Corporate Register 1. LTHT has identified a range of material risks, which are currently being mitigated, whose impact could have a direct bearing on requirements within the NTDA s Accountability Framework, CQC registration or the achievement of corporate objectives should the mitigation plans be ineffective. 2. All corporate risks are co- owned by each member of the Board of Directors and each risk has an executive director lead identified for oversight, leadership and monitoring purposes. Currently, the material risks identified relate to the following areas: Nature of Current Score Within Tolerance? Safety & Quality CRR1 Inadequate Nurse Staffing Levels Chief Nurse 20 No 3 CRR2 Exposure to Healthcare Associated Infection - Clostridium difficile & MRSA Chief Medical Officer 25 No 4 D129 Impact of undertaking repairs to Woodhouse Tunnel Director of Estates & Facilities 15 No 5 Financial CRR9 Failure to ensure a minimum FRR of level 3 Director of Finance 25 No 6 People CRR10 Inadequate employee appraisal or supervision Director of Human Resources 16 No 7 CRR11 Inadequate completion of mandatory training Director of Human Resources 16 No 8 CRR15 62- Day Cancer Target Chief Operating Officer 15 No 11 CRR18 Reducing supply of doctors in training Chief Medical Officer 16 No 13 Compliance CRR12 A&E Target non- compliance Chief Operating Officer 15 Yes 9 CRR13 18- week RTT target non- compliance Chief Operating Officer 20 No 10 CRR17 Inadequate data quality and data governance Director of Informatics 15 No 12 Symbols used in this report Inherent and Unmitigated Score Residual Score (Current Exposure)! Target / Appetite Threshold " Page
APPENDIX 1: LTHT MATERIAL RISK ANALYSIS January 2014 LTHT CORPORATE RISK REGISTER V13 04/03/2014 CRR1: Inadequate Nurse Staffing Levels 1 2 3 4 5 6 8 9 10 12 15 16 20 25 L=4 "! Safety & Quality CORPORATE OBJECTIVE 1: Drive quality improvement for patients to become among the safest organisations in the country 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 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 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 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 Further Actions Planned Investment options to be presented to and supported in principle by Finance & Investment Committee (Chief Nurse 09/01/2014) Shorter term supply management - recruitment process over next 12 months commenced (Chief Nurse - In Progress) Agree recruitment and retention premia where appropriate (Chief Nurse - expected to be agreed by 31st march 2014) Deliver agreed priority investments in staffing as per acuity tool (see investment plan - Chief Nurse - In Progress) ANTICIPATED EFFECT ON CONTROL / COMMENT Clinical Practice 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. Board of Directors 27/03/2014 3
CRR2: Exposure to Healthcare Associated Infection - Clostridium difficile & MRSA Board of Directors 27/03/2014 4 LTHT CORPORATE RISK REGISTER V13 04/03/2014 1 2 3 4 5 6 8 9 10 12 15 16 20 25 L=5 "! Compliance National Target CORPORATE OBJECTIVE 1: Drive quality improvement for patients to become among the safest organisations in the country Potential Effective management systems are not in place or sufficient to protect people from the risk of hospital acquired Clostridium 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 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 MRSA Screening Procedure Surgical site infection surveillance 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 Review 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 Ward Health Check - Monthly 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) Increase the number of hand hygiene basins (at strategic locations within or adjacent to specified clinical areas) (Chief Medical Officer - In Progress) Ensure all staff undertake and complete mandatory training (Director of HR - see CRR11) Accelerate planned programme of whole ward decant HPV fogging (Director of Estates & Facilities - TBC) Review the need for cohort isolation facilities for CDI at LGI (Chief Medical Officer - 31st March 2014) Improve reliability of senior review of antimicrobial prescriptions (Chief Medical Officer - TBC) Explain to commissioners the increased sensitivity of the Cell Cytotoxin Assay test and it s the impact on the number of cases identified at LTHT, and reach agreement in advance with commissioners which CDI cases will count towards the Trust s trajectory for financial penalties in future (Chief Medical Officer - date TBC) Clinical Practice The 2013/14 year-end outturn will be above trajectory for Clostridium difficile, although the Trust remains on course to achieve an overall reduction in the number of cases by approximately 10% compared to 2012/13. The 2013/14 year-end outturn will be above target for MRSA. 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.
D129: Impact of undertaking repairs to Woodhouse Tunnel LTHT CORPORATE RISK REGISTER V13 04/03/2014 1 2 3 4 5 6 8 9 10 12 15 16 20 25 L=3 "! Safety & Quality CORPORATE OBJECTIVE 1: Drive quality improvement for patients to become among the safest organisations in the country Potential Potential disruption to the provision of paediatric and trauma/orthopaedic services at LGI on a scale likely to have significant impact across the Leeds health economy Caused by excessive vibration and noise arising from drilling deep within Woodhouse Tunnel May result in a higher frequency of inter-hospital transfers overnight during the period of repairs; increased cancellations for non-clinical reasons; loss of activity; increased operational pressure across the health economy should it not be possible to operate a full service in floors A and B of Clarendon Wing. Darryn Kerr Not applicable. Treatment Civil Engineer s / Surveyor s Reports Briefings from Directors of Estates & Facilities Minimise impact by undertaking work at night (this will help keep the MR scanner operational during periods of peak activity) The works directly beneath Clarendon Wing to be active during the month of August 2014 when demand is expected to be less intensive for Paediatrics and Orthopaedics. Develop and agree with contractors procedures to halt drilling should vibration compromise image quality of scans and it be necessary to undertake an emergency MR scan during the night (Director of Estates 28th Feb 2014) Undertake and review a formal Health & Safety Assessment, taking whatever steps are necessary to protect staff and patients from the effects of excessive noise and vibration (Director of Estates 28th Feb 2014) Develop, approve and test a contingency plan for use in the event of a significant deterioration in the condition of the tunnel, or should it become necessary to temporarily close floors A and B of Clarendon Wing during the period of repairs (Director of Estates & Chief Operating Officer 28th Feb 2014) Assessment Recommendation/Decision Required: accept the level of risk exposure subject to satisfactory confirmation of further actions outlined above. Board of Directors 27/03/2014 5
CRR9: Failure to ensure a minimum FRR of level 1 2 3 4 5 6 8 9 10 12 15 16 20 25! L=5 " Financial CORPORATE OBJECTIVE 6: Improve financial margins to support the delivery of high quality care Potential Effective management systems are not in place or sufficient to ensure a minimum FRR of level 3. Caused by the aggregate effect of insufficient income, inadequate financial control/information, insufficient liquidity, contract penalties, insufficient CIP delivery and SC affordability. May result in the Trust entering special administration. Tony Whitfield Treatment 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 s Monthly board/budget reporting and outturn forecasts Liquidity score calculated and reported monthly Performance Review Meetings with Finance/COO Corporate approach to problem resolution Negotiation with TDA on surplus or deficit Application to TDA for borrowing or, in extremis, distress funding In-year review and revision of capital commitments Renegotiation with Commissioners to minimise threat of penalties Appointment of Financial Turnaround Director - commenced 2nd Jan 2014 Develop Financial Turnaround Plan and agree with TDA/Commissioners (Director of Finance 31/03/14) Delivery of identified CIP in 2012/13 and 2013/14 (All Directors plus CSU ownership of delivery with Finance support) Redevelop LTFM In line with Board strategy (Director of Finance 31/03/14) Agree realistic thresholds and deliver all CQUINs in 2013/14 (Delivered via CSUs supported by Finance) Modify Scheme of Delegation to reduce authorisation limits (Director of Finance 31/03/14) Establish Working Capital Loan Facility (Director of Finance 31/03/14) Establish I&E/P&L accounts for service lines (Director of Finance 31/03/14) Develop and improve capacity planning to enhance income position (Director of Finance, Director of Strategy & COO 31/03/14) Robustly verify data completeness, accuracy and income coding to enhance income position (Director of Finance 31/03/14) Review SFI s taking whatever action is necessary to strengthen core financial governance (Director of Finance 31/03/14) Deliver training on MyFIT to all budget holders(director of Finance 31/03/14) Consider options for Pay restraint (Director of HR/Finance) Review staff benefits - CEA s, subsidies (Director of HR & Director of Finance 31/01/14) Review stock control/review/run down where appropriate (Director of Finance & COO 31/03/14) Attempt to reduce/influence prices - procurement opportunities (Director of Finance 31/03/14) MARS/PAUL (Planned Additional Unpaid Leave) Schemes (Director of HR & Director of Finance 31/03/14) Board of Directors 27/03/2014 6 Assessment 31/03/2014 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.
CRR10: Inadequate employee appraisal or supervision S=4 1 2 3 4 5 6 8 9 10 12 15 16 20 25 L=4 "! People CORPORATE OBJECTIVE 2: Develop a highly engaged, high performing workforce and positive patient centred culture delivering great care to patients Potential Effective management systems are not in place or sufficient to ensure all employees receive an appraisal or the level of supervision required. Caused by lack of time, inefficient processes or insufficient priority assigned by management. May result in a failure to remedy personal development needs, insufficient service improvement and/or breach of CQC conditions of registration. Jackie Green Treatment Appraisal policy, paperwork and system for recording are in place for medical and non-medical staff Consultant appraisal linked to revalidation User guides available for managers and employees Training programme available for managers Monthly reporting at department / CSU / organisation-wide level Assurance reported to Workforce Committee CSU performance reports include appraisal compliance Updates reported to COO and utive Team Targeted intervention for worst performing departments Revised policies for appraisal and pay progression (Director of HR - 31st March 2014) Refreshed paperwork incorporating Leeds Way (Director of HR - 31st March 2014) Communication / training plan (Director of HR - 31st March 2014) Pay progression dependent on satisfactory appraisal for non-medical staff (to be agreed) (Director of HR - 31st March 2014) Successful appraisal for line managers will include appraisal compliance for staff they manage (to be agreed) (Director of HR - 31st March 2014) Performance Management 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. Board of Directors 27/03/2014 7
S=4 CRR11: Inadequate completion of mandatory training 1 2 3 4 5 6 8 9 10 12 15 16 20 25 L=4 "! People CORPORATE OBJECTIVE 2: Develop a highly engaged, high performing workforce and positive patient centred culture delivering great care to patients Potential Effective management systems are not in place or sufficient to ensure all employees complete and keep up to date with their mandatory training requirements. Caused by lack of time, inefficient processes or insufficient priority assigned by management or employees. May result in a failure to remedy personal development needs, unsafe care, insufficient service improvement and/or breach of CQC conditions of registration. Jackie Green Treatment Systems and procedures in place for delivering and recording mandatory training Consultant revalidation requires mandatory training compliance Training interface available for managers and employees to view their personal mandatory training record, requirements and advice on accessing training Extensive mandatory training programme available including open days and on-line resources Monthly reporting at department / CSU / organisation-wide level Monitored at Workforce Committee Assurance reported to Workforce Committee CSU performance reports include mandatory training compliance Mandatory Training leads meet every month to address areas of poor performance Revise training policies incorporating mandatory and priority training (Director of HR - 31st March 2014) Satisfactory appraisal dependent on individuals mandatory training being up-todate (to be agreed) (Director of HR - 31st March 2014) Review capacity to deliver required mandatory training and develop proposals for improvement (Director of HR - 31st March 2014) Optimise use of electronic learning opportunities. E-learning available on interface from February (Director of HR - 28th Feb 2014) Review all options to widen access to training materials in order to increase uptake and improve completion rates (Director of HR - 31st March 2014) Performance Management 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. Board of Directors 27/03/2014 8
CRR12: A&E target non-compliance 1 2 3 4 5 6 8 9 10 12 15 16 20 25 L=3 "! Compliance National Target CORPORATE OBJECTIVE 4: Deliver all mandatory standards in line with NHS Constitution and all regulatory requirements including improvement of care, capacity and demand management 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 failure to discharge patients to manage demand and may, when aggregated with other potential factors, contribute to an inadequate patient experience and/or deterioration in LTHT s governance rating. Mark Smith Treatment Capacity and demand modelling refreshed every 6 weeks within the Emergency Department Agreed staffing levels with rotas aligned to seasonal variation and anticipated peaks in demand Rapid Assessment - Consultant led in place Triage protocols developed and in use Pathways for rapid specialty referral and response Admission avoidance schemes articulated cross organisation Direct Admission to Medicine and Elderly Services (DAMES) in place to accelerate flow and reduce duplication Early Senior Review Availability of prescribing pharmacist Access to Allied Health Professionals within ED and medical assessment 7/7 Consultant presence within the ED 24 hours 24 hour assessment facility in operation within surgery and medicine at SJUH and Children s at LGI Early Discharge Assessment Team (during core hours) comprising Occupational Therapist, Physiotherapist, Discharge Nurse, Social Worker and Geriatrician, working across primary, secondary and social care sectors s Performance monitored hour by hour, every day NHSBAR iphone App - real-time remote access to performance monitoring operational issues Weekly performance email sent to CSU senior leadership and relevant corporate leads Weekly Trigger Meeting Root Cause Analysis for breaches Monitored via Integrated Quality & Performance Report Daily Operational Performance Meeting chaired by ADOP to ensure balance of activity aligned to ensure delivery Discretionary use of Bank/Agency/Locum to address shortfalls in staffing levels Escalation routines including procedures to apply depending on the level of performance (refreshed hourly) Specific plan for handling an unexpected surge in demand Board of Directors 27/03/2014 9 Length of Stay reduction - trust-wide adoption and use of Expected Discharge Dates for all inpatient admissions - implemented by local CSU management teams by end of QTR 1 2014/15 (Chief Operating Officer) Develop capacity to report live bed state - real-time Admission, Discharge or Transfer (ADT) information (Chief Operating Officer - date TBC) Through the work of the Strategic Urgent Care Board, actively engage to develop proposals to reconfigure urgent care models across Leeds (Chief Operating Officer - In Progress) Performance Management LTHT has met this standard consistently since June 2013. There remains some uncertainty regarding the demand for urgent care during the remainder of the winter period and the potential impact on year end outturn; thus, whilst the current risk is tolerable, the residual risk remains significant at 15 reflecting a cautious approach. Recommendation/Decision Required: accept the level of risk exposure subject to satisfactory confirmation of further actions outlined above.
CRR13: 18-week RTT target non-compliance 1 2 3 4 5 6 8 9 10 12 15 16 20 25 L=4 "! Compliance National Target CORPORATE OBJECTIVE 4: Deliver all mandatory standards in line with NHS Constitution and all regulatory requirements including improvement of care, capacity and demand management Potential Failure to achieve the maximum waiting time of 18-weks from referral to treatment (90% for admitted pathway, 95% for non-admitted pathway). 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, unacceptable delays for patients, and/or deterioration in LTHT s governance rating Mark Smith Treatment Capacity and demand modelling is in place for priority RTT specialties All CSUs have established targets for 1st and 2nd OP waits and are provided with data to monitor this as part of their weekly access meetings Access Policy and Procedures Waiting List management and referral procedures Bed management and discretionary (limited) use of ring-fencing Theatre utilisation Restrict the use of medical outlying Pathways of care s Weekly performance email sent to CSU senior leadership and relevant corporate leads Weekly Trigger Meeting 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 Contingency Discretionary use of Bank/Agency/Locum to address shortfalls in staffing levels Escalation routine to Medical Director for Operations, Associate Directors of Operations and Director of Planned Care Escalation to Chief Operating Officer Enactment of Special Measures - intensive monitoring and support in the event of significant performance dip Length of Stay reduction - trust-wide adoption and use of Expected Discharge Dates for all inpatient admissions - to be implemented by local CSU management teams by QTR 1 2014/15 Complete capacity & demand modelling and roll out to all specialties with quarterly refresh (Chief Operating Officer - date TBC) Extend pathways of care to cover full range of elective services provided (Chief Operating Officer - date TBC) Optimise theatre utilisation (Chief Operating Officer - date TBC) Roll out and extend use of Clinical Portal (Chief Operating Officer - date TBC) Roll out Order Comms (Chief Operating Officer - date TBC) Performance Management 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. Board of Directors 27/03/2014 10
CRR15: 62-Day Cancer Target 1 2 3 4 5 6 8 9 10 12 15 16 20 25 L=3 "! Compliance National Target CORPORATE OBJECTIVE 4: Deliver all mandatory standards in line with NHS Constitution and all regulatory requirements including improvement of care, capacity and demand management 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. Mark Smith Treatment 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 s Weekly performance email sent to CSU senior leadership and relevant corporate leads Weekly Trigger Meeting 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 Contingency Discretionary use of Bank/Agency/Locum to address shortfalls in staffing levels Escalation routine to Medical Director for Operations, Associate Directors of Operations and Director of Planning Escalation to Chief Operating Officer Enactment of Special Measures intensive monitoring and support in the event of significant performance dip Length of Stay reduction - trust-wide adoption and use of Expected Discharge Dates for all inpatient admissions - to be implemented by local CSU management teams by QTR 1 2014/15 Complete capacity & demand modelling and roll out to all specialties with quarterly refresh (Chief Operating Officer - date TBC) Extend pathways of care to cover full range of elective services provided (Chief Operating Officer - date TBC) Optimise theatre utilisation (Chief Operating Officer - date TBC) Roll out and extend use of Clinical Portal (Chief Operating Officer - date TBC) Roll out Order Comms (Chief Operating Officer - date TBC) Performance Management 31/03/2014 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. Board of Directors 27/03/2014 11
CRR17: Inadequate Data Quality or Data Governance LTHT CORPORATE RISK REGISTER V13 04/03/2014 1 2 3 4 5 6 8 9 10 12 15 16 20 25 L=3 "! Compliance National Target CORPORATE OBJECTIVE 4: Deliver all mandatory standards in line with NHS Constitution and all regulatory requirements including improvement of care, capacity and demand management Potential Effective management systems are not in place or sufficient to ensure data completion, data quality or data governance. Caused by a large volume of local systems lacking administration and local control. May result in erroneous reporting; inadequate board assurance; loss of stakeholder confidence; financial or regulatory penalty. Alison Dailly Treatment All staff are made aware of their specific duties in respect of data governance via Information Governance training provided on induction and annual updates thereafter All new database or software systems require prior approval of Informatics Board before installation (this control has been in operation for 4 years) Approval is verified before system is procured or purchased Access to install any database or software without authorisation is denied and can only be installed by authorised informatics staff Technical controls exist to minimise risk of inadvertent, accidental or malicious installation of software onto trust systems Access to system is restricted to those with authorised log in Responsibilities are reinforced at each log in Use of portable devices is restricted to trust standard encrypted devices Clinical coding undertaken by trained coding practitioners in association with clinical teams Verification via order/supplies route Formal business case gateway Back office checking reporting reviewed by Systems Administrators and Data Quality Team with KPIs for Trustwide systems and a subset of local systems Data Quality Audits undertaken for core data sets undertaken as part of a rolling programme Any violation of technical controls is subject to disciplinary action Continue to deliver Informatics Strategy - Director of Informatics and reduce volume of small/bespoke clinical systems (Director of Informatics - In Progress) Conclude baseline audit of data governance in all clinical systems (Director of Informatics - 31 st March 2014) Identify and plan data governance requirements for each clinical system (Director of Informatics - ongoing throughout 2014/15) Reach agreement on extending the provision for data quality audits to cover non-core data sets that may be subject to external reporting requirements (Director of Informatics - 31st March 2014) Assessment There is a particular vulnerability in respect of the volume of databases/systems not under sufficient control within clinical areas. 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. Board of Directors 27/03/2014 12
S=4 CRR18: Reducing supply of doctors in training 1 2 3 4 5 6 8 9 10 12 15 16 20 25 L=4 "! Compliance National Target CORPORATE OBJECTIVE 4: Deliver all mandatory standards in line with NHS Constitution and all regulatory requirements including improvement of care, capacity and demand management 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 non complaint 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 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 DatixWeb Attendance Management Use of locum doctors Merging of rotas leading to less specialist input Use of consultants in place of trainees 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 date TBC) 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. Board of Directors 27/03/2014 13