.slcsu provide contract management for SEL contracts. Rigorous investigation of CHS over performance Evident reduction of activity Gover Body not receiving reports on a specialty basis; requires special level reporting and drivers Acute Task Monthly contract meetings Senior Mgmt. Team / Recovery QIPP Operational Board 25(5x5) Actions to reduce A&E/UCC attendances. More control over non-elective activity needed. Working with CUH to understand demand and capacity Review waiting list data at CUH (31/03/13) 25(5x5) Di Carter CSU Contracts Manager 1.2 To ensure delivery of QIPP schemes (2013 2014) Failure of acute pathway redevelopments to deliver savings Year end negotiations Planned care developments included in contract LTC savings have long stop date of 30 th May for inclusion Acute Task 20 (5x4) Pathway activity data to be reflected in SLAM from M4. (31/3/13) 20 (5x4) Di Carter CSU Contracts Manager Page 1 of 17
to Delivery Key Assurance on we have in in our are MH/SLAM Acute inpatient financial over performance Insufficient commissio resource available to deliver savings. agreement with SLaM; regular contract monitoring, which has been included in this year s contract. Temporary resource identified to support key areas, e.g. urgent care, LTCs. Additional support from Price Waterhouse Cooper (PWC) Approach for management Business case not yet completed and agreed as at 07-03-2013 None identified QIPP Operational Performance SMT/ Recovery SMT/Recovery None identified 16 (4x4) Approve SLaM business case for service re-design, including new triage ward. (31/3/13) 2013/2014 contract negotiations Adopt matrix structure at SMT level. Rapidly progress recruitment into posts covered by interims Development of ICU structure Maximise CSU support for all related areas 12(3x4) 12 (4x3) John Haseler Senior Mental Health ner Slippage in QIPP delivery Developing and delivering QIPP plan that delivers PCT/ only supporting new investments that Too early in the process to assess results Robust reports which triangulate activity and QIPP schemes Too early in the process to assess results TBC 25(5x5) Develop QIPP plans that will deliver. EMW regular opportunity with wider engagement to develop new QIPP schemes 25(5x5) Page 2 of 17
to Delivery Key Assurance on we have in in our are 1.3 To identify plans for longer term recovery (2013/2014 to 2015/2016)) Continuing care retrospective review result in additional claims Unable to identify further schemes supports QIPP. New dedicated CC Nurse working on this. Claims being reviewed Admin resource has been identified and allocated to assist the CC nurse. All scheme to be stretched where possible e.g. prescribing, corporate. Ongoing project with PWC to review benchmark and develop new initiatives OD plan with GP networks including Final findings of review awaited Further understanding of potential areas to focus on Developing and delivering QIPP plan that delivers PCT/ only supporting new investments that supports QIPP. Governance structure in. Strengthened by QIPP network across South London, initiated in Croydon. QOB SMT/Recovery Final findings of review awaited 12(3x4) 25(5x5) -Consideration being given to participation in cluster centralised approach to ensure sufficient capacity to undertake the reviews. PWC engaged to support development of schemes Financial review Benchmarking Impact testing from elsewhere Support development of local schemes (to 30-04-2013) Engagement event with Pharmacists, LTC stakeholders 12(3x4) 20(5x4) Mike Sexton Chief Finance Officer Page 3 of 17
to Delivery Key Assurance on we have in in our are leadership (David Colin-Thome) 1.42013/201 4 To identify and manage financial risk arising from allocation/pb R e.g. specialist commissioni ng; primary care (added by CFO 07-03-2013) Increase the recurring financial challenge Reconciliation of baseline return and NCB working papers Reconciliation of specialist commissio transfers Limited information from NCB Formal approach to NCB seeking resolution 25 (5x5) Escalating discussions with NCB 15 (3x5) Mike Sexton Chief Finance Officer 2. To commission integrated, safe, high quality service in the right at the right time Lead: Director of Governance and 2.1 To achieve the improvement and performance targets with a specified focus on A&E, RTT, and Imms Lack of understanding of the key issues and so actions do not deliver the necessary change Monthly dashboard reports reviewed by SMT & gover body Monthly performance discussions at CQR Escalation to Full root cause analysis of poor performance Comprehensive dashboard not in SMT CQR Performance Task and finish group Leads responsible for ensuring action are in CSU to undertake full analysis of key acute indicators not performing to inform action Ensure dashboard covers all indicators - end of February. COMPLETED Review the governance for 12(3x4) Fouzia Harrington Governanc e and Page 4 of 17
to Delivery Key Assurance on we have in in our are A&E performance Type 1 and all performance recovery provider Action plan in Ongoing meeting of the Clinical Outcomes/ Service Spec Operational provider leads group Daily situation reporting from ED and UCC. A&E prioritised Recovery Trajectory agreed following Emergency Care Intensive Support Team follow up review Effective streaming and pathway Urgent Care Integrated Governance SMT/Recovery 20(4x5) management of provider performance - by the end of April Review of the protocols and processes for patient pathways management to ensure ness. Revised streaming pathway to be agreed between ED and UCC clinical leads completed. Agreed pathway documentation to be approved by the Urgent Care Integrated Governance Board. Hold system wide summit to review emergency pathway Review of urgent care diagnostic 20 (4x5) Page 5 of 17
to Delivery Key Assurance on we have in in our are RTT Performance Recovery Meeting held with CHS Action plan to clear back log agreed Action plan for sustainable performance SMT - 20(4x5) Further analysis to be completed with (Mid Feb) COMPLETED input to the development of a sustainable by end of April 20 (4x5) Fouzia Harrington 2.2 To achieve improved quality of service at CHS Unable to deliver Improving Access to Psychological Therapies in accordance with the NHS Operating Framework Lack of focus on key issues - clinician led review group for all psychological therapies. -Current budgets and services reviewed CHS clinical quality review group has a programme of focus Alignment of all interested organisations expectations Clear measurable improvements not defined -Value for money reviewed at monthly SLAM CQR (part 2 Business/Perfor mance) & at relevant contract meetings with other providers. Monitoring CHS Clinical Review SMT 20(4x5) -Report going to SMT regarding gap with demand and current commissioned service Agree with CHS, NCB and TDA priorities and improvement expected (mid march 2013) Revised time scale end of May Development of dashboard (mid march 2013) () Revised timescale end of 12(3x4) 15(3x5) John Haseler Senior Mental Health ner Fouzia Harrington Governanc e and Page 6 of 17
to Delivery Key Assurance on we have in in our are Committee May Align CQUINS where possible (mid march 2013) Develop a quality strategy and plan. (end of May 2013) Failure to deliver an Community Diabetic Service Improvement agreed with clinical lead and CHS 7.12.12. LES brought back to by 1.12.12. Assurances to be provided by CHS on patient education arrangements None identified SMT/recovery Discussion of risks at CQR April 2013 None identified to carry out a peer lead skills development programme for Primary Care. 12(4x3) Page 7 of 17 Project plan on to reprocure intermediate service and
to Delivery Key Assurance on we have in in our are patient education to April Gover Body 2.3 To achieve improved patient experience Lack of focus on key issues CHS clinical quality review group has a programme of focus Alignment of all interested organisations expectations Clear measurable improvements not defined Monitoring CHS Clinical Review SMT Committee 20(4x5) Agree with CHS, NCB and TDA priorities and improvement expected (mid march 2013) Revised time scale end of May Development of dashboard (mid march 2013 Revised timescale end of May Align CQUINS where possible (mid march 2013) 15(3x5) Fouzia Harrington Governanc e and Develop a quality strategy and plan. (end of May 2013) 2.4 To ensure safe services Management of within Health Visiting Bank staff have been used. Weekly prioritisation of allocated workload. TBC Weekly meetings with Sector Director of Nursing, designated Nurse for ners 20(4x5) -Escalation plan to be reviewed by CBT and Sector. CBT commissioners to confirmed core requirements for 2012/13. 9(3x3) Jane McAllister Senior Children s ner Page 8 of 17
to Delivery Key Assurance on we have in in our are Fully used of skill mix. Child health clinics reduced. 3 year CQUIN agreed that includes increase to number of HV's to an acceptable ration and Public Health. CHS HVs up to establishment of 52 WTE as of 13-02-2013 Target level of 60 WTE by 31-03-2013; 62 WTE by 2014/2015 Root cause analysis carried out on low levels of under-one reviews. Insufficient regarding Urgent Care Children processes Liaison Health Visitor in Action Plan in and regular meetings with designated Lead. Further Named GP Lead Children's Governance. Provision of processes are being followed in accordance with contract. Action plan (see ) may not be meeting all its milestones because of insufficient /evidence received from provider. 9(3x3) Sally Innis Head of Safeguardi ng Page 9 of 17
to Delivery Key Assurance on we have in in our are Insufficient regarding Edridge Road children processes engagement from UCC. Action Plan in and regular meetings with designated Lead. Action plan updated Dec 2012, and progress made. TBC Named GP Lead Children's Governance. Evidence to be provided that robust processes are in and being followed. Although some evidence has been received this will remain an action until all s received. 9(3x3) Sally Innis Head of Safeguardi ng Lack of within GP Practice DBSDisclosure and Barring Service (DBS) checks have been completed Lead nurse has increased capacity to manage safeguarding children. DBS check is completed for all GPs when joi their Performers List stating they know there are no gaps and all GP on their Performers List will have had an enhanced DBS undertaken SW London Primary Care Team provided /evidence of DBS checks as part of Primary Care Report DBS checks in GP Practices now the responsibility of CQC as part of the registration process risk CLOSED Page 10 of 17
to Delivery Key Assurance on we have in in our are No Named GP for Children. No of Accreditation of Intermediate Services (GPSI) and Enhanced Services because it is a mandatory requirement Recommendation reported to SMT. SMT have approved recruitment into post. -Action plan in for the recruitment process. -Post is advertised on NHS Jobs. Intermediate/Enh anced Services CQR has established an accreditation document to record information and this has been reviewed at the monthly CQR meeting. Vasectomy Intermediate Recruitment process to be completed - interview date now arranged. TBC transferred SMT 12(4x3) COMPLETED 9(3x3) Sally Innis Head of Safeguardi ng CQR Medical Director has provided in relation to the 12(4x3) Assurance to be provided that all Enhanced services are accredited where relevant and recorded on the approved accreditation document reviewed at the monthly CQR. 9(3x3) Page 11 of 17
to Delivery Key Assurance on we have in in our are CAMHS Demand and Capacity not being met Service currently not GPSi accredited Additional investment of 250k negotiated through the NHS contract for SLAM 2012/13. Shared Care Prescribing Protocols. Further management of demand Addressing capacity Additional of safeguarding safety of the service to the lead commissioner. CAMHS Partnership SLAM Clinical Review Croydon Borough SMT /Recovery None identified Review of prescribing and intensive outreach support required at Primary Care level through enhanced service provision (Complete) Review of the referral criteria. (Complete) 12(4x3) Jane McAllister Senior Children s ner QIPP Operational Board Shared Care Prescribing Protocols to be extended. (Complete) Data to be reviewed on current estimated waiting times of 7 months. (31/3/13) Page 12 of 17 Data to be reviewed on why approximately 50% of referrals from Primary Care are rejected. (31/3/13)
to Delivery Key Assurance on we have in in our are Recruitment requirements to be reviewed. (31/3/13) issues to be reviewed. (31/3/13) 3. To have collaborative relationships to ensure integrated approach Lead: Director of Governance and 3.1 To improve and sustain robust and working relationships Deterioration of relationships led Transformation Board has all partners Active Membership of the HWBB Engagement strategy in Increased GP engagement. Implementation of engagement strategy Engagement Manager post established SMT - 12(3x4) Present priorities to SMT ((February 2013) COMPLETE Appoint to Engagement Manager position (March 2013) Review of key partnership executive meetings to be completed by 28.2.13 COMPLETED 8(2x4) Fouzia Harrington Governanc e and Review of partnership executive meetings. Seeking alternative methods of engagement Page 13 of 17
to Delivery Key Assurance on we have in in our are 4. To develop as a mature membership organisation Lead: Director of Governance and Executive & Senior focus and Capacity other than formal meetings where practical. Clear Organisational Prioritised Director & Work Plans Prioritised Dire ctor & work plans See below Integrated Strategic Operating Plan (ISOP) Regular 1:1 with CO Formalised assessment of progress Formalised assessment of Progress 12 (3x4) Quarterly Review of Progress against ISOP Development of prioritised director & work plans by function (End of May 2013) Monthly Review of Progress. 9 (3x3) Paula Swann Chief Officer Full Recruitment to Permanent Posts (see below) See below See below Delivery of End to end CSU service (see below) See below Contingency monies available for gaps in Page 14 of 17
to Delivery Key Assurance on we have in in our are functions not commissioned Lack of Permanent Recruitment to & PMO posts Full Recruitment to Permanent Posts Vacancies in team Vacancy Monitoring Manpower Reporting Review of Capacity Recruitment plan for permanent posts. Monthly Review of Manpower & Capacity CSU do not deliver the commissio support required End to end service specification in with KPIs including responsiveness CSU MD is the account manager Contingency monies available for gaps in functions not commissioned Responsiveness of CSU Staff understanding Croydon and the new model of commissio Monthly Contract Meeting Monthly KPI reporting Performance management escalation process in contract Deputy Director lead for contract management Regular Monthly Contract Meeting Monthly KPI reporting 20 (5x4) Internal Audit Review of CSU Contract Management Formal review of capacity CSU and staff joint event (May 2013) Develop an exit strategy including alternative structure and process in case of CSU non-delivery Page 15 of 17 Monthly contract meetings
to Delivery Key Assurance on we have in in our are 4.1 To achieve authorisation 4.2 To ensure wider GP member involvement in the commissioni ng agenda Delivery of the authorisation conditions and directions GPs do not engage sufficiently Progress reports to SMT and Board GP network s with CL leading each network Development of commissio support to networks and engagement framework. Single project plan for addressing each of the caveats Plans still to be implemented Regular report to SMT and Gover Body Gover Body Clinical Leadership - 20(4x5) Authorisation implementation plan (COMPLETE) - 20(5x4) Implementation of : - support -Engagement LES 8(2x4) Fouzia Harrington Governanc e and Lack of understanding and willingness from GP s to engage Delegation of budgets / QIPP Plan to GP Practices. Engagement LES As above As above As above - 20(4x4) GP development programme to be implemented (Start March 2013) 12(3x4) Page 16 of 17
to Delivery Key Assurance on we have in in our are 4.3 To Ensure Conflict of interests are managed ly Lack of robust governance structures in with trai Governance in conflicts of interest register updated monthly GB and CL members Lack of formal governance and reporting processes by practice cluster groups Integrated Governance and Audit Committee 20(4x5) Implement management of conflict of interest trai by 2013 Roll out formal conflicts of interest register to all members (Sept 2013) 12(3 x4) Fouzia Harrington Governanc e and 5.1 To ensure all functions/ responsibiliti es / contracts are handed over Failure to manage transition PWC leading on transition Capacity of commissioners Progress reports to SMT. 20(5x4) Ensure function sheets completed Identify additional capacity for commissioners (Feb 2013) Completed Identify project manager capacity post 1 April Fouzia Harrington Governanc e and Page 17 of 17