Public Board Papers Buckinghamshire Healthcare NHS Trust 27

Transcription

Buckinghamshire Healthcare Trust Board Meeting in Public 27 Jan 2016
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0.0 Agenda Public Board 27 January 2016
2. Board Protocol
4.0 Public Minutes 25 Nov draftv.er eh.hld.nd
6.0 CHIEF EXECUTIVE'S REPORT - January 2016
7.1 Risk Paper for Trust Board Jan 16
8.1 Developing Community Hubs public 270116
8.2 Values and Behaviours Communication Plan
9.1 Trust Board Report - Workforce Report January 2016
9.2 Organisational Development
10.1a Front Sheet Patient Story 27.1.16
10.2 Quality Report for Trust Board Jan 16
10.3 QIP January 2016
10.4 January Quality Committee summary for Board
10.5 IPC Report for Public Trust Board Jan 27th 2016
11.1 Operational Performance Report
12.1 December F&BP Summary for Board Jan 16
12.2 Financial Performance Rport M09 Board Report V5
13.2 Board Paper - December Self certif
13.3 Working Capital Policy 27.1.16
13.4 Risk Management Strategy and Risk Management Policy
14.1 Private Board Summary Report
14.2a. Board Attendance Record
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Agenda for the Trust Board Meeting in Public on
Wednesday 27 January at 9.00am
in the Hampden Lecture Theatre, Wycombe Hospital
Time
Start
Item
Enclosure
No TB2016/
‘GOING THE EXTRA MILE AWARDS’ – presentation to the October, November and December 2015 winners
09:00
Subject
Lead
Purpose
09:10
QUESTIONS FROM THE PUBLIC - members of the public will be given an opportunity to raise questions related to
agenda items at the beginning, middle and end of the meeting. Questions are welcome in advance in writing, by email
or telephone; or verbally at the meeting. The Board will respond to questions during the content of the meeting. If
members of the public wish to raise matters not on the agenda, then arrangements will be made for them to be
discussed after the meeting with the appropriate director.
09:20
1.
Apologies for absence: Les Broude
2.
Chair’s Welcome and Opening Remarks
& Meeting Protocol
Chair
3.
Declaration of Interests
4.
Minutes of last meeting (25 November 2015)
Director for
Governance
Chair
5.
Matters Arising and Action Matrix
Chair
6.
Chief Executive’s Report
Chief Executive
09:35
Organisational Risk Profile
8. STRATEGY
8.1
Your Community, Your Care proposal
8.2
Values & Behaviours Communication Plan
QUESTIONS FROM THE PUBLIC
10.00
10.20
Verbal
TB2016/001
Note
Verbal
Note and
approve
Note and
approve
Assurance
TB2016/002
Assurance
TB2016/004
Verbal
TB2016/002
TB2016/003
7. RISK AND ASSURANCE
7.1
09.40
Verbal
Director for
Governance
Director of Strategy and Review
Business Development
Director of Human
Decision
Resources
TB2016/006
TB2016/007
9. WORKFORCE PERFORMANCE
9.1
Workforce Performance Report
Director of Human
Resources
Review
TB2016/008
9.2
Organisational Development
Director of Human
Resources
Review
TB2016/009
10. QUALITY
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Time
Start
10.50
Item
11.20
Enclosure
No TB2016/
Chief Nurse
Presentation
TB2016/010
10.2
Quality Performance Report
Review
TB2016/011
10.3
Quality Improvement Plan
Review
TB2016/012
10.4
Quality Committee Chair’s report
Chief Nurse / Medical
Director
Chief Nurse / Medical
Director
Committee Chair
Assurance
TB2016/013
10.5
Infection Prevention & Control Monthly Report
Medical Director
Assurance
TB2016/014
Chief Operating Officer
Review
TB2016/015
11. OPERATIONAL PERFORMANCE REPORT
Integrated Operational Performance Report
12. FINANCE PERFORMANCE
12.1
Finance and Business Performance Committee Chairman , FBP
Chair’s Report
Committee
Assurance
TB2016/016
12.2
Financial performance report
Director of Finance
Review
TB2016/017
13. REGULATORY AND COMPLIANCE
13.1
Audit Committee Chair’s report
Audit Committee Chair
Assurance
Verbal
13.2
TDA Self-Certification
Director of Strategy
Decision
TB2016/018
13.3
Working Capital Policy
Director of Finance
Ratification
TB2016/019
13.4
Risk Strategy & Policy Review
Director for
Governance
Ratification
TB2016/020
Director for
Governance
Director for
Governance
Information
TB2016/021
Decision
TB2016/022
Director for
Governance
Review
Verbal
14.1
Private Board Summary Report
14.2
Board attendance record
15. ANY OTHER BUSINESS
16.
Risks identified through Board discussion
11.50
Purpose
Patient Story
14. FOR INFORMATION
11.45
Lead
10.1
11.1
11.00
Subject
17. DATE OF NEXT MEETING
Wednesday 30 March, 9am, Hampden Lecture Theatre, Wycombe Hospital
The Board will consider a motion: “That representatives of the press and other members of the public be excluded
from the remainder of the meeting, having regard to the confidential nature of the business to be transacted, publicity of
which would be prejudicial to the public interest” Section 1 (2) of the Public Bodies (Admission to Meetings) Act 1960.
Papers for Board meetings in public are available on our website www.buckshealthcare.nhs.uk
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Public Board Meeting: 27 January 2016
Agenda Item: 2
Enclosure No: TB2016/001
TRUST BOARD MEETINGS
MEETING PROTOCOL
The Buckinghamshire Healthcare NHS Trust Board welcomes the
attendance of members of the public at its Board meetings to observe
the Trust’s decision-making process.
Copies of the agenda and papers are available at the meetings, on our
website www.buckinghamshirehealthcare.nhs.uk, or may be obtained in
advance from:
Elisabeth Ryder, Senior Board Administrator
Stoke Mandeville Hospital
Mandeville Road
Aylesbury
Buckinghamshire HP21 8AL
Direct Dial: 01296 418186
e-mail: [email protected]
Members of the public will be given an opportunity to raise questions related to agenda items at
the beginning of the meeting. Questions are welcome in advance in writing, by email or
telephone; or verbally at the meeting. The Board will respond to questions during the content of
the meeting.
If members of the public wish to raise matters not on the agenda, then arrangements will be
made for them to be discussed after the meeting with the appropriate director.
Hattie Llewelyn-Davies
Chair
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Agenda item: 4
Enclosure no: TB2016/002
Minutes of a Trust Board Meeting in public held on Wednesday 25 November 2015
in the Olympic Room, The Gateway, Aylesbury
Present:
Voting Members:
Non-Voting Members:
Ms H Llewelyn-Davies
Mr N Dardis
Mr L Broude
Mr R Jaitly
Mr G Johnston
Dr T Kenny
Mr N Macdonald
Mrs C Morrice
Mr M Naylor
Mr Ian Anderson
Mrs R Devonshire
Mr D Garmon-Jones
Mr D Williams
In Attendance:
Miss E Hollman
Mrs E Ryder
Mrs J O’Driscoll
Ms K Hart
Chair
Chief Executive (interim)
Non-Executive Director
Medical Director
Chief Operating Officer (interim)
Chief Nurse
Director of Finance & IT / Deputy Chief
Executive Officer
Director of Human Resources
&Organisation Development
Associate Non-Executive Director
Director of Strategy and Business
Development
Director for Governance
Senior Board Administrator (minutes)
Director of Infection Prevention and Control
(for agenda item 10.5)
Healthier Lifestyles and Staff Well Being
Manager (for agenda item 8.3)
157/2015
APOLOGIES: Apologies were received from Professor D Sines, Associate NonExecutive Director, Dr D Amin, Non-Executive Director and Professor M
Lovegrove, Non-Executive Director.
158/2015
There were no questions from the public.
159/2015
CHAIR’S WELCOME AND OPENING REMARKS
The Chair welcomed everyone to the meeting.
160/2015
MEETING PROTOCOL
The Chair referred the Board to the meeting protocol as set out in the agenda
papers.
161/2015
DECLARATIONS OF INTEREST
There were no declarations of interest relevant to the meeting.
162/2015
MINUTES OF 30 SEPTEMBER 2015
The minutes of the meeting on 30 September 2015 were agreed as a true and
accurate record after the following amendments on the list of attendees:
Dr Kenny should be shown as Medical Director and Mrs Devonshire as a nonvoting member.
163/2015
MATTERS ARISING AND ACTION MATRIX
There were no matters arising.
164/2015
CHIEF EXECUTIVE’S REPORT
The Chief Executive highlighted the significant financial pressure on the NHS
nationally, noting the Trust’s response to reducing the deficit by reviewing year end
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targets and establishing targets for spend on agency staff. He noted the challenge
in finding solutions for the long standing challenges the Trust faced explaining that
working together with partners to find joint solutions was fundamental.
He highlighted that work was continuing to develop the leadership of the Trust with
an accompanying focus on staff engagement and organisational culture. The Chief
Executive informed the meeting of the great impact of the staff awards event.
Mr Johnston highlighted that involvement with stakeholders to create good
partnerships was very good although he found there was a lack of clarity around
understanding the different partnerships. He therefore asked if there could be a
Board Seminar to understand the landscape of partners. Mr Williams noted that
there would be an opportunity at the December Seminar to discuss the challenges.
The Chair noted that she had met with Chief Executive Officers and Chairs of the
local Clinical Commissioning Groups with the Chief Executive. This had been a
useful meeting and she would keep the Board updated of future meetings.
Mr Jaitly raised a query around the information in the Board Leading indicators
paper noting that much of the information was only up until August. It was
explained that with the implementation of the new patient administration system
there was a lag in up-to-date information being provided.
165/2015
ORGANISATIONAL RISK PROFILE
The organisational risk profile was presented to the Board by the Director for
Governance, including the full Board Assurance Framework and the top risks from
the Corporate Risk Register. These documents had been reviewed in more detail
at the Audit Committee where there was a detailed discussion on risk. The top
three risks emerging from the risk reporting process included the recruitment and
retention of high calibre staff, delivery of the financial plan including the risk around
the cash position and the switch over to the new Patient Administration System.
The risk around the electronic discharge summary was noted which resulted in a
gap in assurance due to a delay in reporting progress with compliance.
The Board were asked to consider the documents in the context that the risks
would be considered in more detail through the items on the agenda and that there
would be an opportunity to reflect at the end of the meeting on whether the
documents sufficiently reflected the emerging risk profile.
It was highlighted that work on the ‘referral to treatment’ pathway was taking place
to resolve delays. With regard to clinical risks, the urgent care risk would now be
revised upwards due to pressure being experienced in the system. Mr Jaitly
queried when the issues with the Medway system would be resolved and asked for
a date by which the system would be up and running smoothly. The Director for
Strategy noted that the Finance and Business Performance Committee would
receive an update on the situation, with the Chief Operating Officer noting that
‘referral to treatment’ rates should be up to date by the end of December. The
detail would be presented to the Finance and Business Performance Committee for
oversight and with a timescale.
The Director of Strategy and Business Development noted that the clinical systems
board was focused on delivering the benefits of the new system. This would
require changes in behaviours and capturing of real time information particularly in
outpatients. Mr Johnston acknowledged that the new patient administration system
had been a major installation and asked if the Trust had a sense of whether the
problems were being overcome or if there were more potential issues to come.
The Director of Strategy explained that in outpatients there was a process in place
to improve capturing information at source. Mr Broude asked for a debrief to come
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to the Board on the Medway system, highlighting lessons learnt, a review of costs
and a full debrief with the benefits and a realization piece. This would be
presented to the Trust Board in March.
The Chair noted the frustration from patients around outpatient appointments and
requested a report back to the January Board Meeting.
The Board noted the risk and assurance documents.
166/2015
CORPORATE OBJECTIVES REVIEW
The Director for Strategy and Business Development presented a paper updating
the Board on the progress made towards the achievement of the 2015/16
corporate objectives. It was explained that a RAG rating for the objectives was
being used to highlight whether an objective was being achieved or not. There had
been progress with Quality Improvement, in particular a reduction in medication
errors and an improvement in end of life care. There had been progress in working
with partners at Bucks Urgent Care and South Central Ambulance Service in
developing urgent care with a new model of care for Buckinghamshire planned for
2017. Additionally the Trust has partnered with Care UK to develop a MusculoSkeletal model which has met the Clinical Commissioning Group’s objective of
being a ‘most capable’ provider.
Revised objectives for the Board’s consideration would be developed as part of the
Business Planning Process for 2016/17. The Chief Executive Officer noted that the
Board would need to be more agile in prioritising and rationalising objectives and
be focussed on the main area of transformation.
Mr Jaitly explained that he believed the objectives should be reviewed as there
were areas where the RAG rating was incorrect in his opinion such as staff
retention. He had concerns around linking objectives and milestones and
triangulating the work as at present it was not joined up. Mr Broude had found the
paper difficult to read and commented that it needed to be a useful document set at
the beginning of the year. Mr Johnston found the paper a good read with actions
and milestones however it was hard to see how the Trust was doing and where the
issues where that still needed to be tackled.
The Chief Nurse noted that it had evolved with better information provided but the
trajectories and objectives needed to match.
The Board noted the progress on delivery of the Trust’s 2015/16 objectives.
167/2015
LISTENING TO OUR PATIENT AND CARER VOICE
Tracey Underhill, Head of Membership, Engagement, Equality and Diversity
presented a paper to the meeting on patient engagement, involvement and
participation activities from April to November 2015. The paper highlighted the
actions staff were taking as a result of listening to patients and carers and noted
the wider benefits that meaningful patient engagement brought. It was explained
that the Trust was changing the way it provided care around end of life and
enhanced recovery. The patients had asked for changes and these had been
made.
Mr Johnston noted that it was a great report and made him proud but also gave
him cause for thought. He had concerns around patient confidentiality in A&E
noting that significant numbers of patients had concerns. Mrs Underhill explained
that the reception areas and modernisation of A&E and outpatient reception areas
had helped to improve confidentiality. Mrs Devonshire had recently toured the A&E
department and had noted the improvement in the reception area.
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Mr Jaitly queried the extent of the ethnic voice in the patient engagement strategy
and questioned whether there was a tendency for the same people to respond to
surveys. He also queried if the positive comments were triangulated with
complaints and if these were reflected.
Mrs Underhill noted that she was also responsible for Equality and Diversity in the
Trust and responses for all results were published. There were representatives for
all groups in the network with groups throughout the community. It was explained
that work with the patient experience manager around complaints was cross
referenced.
The Chief Executive queried if there was more the Trust could do to provide better
quality for the patient. There needed to be a stronger focus in the feedback from
the community services to put into the strategic improvement and direction. The
Director of Strategy and Business Development noted that improving responses in
outpatients would continue to close the loop around strategic position, priorities and
resource.
Mrs Underhill noted the need to promote translation and interpretation services and
for it to be used more widely to identify objectives and prioritise. The Chair noted
this was a good challenge. The Chief Nurse noted that managing patient
expectations and communication was key to success. The Chair summarised by
noting the importance of involving patients in the strategy and strengthening ethnic
work.
The Board noted the key messages from patients.
168/2015
HEALTH & WELL BEING PRESENTATION
The Director of HR and organisation development introduced Karon Hart, Healthier
Lifestyles and Staff Well Being Manager to the meeting to present on staff
engagement, a sense of belonging and healthy lifestyles and wellbeing.
It was explained that this was a new service offering help and support to staff using
a holistic approach which would enable staff to create a work / life balance, offer a
positive culture, help in attracting and retaining staff, reduce stress, create savings
by cost avoidance, offer resilience and offer practical support. An in-house weight
management programme was on offer in addition to a physical activity programme,
a drop in service and a healthy green space for staff to use. Clinicians were raising
awareness and empowering people to take care of their own health and supporting
them to do it.
Mr Garmon-Jones questioned if the initiative was part of the occupational health
department and it was noted that they worked in conjunction. However the funding
was fragmented. Mr Broude queried if the team had considered private funding as
a way to back up funds. This would be looked into as well as sponsorship.
The Medical Director noted that in future, numbers identified in the database would
help the Trust to understand the benefit of working with Public Health.
Thanks were expressed to Ms Hart for the presentation.
169/2015
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WORKFORCE PERFORMANCE REPORT
The Director of Human Resources and Organisational Development presented the
Workforce Report for October to the Board in particular noting the continuing
challenges in recruiting and retaining nursing staff. With regard to temporary
staffing it was noted that spend on agency staff had decreased from September
levels and while challenges remained, there was optimism that forecast spend
levels would be met for November and beyond. It was noted that there had been
great work underpinning great work of change. With regard to industrial action by
Junior Doctors, it was noted that contingency plans were in place.
Mr Broude queried if the Trust was penalised for exceeding the cap in agency
spend. The Director for HR noted a weekly report was sent to the Trust
Development Authority, which allowed for pre-booked shifts, anything outside of
the directive from the TDA had to be reported. The Chief Nurse noted that it was a
challenge especially in specialist services and the Trust competing against London
waiting.
Action: A report was requested for the end of the month to be circulated to the
Board on the latest position for the Trust.
Mr Jaitly asked what the Trust could do differently with regard to the agency and
winter pressures. The Director for HR noted that the Trust needed to do what it did
better, there was a need to recruit up to 100 nurses which was a challenge. The
immediate challenge was to reduce demand. Mr Jaitly queried what the Trust
could realistically do to reduce agency spend. The Chief Nurse noted that the
Trust was looking at innovative ways of using band 4 staff, using 12 hour shifts and
exploring what theatres could do differently to reduce spend.
Mr Johnston noted the flow issue initiatives to improve the flow of staff joining the
Trust and efforts to stop them leaving.
The Board noted the Workforce report.
170/2015
PATIENT STORY
Audrey Warren, Head of Midwifery and Lucy Duncan, Lead Midwife for
Governance joined the meeting to present the story of a patient complaint that had
highlighted a patient pathway that was not individualised to the needs of each
mother and baby. The complaint led to a pathway being changed to become user
friendly. The presentation demonstrated how learning from the patient’s
experience had improved and shaped the pathway of care.
Mr Broude asked if the new pathway had been implemented. It was noted that
from December every new baby would be reviewed with triggers in place to ensure
the pathway worked. The new system had been embedded for two months and an
audit was to take place in December. The change had involved many discussions
and the answer had not been straight forward, it had been a complex change.
It was noted that it would be good to give feedback to NICE on the changes the
Trust had made to their recommended pathway and to provide a wider review on
the implementation of NICE guidance.
171/2015
QUALITY PERFORMANCE REPORT
The Chief Nurse presented the Quality Performance Report which reviewed the
progress against the Quality Improvement Plan and achievements towards three
main objectives; reducing mortality, reducing harm and patient experience.
It was noted that there had been no ‘never events’ over the last 12 months.
The number of falls was highlighted as being over trajectory; however there was a
falls reduction strategy in place to reduce this. There had been a reduction in the
number of pressure ulcers per month. It was noted that the reported medication
errors had reduced with steps in place to reduce this further. The continuing focus
would be on the deteriorating patient and divisional leadership in end of life care, in
addition to safe staffing.
Mr Broude noted that the Friends and Family Test response rate was low and
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queried if the Trust was pushing this. The Chief Nurse noted there had been a
push in the community and outpatients and the Trust should see an improvement
with actions in place.
The Board noted the report and approved the actions taken.
172/2015
QUALITY IMPROVEMENT PLAN
The Chief Nurse presented the Quality Improvement Plan to the Board and
outlined the monitoring process to drive improvement. The Board were asked to
note the progress made on the actions and support the approach to driving
improvement and monitoring progress of successful delivery.
It was noted that this was an interim paper with 38 actions of work to be improved
and would go to the Trust Management Committee. By January there would be
less than 100 actions. The proposal for January was for a quarterly plan to go
through the Quality Committee. Current risks around partners actions were being
achieved.
The Board noted the plan.
173/2015
QUALITY COMMITTEE CHAIR’S REPORT
Mr Johnston presented the Quality Committee Chair’s report highlighting the
changed approach to the Committee which would now meet monthly alternating
between deep dive meetings and high level discussions.
It was noted that there were issues with allegations of ‘undermining’ in Trauma and
Orthopaedics with junior doctors being demotivated. A number of staff complaints
had been received. Steps were now in place to resolve the problem and a visit
from Health Education England was expected.
There had been an annual report from the complaints manager showing that on 3
November 2015 there were 20 complaints outstanding from August and 30 that
had breached. There needed to be more attention to the timely response to
complaints. .
The Chair congratulated Mr Johnston on a new way of working for this committee.
The Board noted the level of assurance given.
174/2015
INFECTION PREVENTION & CONTROL REPORT FOR OCTOBER 2015
Dr Jean O’Driscoll, Director of Infection, Prevention and Control presented the
report for October which highlighted information on recent trends in Healthcare
associated infections and hand hygiene compliance to the Board.
The Chief Executive Officer challenged the assurance given on hand hygiene
compliance. It was explained that assurance was given at the Quality Committee
and there were peer audits and random checks but that there would be greater
visibility of these at the Quality Committee.
The Chief Nurse highlighted the pro-active approach to prevention of line infections
and Mr Johnston noted the issue around prescribing practice and leading on
changing prescribing practice with a national drive on reducing the use of
antibiotics.
The Board noted the report.
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175/2015
INTEGRATED OPERATIONAL PERFORMANCE REPORT
The Chief Operating Officer presented the Integrated Operational Performance
Report for October 2015 to the Board.
He drew the Board’s attention to the Referral to Treatment Times figures which
were compliant for the second consecutive month. The Trust’s waiting list had
grown from the pre-Medway implementation. This was being driven by data quality
issues caused by the changeover of the patient administration system. The Board
was informed that by the end of January 2016 the trajectory on data quality issues
should be returned to the expected size.
It was noted that greater detail would be given at the Finance & Business
Performance Committee, showing theatre productivity and outpatient
communications.
Urgent Care had become more challenging. An action plan was tracking speed of
delivery work and work with partners for a single assessment process. Ambulatory
care had been extended into the evening with 3 consultants available at weekends
showing an improvement in quality. Mr Jaitly asked for the impact of the
milestones to be more visible.
The Board noted the integrated operational performance report.
176/2015
FINANCE AND BUSINESS PERFORMANCE COMMITTEE CHAIR’S REPORT
Mr D Garmon-Jones presented the finance and business performance committee
chair’s report noting the importance of being transparent and tackling big issues.
At the October meeting the Committee was not assured that the Trust would
achieve a surplus. At the November meeting the committee was assured that
there was a huge effort within the Trust to achieve financial forecast. The
December figures would be key to seeing the outcomes of the actions taken.
The importance of connecting with chairs of the other board sub-committees was
raised and this would be discussed at a Board Development Session including
whether Non-Executive Directors could attend other committees noting that the
balance of membership was important.
The Terms of Reference were approved and the Board noted the report.
177/2015
FINANCIAL PERFORMANCE REPORT
The Director of Finance presented the financial performance report to the Board for
October 2015, month 7. This showed that the Trust’s activity dropped during
August with an in month deficit. It was explained that there were 2 months of
income which were not clear, which was a risk. Detail had been given at the
Finance and Business Performance Committee and clear actions agreed to
produce a robust forecast and reduce risk to income.
The Board noted the financial performance report, recognising the risks relating to
income, increased activity and CIP performance. A discussion about the cash
position would also take place in part II.
178/2015
AUDIT COMMITTEE CHAIR’S REPORT
Mr Broude presented the Audit Committee Chair’s report and drew the Board’s
attention to the new regulation whereby the Trust could appoint its own external
auditors from March 2017. It was proposed that the Audit Committee would be the
selection committee for the auditors and would then make a recommendation to
the Board.
The Board approved the proposal.
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179/2015
TRUST DEVELOPMENT AUTHORITY SELF CERTIFICATION
The Director of Strategy and Business Development and business development
presented the self-certifications to the Board for approval. It was noted that there 2
risks around A&E and Finance. The Director of Strategy and Business
Development would look at the consistency of the certificates and the wording of
them to be consistent with a formal review.
180/2015
PRIVATE BOARD SUMMARY REPORT
The Board noted this report.
181/2015
BOARD ATTENDANCE RECORD
The Board noted this report.
182/2015
RISKS IDENTIFIED THROUGH BOARD DISCUSSION
The Director for Governance highlighted that the risks emerging through the
discussions at the meeting included Medway, urgent care pathway, finances,
undermining in Trauma and orthopaedics, junior doctors strike and compliance in
agency cap.
183/2015
ANY OTHER BUSINESS
There were no other items of business.
184/2015
DATE OF NEXT MEETING
The next meeting will be held on Wednesday 27 January 2016 at 9.00 am in the
Hamden Lecture Theatre, Wycombe Hospital.
There being no further business the Chair recited the motion to bring the meeting in
public to an end.
Signed ...............................
Trust Chair
Dated.................................
ACTION MATRIX
Minute
108/2015 Six monthly assurance report on national
recommendations action plan to Quality
Committee and update to Board by March 2016
108/2015 Discussion on Duty of Candour and how to build
a culture of openness to come to a Board
Seminar session
108/2015 Explore the possibility of mapping action plan
from the national reviews across to the Board
Assurance Framework
140/2015 Revised Integrated Business Plan
141/2015 Root cause analysis of cardiac arrests to be
presented to a future board meeting
141/2015 Board session on understand the graphs in the
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Lead
Medical
Director
Timescale
March
2016
Director for
Governance
March
2016
Director for
Governance
December
2015
Director of
Strategy and
Business
Development
Medical
Director
Director for
January
2016
January
2016
January
Update
Minute
Lead
Governance
141/2015 The Trust’s performance against the national rate Medical
for avoidable deaths to be presented to a future
Director
board meeting
Timescale
2016
January
2016
165/2015 A full de-brief on Medway to come to Board
Director of
Strategy and
Business
Development
Chief
Operating
Officer
Director of HR
March
2016
Director for
Governance
January
2016
165/2015 A report on outpatients appointments to the
Board
169/2015 A report was requested for the end of the month
on agency spend to be circulated to the Board
on the latest position for the Trust.
176/2015 Agreement of Development workshop to review
attendance at committees.
Update
January
2016
November
2015
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Agenda Item: 6
Enclosure No: 2016/003
TRUST BOARD MEETING IN PUBLIC
27 January 2016
CHIEF EXECUTIVE’S REPORT
1. National context
In December, national bodies including NHS England, NHS Improvement (the new body which will
bring together Monitor and the NHS Trust Development Authority) and the Care Quality Commission
published ‘Delivering the Forward View: NHS Shared Planning Guidance 2016/17 – 2020/21’. This
guidance aims to help local organisations to deliver a sustainable, transformed health service and
improve the quality of care, wellbeing and NHS finances.
The guidance has been backed up by a £1.8bn sustainability fund that will be dependent on trusts
having agreed plans to support their financial position, quality and access standards performance,
sustainability and transformation, as well complying with national staff agency rules and
demonstrating progress in seven-day services.
A clear direction is that Boards should consider quality and finances on an equal footing when making
planning decisions. NHS Improvement and CQC are jointly designing the new ‘use of resources’
assessment and are also exploring ways of sharing information to ensure a more consistent approach
across regulatory bodies, as part of the new, single, provider regulatory framework. It is also
anticipated that they will share revised National Quality Board staffing guidance and a new metric
looking at care hours per patient day.
Last week, as part of his review into operational productivity across the NHS, Lord Carter sent to the
Department of Health his early recommendations to generate £5bn of savings across the health
service by 2020-1. This includes introducing a single reporting framework, addressing delayed
transfers for care, 1% improvement in workforce productivity and controlling pharmacy and
procurement practices. As one of the 32 pilot trusts that have worked with Lord Carter on this review,
we will receive in the coming months our own individual report and final savings recommendations,
however this work is already feeding into our cost improvement planning for 2016/17.
We have also been informed of additional arrangements to tackle agency costs, including introducing
price caps for medical and clinical staff and extending the ban on using non-framework agencies. We
have welcomed the national focus on this important issue. Our HR and operational teams have been
working hard to limit the impact of these restrictions and we have been working closely with
neighbouring trusts to ensure a consistent approach in responding to agency requests.
2. Partnership working
As part of the national planning guidance, all NHS organisations have also been asked to produce a
local health and care system ‘Sustainability and Transformation Plan’, which will cover the next five
years and transform the service they provide, delivering patient-centred care closer to people’s
homes.
We have already begun this planning as a system through the Healthy Bucks Leaders’ Group, which I
chair. We are working closely with local stakeholders including local MPs, Health and Adult Social
Care Select Committee, Health and Wellbeing Board and Healthwatch. I have also commissioned
support from the Kings Fund to help the system in developing its thinking and strategy for the years
ahead. This will support and is in addition to our own facilitated Board sessions on developing our
vision and key strategic objectives for the Trust and setting the priorities for our Strategic
Transformation Committee. In the coming months we will also begin a programme of public and
17 of 208
Agenda Item:
Enclosure No:
patient engagement to inform the development of services in the community. The Director of Strategy
will provide further information about this later in the Board meeting.
In addition, I have been asked by Jim Mackey, the new Chief Executive of NHS Improvement, to join
a CEO Advisory Group that he is establishing to exchange views and ideas and test solutions. This is
a great opportunity and will enable the Trust to shape the national agenda, discuss common
challenges with peers and to learn from others as we take forward our transformation aspirations.
3. Leadership and values
At the end of 2015, I completed my latest round of all-staff open sessions, which took place across
five of our sites capturing acute and community services. It was a good opportunity to discuss with
staff the improvements that have been made following their feedback at previous sessions, as well as
to hear from them about achievements they were proud of within their own teams and departments. I
heard many examples of teams pulling together to support patients, and I saw this in action in one of
our community hospitals where the team were preparing to say farewell to a patient who had come to
them immobile and, over the course of the past six months, they had provided therapy, support and
the confidence to enable this lady to regain her strength and mobility and to go back home. This was
a tribute to the skills of our community teams and the value of team working.
Next month, I will host my next series of leadership sessions, which will focus on transformation. We
will also use this as part of our launch programme for our new organisational values and behaviours –
which were developed with staff over the course of last year. The values are a key part of the BHT
way, and are shaping the way we support, train and recruit our staff.
4. Performance
Our urgent care service managed well over the Christmas period but has experienced greater
challenge since the New Year and we are working hard with system partners to recover and sustain
performance. Investment has been made into the infrastructure to support alternatives to A&E,
including expanding reablement and introducing a night sitting service.
In a time when the NHS is facing unprecedented financial challenge we too are significantly
challenged locally around the delivery of our financial plans for 15/16. It is unlikely that we will meet
our planned total for the year although we continue to work hard to achieve the best possible outcome
by year-end. We have strived this year to fully understand the underlying factors impacting on our
financial performance, including an external review earlier in the year. We have kept the Trust
Development Authority and our commissioners fully briefed about the financial situation and have
spent considerable time reviewing financial information at the Finance and Business Performance
Committee. We are taking all the intelligence and learning we have gained through the year to
develop a clear financial strategy as a foundation for financial sustainability going forward and to
underpin our financial planning for the 16/17 year.
I would like to thank staff for their hard work and support during the recent junior doctor industrial
action. Their efforts, carefully planning or covering shifts, ensured that we were able to maintain
patient safety and keep disruption to a minimum. Around 10% of outpatient appointments needed to
be rescheduled and overall we were able to run the majority of our services as usual. This experience
will put us in a better position in planning for any further industrial action.
The Trust’s leading indicators is appended to this report, which aims to help Board members focus on
areas for discussion throughout the agenda.
5. News and awards
In December we said farewell to Mike Naylor, Finance Director, who is retiring after 40 years of
service with the NHS. I would like to welcome Dominic Tkaczyk to the Board; Dominic is supporting
us as Interim Finance Director whilst we recruit substantively to this post.
18 of 208
Agenda Item:
Enclosure No:
I am pleased to inform the Board that two staff received awards at this year’s Leadership Recognition
Awards, run by the Thames Valley and Wessex Leadership Academy. Jo Hockley, Associate Director
for Service Improvement, won the NHS Innovator of the Year, whilst Dr Andy Tyerman, consultant
clinical neuropsychologist and head of our community head injury service was chosen as NHS Patient
Champion of the Year. Tracey Underhill and Dee Irvin, who lead on our patient and public
engagement, were also finalists in the patient champion category. The regional winners are now
being considered, along with their peers from around the country, for a national award that will be
presented at a ceremony in March.
Congratulations also to district nurse Julie Fenwick who has been awarded the status of Queen’s
Nurse by the Queen’s Nursing Institute in recognition of her work as part of the Wycombe adult
community health care team. The title of Queen’s Nurse indicates a commitment to the values of
community nursing, to excellent patient care, and to a continuous process of learning and leadership.
Julie is the latest in a number of our nurses who have been awarded this title over the past year, and
it is a true testament of the fantastic work undertaken by our community nursing teams.
I would also like to congratulate Janet Sear, Ophthalmology Medical Secretary, who was given an
unsung hero award at the Bayer Ophthalmology Honours. Judges noted Janet’s influence over the
patient experience, commenting that her communication and relationships with patients was
outstanding.
Neil Dardis
Chief Executive
19 of 208
Board Leading Indicators
Nursing Shifts filled
Qualified nurse starters and leavers (FTEs)
Shifts Requested
Shifts Filled
Leavers
Target
2,000
Starters
35
30
1,500
25
20
1,000
15
500
10
5
Mortality Reviews Completed
GP Referrals to a Consultant
Dec-15
Oct-15
Nov-15
Sep-15
Jul-15
Jun-15
May-15
Apr-15
Mar-15
Aug-15
Feb-16
Dec-15
Oct-15
Aug-15
Jun-15
Apr-14
Dec-15
Nov-15
Oct-15
Sep-15
Jul-15
Aug-15
Jun-15
Apr-15
May-15
Mar-15
Feb-15
Jan-15
0%
Apr-15
20%
Feb-15
40%
Dec-14
73%
Oct-14
92% 88%
60%
Aug-14
100%
99%
98%
97%
96%
95%
94%
93%
92%
91%
100% 100%
Jun-14
80%
94% 97%
Feb-15
FFT - Inpatient Positive Response
100%
100% 98%
0
Jan-15
12/10/14
19/10/14
26/10/14
02/11/14
09/11/14
16/11/14
23/11/14
30/11/14
07/12/14
14/12/14
21/12/14
28/12/14
04/01/15
11/01/15
18/01/15
25/01/15
01/02/15
08/02/15
15/02/15
22/02/15
01/03/15
08/03/15
15/03/15
22/03/15
29/03/15
05/04/15
12/04/15
19/04/15
26/04/15
03/05/15
10/05/15
17/05/15
24/05/15
31/05/15
07/06/15
14/06/15
21/06/15
28/06/15
05/07/15
12/07/15
19/07/15
26/07/15
02/08/15
09/08/15
16/08/15
23/08/15
30/08/15
06/09/15
13/09/15
20/09/15
27/09/15
04/10/15
11/10/15
18/10/15
25/10/15
01/11/15
08/11/15
15/11/15
22/11/15
29/11/15
06/12/15
13/12/15
20/12/15
27/12/15
03/01/16
10/01/16
0
Non Elective Activity
15/16
14/15
15/16
10000
14/15
4000
3500
8000
3000
2500
6000
2000
4000
1500
1000
2000
500
0
0
Apr May Jun
Jul
Aug Sep
Oct Nov Dec
Jan
Feb Mar
Diabetes LOS
Apr May Jun
Jul
Aug Sep
Oct Nov Dec
Jan
Feb Mar
Expected values for diabetes are calculated on casemix by Dr
Foster.
Diabetes Readmissions
Actual
Expected
Actual
4.00
7%
3.50
6%
3.00
5%
2.50
Expected
Key
Green - on target or better
Amber - off target but recoverable
Red - off target and not recoverable
4%
2.00
3%
1.50
1.00
2%
0.50
1%
0.00
0%
Jun‐15
20 of 208
Jul‐15
Aug‐15
Jun‐15
Jul‐15
Aug‐15
PUBLIC BOARD MEETING
27 January 2016
Organisational Risk Profile
Title
Responsible
Director
To inform the Board of the range and level of the organisation’s strategic risks.
To highlight to the Board the top 3 risks for the organisation.
Purpose of the
paper
The Board is asked to note the top strategic risks; consider the level of assurance they
receive in relation to these risks; and bear these risks in mind in relation to decision
making taking place through the Board meeting.
Action / decision
required
There is an opportunity at the end of the meeting for the Board to confirm that the range of
risks emerging through discussions at the Board meeting are appropriately reflected on
the Board documents and to recommend any areas for further consideration by the Trust
Management Committee.
Links to BHT Business and Risks
Implications and issues to which the paper relates (please mark in bold)
Patient Quality
Legal
Financial
Performance
Regulatory/
Compliance
Annual Objective
Operational
Performance
Public
Engagement
/Reputation
Strategy
FT Application
Equality &
Diversity
Partnership
Working
New or
elevated risk
Other
All objectives
Links to BHT Board Assurance Framework/Corporate Risk Register
BAF
All risks
Risk Description
Described on the document
CQC Reg. Ref.
Well Led Domain; Outcome 16 Assessing and Monitoring the Quality of Service Provision
Author of Paper
Liz Hollman
Presenter of Paper
Liz Hollman
Other committees / groups where this paper / item has been considered
Audit Committee; Trust Management Committee
Date of Paper
20 January 2016
21 of 208
RISK DOCUMENTATION – BOARD ASSURANCE FRAMEWORK AND CORPORATE RISK REGISTER
1.
PURPOSE
The purpose of this paper is to provide information to the Board about existing and emerging risks across the
organisation. This is set in the context of performance information provided to the Board and the assurance
information provided by sub-committees.
The Board is asked to note the top strategic risks; consider the level of assurance they receive in relation to these
risks; and bear these risks in mind in relation to decision making taking place through the Board meeting.
There is an opportunity at the end of the meeting for the Board to confirm that the range of risks emerging through
discussions at the Board meeting are appropriately reflected on the Board documents and to recommend any
areas for further consideration by the Trust Management Committee.
2.
BACKGROUND
The key risk communication document for the Board is the Board Assurance Framework. The Board Assurance
Framework sets out the controls and assurances underpinning the corporate objectives for the year. Where gaps
in control or assurance are identified this emerges as a risk on the document.
3.
KEY RISKS
The Board Assurance Framework has been developed to reflect the corporate objectives for 15/16. This was
moderated by the Trust Management Committee on the 11 December 2015 and considered by the Audit
Committee on the 7th January 2016. The full BAF is shown in Appendix 1 along with the heat map summary.
The top risks emerging from the document are as follows:
•
Risk around the delivery of the annual financial plan. Further information about financial risk and
management can be found in the financial performance paper.
•
Risk to delivery of organisational objectives if we do not have the right number and calibre of staff. To
address this risk there is a comprehensive recruitment plan in place a drive to improve staff retention.
Further detail about this can be found in the Human Resources performance report.
•
Risk to quality of patients’ experience due to pressure on the urgent care pathway.
It should also be noted that the number of cases of Clostridium difficile has now reached the 2015/16 limit.
The Corporate Risk Register is due to be updated at the Executive Management Committee on the 29th January
2016 and will align with the Board Assurance Framework in terms of top risks. The heat map for the Corporate
Risk Register is shown in Appendix 2.
At the Audit Committee in January 2016 it was requested that the dates in the action column be updated as a
number of them were past their due date. The document has been updated in line with this request.
4.
RECOMMENDATION
These risks are recommended to the Board for discussion and action as necessary.
Liz Hollman
Director for Governance, 20 January 2016
22 of 208
Appendix 1
Risk Profile – Board Assurance Framework December 2015
CONSEQUENCE
Insignificant
(1)
Minor
(2)
Moderate
(3)
Major
(4)
Catastrophic
(5)
LIKELIHOOD
(frequency)
Almost Certain
(5)
Likely
(4)
Possible
(3)
Unlikely
(2)
BAF 11a – Recruitment and retention 
BAF 16a – delivery of annual financial plan 
BAF 16b – Delivery of cost improvement programme
BAF 16d – Capital resources
BAF 1b – Electronic discharge summary 
BAF 16c – cash position
BAF 1a – HSMR
BAF 2a – harm from pressure ulcers and falls
BAF 2b – Nurse staffing levels
BAF 3b – end of life care
BAF 6a – delivery of the Healthy Child Programme
BAF 11b – Staff engagement
BAF 12a – Nurturing skilled leadership
BAF 14a – Capital projects
BAF 4a – urgent care pathway
BAF 7b Develop out of hospital care 
BAF 17a – development and delivery of 5 year strategy
(new)
BAF 3a – Friends and Family test for patients
BAF 13a – Defining and embedding organisational values
and behaviours
BAF 11c – Board stability due to number of changes
BAF 15b – issues with information management on
some clinical pathways since introduction of
Medway (new)
BAF2c Safeguarding children
BAF 2d Safeguarding adults
BAF 7a Redesign urgent care pathway 
BAF 8a – Redesign musculo-skeletal services
BAF 9a – Development of Specialist Services 
BAF 10a – Changes to model of care in NSIC 
Rare
(1)
Key: = risk score has risen; = risk score has dropped; = no change.
23 of 208
Buckinghamshire Healthcare NHS Trust
Assurance on controls
Assurance
RAG
Current Risk
Rating
(mitigated by
controls)
Key controls
Risk score
unmitigated by
controls
Description of risk to achieving
objective
Lead
Reference
BAF 15 16 19 January 2016
Gaps in controls or
assurance
Action to address gap
BOARD ASSURANCE FRAMEWORK:
ASSURANCES AND RISKS IDENTIFIED AGAINST CORPORATE OBJECTIVES (STRATEGIC RISK)
1. To reduce mortality as reported by HSMR by 5 each year for 2 years (Achieve HSMR <=99 by March 2016)
• Roll out Electronic Discharge Summaries
• Improve coding to capture all co-morbidities
• The number of patients with triggering scores are recognised.
• Patients recognised are escalated appropriately.
• Increase the number of mortality reviews completed within 3 months of death.
Related Care Quality Commission Regulations: Regulation 9: Person-centred care; ; Regulation 10: Dignity and respect; Regulation 12: Safe care and treatment; Regulation 14: Meeting nutritional and hydration needs; Regulation 20 Duty of Candour
Monitoring Committee: Quality Committee
Minutes from Mortality Reduction Group. (IA)
BAF1a
There is a risk that the targeted reduction
in mortality as measured by the HSMR will
not be achieved.
Medical Director
1). Monthly Mortality Reduction Group chaired by the Medical
Director. Annual review of Terms of reference. Information flows
have been reviewed, suite of agreed reporting information
developed.(IC)
2). Mortality Reduction Action plan. Educational programme
redesigned to focus on the deteriorating patient. Plan rolled out for
prioritising services requiring education.
Learning from mortality reviews shared using a variety of
communication methods. (IC)
Monitoring of results from audit programme. (IA)
25
12
(4x3)
3). Clinical audit programme for mortality. Audit programme
reviewed, clinical audit lead attending mortality workstream. (IC and
EC)
Medical Director
Funding approved through the Capital Management Group via a
business case approved on 13/5/2015 (IC)
Clinical and Pharmacy involvement in the project board to help
ensure that this can be progressed to plan (IC)
G
Relevant clinical audits being reviewed
to confirm that they are fit for purpose.
This will be completed by end
December 2015. Mortality paper
reviewed by Quality Committee in
Controls 2/4). There is a gap in
January 2016 but more work required
control around poor
to confirm range of clinical audit.
classification of co-morbidities
(March 2016)
on admission.
(Control 3). Current audit
programmes are not completed
routinely enough and are too
complex in their design.
Comprehensive mortality reduction
action plan in place due to deliver by
end March 2016.
Root cause analysis programme for cardiac arrests
refreshed in August 2015. findings reported to Mortality
Reduction Group. (IA)
Full project structure in place with a project manager in IT, a Senior
Responsible Officer and a roll out team (IC)
Managed through the Electronic Discharge Summaries Project
Board with a reporting line up to the Clinical Systems Programme
Board. (IC)
Trust Development Authority ongoing review of mortality
processes (EA)
Internal Audit - Divisional Governance (EA)
5) Newsletter has been introduced in July 2015 across the Trust
and is being issued on a quarterly basis.
Electronic Discharge Summary programme
not delivered within the required
timescales which has a potential negative
impact on patient care, finance and
mortality indicators.
HSMR and SHMI and crude mortality reported in the
Quality Report to Quality Committee and Trust Board. (EA)
Minutes from Quality Committee demonstrating monitoring
of Mortality Reduction Action Plan including compliance
with medical review of every death. (IA)
4). SDU and Divisional clinical governance processes. (IC)
BAF 1b
(links to
Obj 15)
There is a gap in control in that
some of the activities
contributing to the programme
for mortality reduction are not
tightly co-ordinated. (Control 4))
Minutes from SDU clinical governance meetings and
Divisional Boards. (IA)
Associate Director for Healthcare
Governance working with Divisions to
improve SDU and divisional
governance structures and processes.
This is monitored through the
performance reviews with each
division.
Monitoring Committee: Finance and Business
Performance Committee
Electronic Discharge Summaries Project Board minutes (IA)
16
16
(4x4)
Programme monitoring by Clinical Systems Programme
Board (IA)
Metrics being monitored: number of services using EDS
(now 100%); uptake of EDS within each service
(information not yet available). (IA)
R
Lack of information as the
IT and information team
Monitoring crude numbers until there is
support for the programme
sufficient capacity to focus on this
has been diverted on to
programme. (January 2016)
Medway
implementation.(C, A)
24 of 208
Page 1
Assurance
RAG
Current Risk
Rating
(mitigated by
controls)
Key controls
Risk score
unmitigated by
controls
objective
Lead
Reference
Gaps in controls or
assurance
2. To reduce harm
- by ensuring at least 95% of all patients cared for by the Trust receive harm free care as measured by the safety thermometer
- by ensuring that wards will have greater than 90% fill rates for Registered Nurses and Healthcare Assistants on every shift to ensure compliance with safe staffing and maintain safety for patients
- through Safeguarding, protecting vulnerable adults
- through Safeguarding, protecting children
Related Care Quality Commission Outcomes: Regulation 9 Person Centred care; Regulation 10 Dignity and Respect; Regulation 12 Safe care and treatment; Regulation 13 Safeguarding service users from abuse and improper treatment; Regulation 18 Staffing; Regulation 20 Duty of candour
Programme of Safety Thermometer prevalence audits in place - a
monthly snapshot of harm against a national benchmark. (IC)
BAF 2a
The current results from the Safety
Thermometer prevalence audit indicate
that patients are at some risk of falling and
developing pressure ulcers whilst in our
care.
Chief Nurse
SSkin 5 step care bundle for pressure ulcer prevention for inpatients is in place. (IC)
Intentional rounding in all in-patient areas, Accident and Emergency
and Maternity. (IC)
Pressure ulcer panels in place to review causes of all Grade 3 and 4
pressure ulcers. (IC)
20
12
Results from monthly Safety Thermometer prevalence
audits measured against national benchmark. (IA & EA)
(4x3)
Quality Boards in each inpatient area displaying numbers
of falls and pressure ulcers for patients, relatives and staff
to see. (IA)
A
Not yet at zero avoidable
pressure ulcers and harm
from falls.
Falls service in the community is now in place. (IC)
Stay in the Bay' initiative to be rolled
out to wards where patients are at risk
of falling - by March 2016.
Extended visiting hours to be rolled out
to in-patient areas by March 2016.
Monitoring of interventions through the falls collaborative
(IA)
Actions emerging through the falls collaborative (IC)
Culture of zero tolerance for harm. (IC)
Dissemination of learning from falls collaborative (IC)
Nursing establishments in place in each in-patient and out-patient
area. (IC)
RosterPro in place for preparing nursing staff rotas. (IC)
BAF 2b
(links to
BAF
11a)
There is a risk to delivering high quality
care if the fill rates for Registered Nurses
and Healthcare Assistants drops to below
90%.
Chief Nurse
System in place for booking temporary staff where there are gaps in
rotas. (IC)
Three times daily reporting of numbers of staff on each shift with
management controls to respond to this reporting. (IC)
12
20
Focus on recruitment and retention of
permanent staff to reduce the need for
temporary staff.
UNIFY staffing returns (IA and EA)
(4x3)
Flexible use of staff across wards and departments (IC)
Safe staffing paper to Trust Board. (IA)
Monitoring of Datix incidents where staffing is indicated as an issue
(IC)
UNIFY return published on Trust web-site. (IA)
A
Current establishments
under review pending
Continued management of safe staffing
outcome of
on a shift by shift basis.
acuity/dependency review.
Availability of temporary
staff for all requests is not
guaranteed.
Revised establishments to be
submitted to Finance and Business
Performance Committee in February
2016.
Revised shift times have been introduced to meet models of care
(IC)
Agency reduction plan introduced in October 2015.
25 of 208
Page 2
Assurance
RAG
Current Risk
Rating
(mitigated by
controls)
Key controls
Risk score
unmitigated by
controls
objective
Lead
Reference
Gaps in controls or
assurance
BAF 2c
There is a risk that children could come to
harm if Safeguarding Children processes
are not sufficiently robust.
Chief Nurse
Safeguarding Children team in place. (IC)
10
Safeguarding Children policy and procedures in place (IC)
Safeguarding Board meets monthly chaired by Chief Nurse. ©
25
(5x2)
Chief Nurse
BAF 2d
G
New Level 3 training
requirements not yet
achieved.
G
Not all staff yet trained
with PREVENT training (2
years to achieve
compliance)
Minutes of Safeguarding Board (IA)
Buckinghamshire Safeguarding Children Board meets monthly and
Chief Nurse is a member. (EC)
Minutes of Buckinghamshire Safeguarding Children Board
(EA)
Safeguarding Adults team in place. (IC)
There is a risk that vulnerable adults could
come to harm if Safeguarding Adults
processes are not sufficiently robust.
External reviews of Safeguarding Children processes by
Lambeth Council and the Local Government Authority (to
be presented to Quality Committee in January 2016) (EA)
10
Safeguarding Children policy and procedures in place (IC)
Safeguarding Board meets monthly chaired by Chief Nurse. (IC)
25
(5x2)
Buckinghamshire Safeguarding Adults Board meets monthly and
Chief Nurse is a member. (EC)
External review of Safeguarding Adults processes (EA)
Minutes of Safeguarding Board (IA)
Minutes of Bucks Safeguarding Adults Board (EA)
Work with partners across the health
economy in delivering the actions
arising from the Ofsted review.
Gap analysis for training requirements
with resulting training plan to achieve
compliance by March 2016.
System wide approach to using the
Care Act to identify and protect the
vulnerable.
Training programme to deliver
PREVENT training within 2 years.
3. Offer a great patient experience as measured by having a net promoter score of 95 for Friends and Family Test in all areas including A&E, Maternity and Outpatients; and through effective end of life care.
BAF 3a
There is a risk that patients will not have a
great experience as monitored through the
Friends and Family Test if we do not
delivery high quality services.
Chief Nurse
Related Care Quality Commission Outcomes: Regulation 9 Person-centred care; Regulation 10 Dignity and respect; Regulation 11 Need for consent; Regulation 16 Receiving and acting on complaints
Implement the patient experience
strategy.
Quality Strategy and Quality Improvement Plan in place to deliver
great patient experience. (IC)
20
Programme for capturing patient feedback through the Friends and
Family test is in place.
8
(4x2)
Friends and Family Test results (IA)
A
None identified.
Expand the F&FT to include
Outpatients and the community.
Patient Experience Strategy to be
presented to March 2016 Board.
26 of 208
Page 3
Assurance
RAG
Current Risk
Rating
(mitigated by
controls)
Key controls
Risk score
unmitigated by
controls
objective
Lead
Reference
Gaps in controls or
assurance
BAF 3b
There is a risk that patients and their
families will not experience the best end of
life care if our end of life care processes
are not sufficiently robust.
Chief Nurse
Implement the person centred care
plan for patients (owned by the
patient/carer) identified as being in the
last month of life to help communicate
people’s wants and wishes, wherever
they are being cared for.
Individualised patient centred care plans in place for end of life care.
(IC)
Medications for end of life symptom management are readily
available in wards and community hospitals. (IC)
20
12
Minutes of the End of Life Care Steering Group (IA)
(4x3)
R
Inconsistent application of
person centred care plan.
Clinical case note review (IA)
End of Life Care Steering group chaired by Chief Nurse (IC)
Demonstrate more evidenced based
symptom control for patients at the end
of life through the training of relevant
staff and ensure improved access to
appropriate medicines.
Increase the number of people
discharged to their preferred place of
care
Develop use of electronic notification of
death to general practices specifically
in relation to inpatient deaths.
4. High quality emergency care 24/7
4.1 Redesign front-door processes, and embed ambulatory care service at SMH
4.2 Transform discharge planning and processes
4.3 Implementation of 7 day working clinical standards
Related Care Quality Commission Outcomes: Regulation 9 Person-centre care; Regulation 10 Dignity and respect; Regulation 12 Safe care and treatment; Regulation 18 Staffing
Reforming Urgent Care Programme Board chaired by Chief
Operating Officer (IC)
BAF 4a
There is a risk to the quality of patient
experience and outcomes if we do not
rapidly reform our urgent care pathways
Integrated Care Board - chaired by Director of Strategy (IC)
System Resilience Group (EC)
Performance dashboards - SDU / Division / Board (IA)
Dedicated pathway redesign project management support (IC)
Support from the Emergency Intensive Support Team and
Ambulatory Care Network (EC)
Performance Management framework and Divisional Governance
Structures (IC)
Support from the NHS Improving Quality 7 day working team (EC)
Revised Divisional Structure to improve management capacity. (IC)
Workforce vacancies for
nursing ( c)
25
12
(4x3)
Reforming Urgent / Integrated Care programme - quarterly
reports to Trust Management Committee (IA)
Reforming Urgent Care Board minutes (IC)
ECIST /Ambulatory Care network reports (EA)
system Resilience Group workplan and project report (EA)
G
Detailed work programme through the
Reforming Urgent / Integrated Care
Groups. This programme is scheduled
to the end of March 2016.
Bed capacity and ability to
deploy flexibly across 2
System wide capacity and demand
hospital sites ( c)
planning via the System Resilience
Group was completed in November
Variability in external
2015.
supporting capacity (social
care) ( c)
Chief Operating Officer chaired daily
whole system capacity management
meeting. October 2015 - March 2016
Reforming Integrated Care Board work programme (IA)
Fully established Emergency Department medical workforce (IC)
27 of 208
Page 4
Assurance
RAG
Current Risk
Rating
(mitigated by
controls)
Key controls
Risk score
unmitigated by
controls
objective
Lead
Reference
Gaps in controls or
assurance
5. Partnership working on urgent care
Work with BUC and SCAS to develop new joint urgent care service
Related Care Quality Commission Outcomes: Regulation 9 Person-centred care; Regulation 12 Safe care and treatment
The risk associated with this objective is
articulated on BAF 7a
6. Keeping adults and children healthy and well
6.1 Develop new diabetes pathway
6.2 Ensure full delivery of the Healthy Child Programme
6.3 Provide additional support for the most vulnerable children including Looked After Children
6.4 Provide the highest quality maternity services
BAF 6a
There is a risk that children may not get
the best start in life if we do not deliver the
Healthy Child Programme
Chief Nurse
Related Care Quality Commission Outcomes: Regulation 9 Person-centred care; Regulation 12 Safe care and treatment; Regulation 13 Safeguarding service users from abuse and improper treatment
Children's Services Improvement Board co-chaired by Chief
Operating Officer and Chief Nurse (IC)
16
12
(4x3)
Minutes of Children's Services Improvement Board (IA)
A
Healthy Child Programme Key Performance Indicator
monitored at weekly Access and Performance
Management Group
• Increase number of births that receive
a face-to-face New Birth Visit by a
Healthy Child Programme Health Visitor within 14 days.
key performance indicator • Increase number of children who
receive a 2 – 2.5 year review.
is not being achieved.
• Number of year 6 children to receive a
Health & Wellbeing review.
7. Strengthening out of hospital care
7.1 Implementation of rapid reablement and assessment service 24/7.
7.2 Redesign of integrated locality teams and community hospital services
BAF7a
(links to
obj 5)
There is a risk that if we do not work with
partner organisations to redesign urgent
care services admissions and attendances
will rise beyond capacity in BHT and this
will adversely impact on quality of service.
Development
Related Care Quality Commission Outcomes: Regulation 9 Person-centred care; Regulation 10 Dignity and respect; Regulation 12 Safe care and treatment
Reforming Urgent Care Programme Board (IC),
System Resilience Group (EC)
Strategic working with partner organisations across Thames Valley
(EC)
Winter planning process (IC)
Business continuity planning and escalation processes (IC)
25
of System Resilience Group (EA),
15  Minutes
Urgent Care System Dashboard (IA) (EA) ,
(5x3)
Reforming Urgent Care Board minutes (IA)
Bucks Commissioners 5 year plan (EA)
Thames Valley Urgent and Emergency Care Network
minutes attended by Director of Strategy (EA)
G
Board has not yet seen a
system wide winter plan.
(A)
Provider workshops with SCAS and
BUC to develop and action plan for
more cohesive working. Workshops
held from July to October, Actions have
been prepared following these
workshops and will be fed into the
reprocurement process.
NHS 111 and Out of Hours to be reprocured by CCGs for April 2017
implementation.
28 of 208
Page 5
Assurance
RAG
Current Risk
Rating
(mitigated by
controls)
Key controls
Risk score
unmitigated by
controls
objective
Lead
Reference
Gaps in controls or
assurance
BAF 7b
(links to
obj 5)
There is a risk if we do not develop out of
hospital care that services will not support
patients to keep healthy and well at home.
Development
Reforming Integrated Care Board (IC)
Division of Integrated Medicine Board (IC)
Negotiations with Commissioners to
reflect growth in community services
(March 16)
Child Health Improvement Board chaired by Chief Nurse and Chief
Operating Officer (IC)
Performance data linked to locality teams and reablement
service (IA)
Healthy Bucks leads (EC)
25
Integrated care programme board (EC)
12  Reduction in admissions and attendances for ambulatory
(4x3)
Development of integrated locality teams (IC)
A
care conditions (IA)
National patient survey re: long term conditions (EA)
Sustainability and transformation plan due in June 2016. (EC)
Block contract for
community services
means additional growth in
Expand single access point for
community capacity is
rehabilitation and reablement services.
limited.
(April 2016)
Engagement process with
commissioners and the public around
community hubs (April 2016)
Strategic Transformation Committee minutes (IA)
Process for acting on feedback from executive to GP liaison
programme in place - quarterly reports to EMC.
8. Improve access and efficiency in planned care
8.1 Redesign of MSK pathway
8.2 Transform the experience in outpatient care
Service Redesign and business case linked to new service
(IA)
BAF 8a
If we do not redesign our musculo-skeletal
services with our partners there is a risk
the that service will be competitively
tendered. If this happens and we are not
successful in bidding for the tender it is
possible that we would lose control of the
provision of secondary care MSK services
(risk to recruitment, patient care and
finance)
Transformation Committee (IC)
Feedback from patients (EA)
MSK Redesign Group (IC)
Right Care Group (CCG) - (EC)
20
Actuarial review of system MSK activity and financial long term
model (EC)
Confirmed as 'most capable provider' (EC)
10
(5x2)
Report from Actuarial review (EA)
18 week RTT performance (IA)
G
Implementation delayed by CCG's to
September 2016. Service redesign
process continuing.
Transformation Committee minutes (IA)
Right Care Group minutes (EA)
Presentation of future service model and contractual
vehicle to CCG boards in November 2015 (EA)
Board Seminar presentation in January 2016. (IA)
29 of 208
Page 6
Assurance
RAG
Current Risk
Rating
(mitigated by
controls)
Key controls
Risk score
unmitigated by
controls
objective
Lead
Reference
Gaps in controls or
assurance
9.Regionally renowned centres of excellence
9.1 Extend Hyper Acute Stroke Unit (HASU) catchment to East Berkshire
9.2 Cardiology – increase activity at Wycombe Hospital & improve cover at Stoke Mandeville Hospital
9.3 Implement new model at Wycombe Birth centre
BAF 9a
There is a risk that without meeting
planned objectives in the development of
specialist services that the Trust will lose
significant market share
Wycombe Review Group (IC)
Business cases linked to new service developments (IA)
Dedicated project management support (IC)
Capital management group (IA)
Clinical Senate commissioning intentions (EC)
20
Transformation board (IC)
10
National stroke standards performance (EA)
(5x2)
Obtainment of revised cardiac activity plan (IA)
G
Capital plan was developed in
Ability to develop capacity
December 2015 as part of overall
to meet requirements of
HASU business case and this is under
Berkshire HASU transfer.
review - March 2016.
A
Develop a commissioning proposal for
Ability of commissioners to
new model of care and agree as part of
respond to new models of
2016/17 contracting plan - Feb/March
care
2016.
Transformation board work plan and minutes (IA)
Cardiology monitored through Performance Improvement
deep dive meetings. (IA)
Clinical Senate work plan (EA)
10. NSIC as pre-eminent national rehabilitation service
10.1 Establish NSIC as pre-eminent specialist service, extending market reach
BAF 10a
There is a risk that failure to deliver
changes to the model of care in spinal cord
injury services will lead to loss of market
share and have a detrimental impact on
patient experience
Specialist services divisional board (IC)
Scorecards - board / divisional / SDU (IA)
NSIC clinical strategy development workshops (IC)
Strengthened management team (IC)
Expansion of spinal surgery programme (IC)
20
10
Patient experience - feedback (EA)
(5x2)
Contractual performance (IA)
Feedback from specialist commissioners (EA)
Feedback from spinal charity stakeholders (EA)
11. Skilled and committed people
11.1 Develop our employment proposition to attract and retain more high quality staff.
11.2 Ensure staff feel engaged and motivated to deliver high quality care
Related Care Quality Commission Outcomes: Regulation 5 Fit and proper persons: directors; Regulation 18 Staffing; Regulation 19 Fit and proper persons employed
30 of 208
Page 7
BAF 11b
BAF11c
If staff are not actively engaged with
organisational goals there is a risk that
these objectives will not be delivered.
There is a risk to board stability and
sustainability with the number of changes to
both executive and nonexecutive Board
members over a short period of time.
Assurance
RAG
Current Risk
Rating
(mitigated by
controls)
Recruitment and retention plan (IC).
Efficient and effective recruitment process. (IC)
Analysis of leavers' interviews (IC).
Weekly reviews of the performance of Bank Partners and the use
of temporary staff (IC).
Nursing and Midwifery Workforce Transformation Group (IC)
Medical and Nursing Revalidation processes. (IC/EC)
Establishment of Nurse and HCA retention group to reduce attrition
(IC)
HR & Workforce Committee (IC)
Participation in regional forums on efficient staffing (EC)
Monthly deep dive on workforce in all divisions. (IC)
Weekly agency recovery meeting for nursing, fortnightly for medical
staff (IC)
Board approved Bank and Agency recovery plan (IC)
Overseas recruitment in Portugal took place in September resulting
in 18 nurse offers and 6 radiographer offers. The first of the new
staff will commence employment in October 2015 with all staff in
place before the end of 15/16.
Up to 80 posts identified that could convert to Band 4. Recruitment
plan and Bucks New Uni 2 year training programme in place. (IC)
Risk score
unmitigated by
controls
Lead
Director of Human Resources and Organisational Development
There is a risk to delivering organisational
objectives if we do not have the right
number and calibre of staff.
Key controls
Director of Human Resources and Organisation Development
BAF11a
objective
Chair and Chief Executive Officer
Reference
Gaps in controls or
assurance
Revised establishments to be
submitted to Finance and Business
Performance Committee in February
2016.
20
16
(4x4)
Robust monthly management reporting on vacancy,
turnover, flexible labour (IA).
Report to Board on progress against workforce recruitment
trajectories (IA).
Safe staffing report to Board. (IA)
Minutes of Finance and Business Performance Committee.
(IA)
Minutes of HR and workforce committee (IA)
Minutes of performance reviews of the HR service (x3 a
year) (IA)
Audit of employment checks. (IA)
Feedback from CQC on compliance with safe staffing. (EA)
Workforce Committee minutes. (IA)
Internal Audit - Consultant Job Plans (EA)
Internal Audit, Temp staffing (EA)
G
Some staff groups are
particularly difficult to
recruit to (e.g. nurses,
ODPs and some AHPs).
Gap in agreed nursing
establishments.
Focused recruitment for hotspot areas
including exploration of increasing the
number of overseas nurse recruits.
Recruits not likely to be in place from
non EU countries until early 16/17.
Re-visit to Portugal took place in
December 2015 with 12 offers made
and Skype interviews taking place in
January.
Recruit Band 4 staff in
challenging market and train our own.
EU recruitment taking place in January
2016.
Proposal being developed for
increased resource in recruitment.
An organisation wide staff survey action
plan has been supplemented by TMC
workshop. Evidence of progress will be
demonstrated through the 2015 Staff
Survey. Initial results are likely to be
available in January 2016.
Appraisal process (IC)
Actions in place in response to national staff survey (IC)
Quarterly engagement events with leaders in the organisation
hosted by the Chief Executive (IC)
Wider engagement events hosted by Chief Executive on topical
issues (IC)
Relaunch of Team Brief (IC)
Board walkabout programme (IC)
Executive front line visibility programme (IC)
Health and Wellbeing Board and work programme. (IC)
PSED and Workforce race equality scheme (IC)
Appraisal and appraisee training completed. (IC)
Executive Back to the floor sessions (C)
Workforce performance report to Trust Management
Committee and Board. (IA)
The calibre of appraisals (C
and A)
Feedback from quarterly staff Friends and Family Test (IA)
20
12
Staff Survey results (EA)
(4x3)
G
Health and Wellbeing Board minutes. (IA)
Visibility of information
coming from board walkabout
programme (A)
Notes of board walkabouts and actions (IA)
Published Public Sector Equality Duty (PSED) (IA)
Monitored by Trust Board
Clear designation of areas of responsibility for both executive and nonexecutive directors. (IC)
Board development programme in place. (IC)
Clear risk reporting processes to pick up any concerns early. (IC)
Succession planning in place. (IC)
200 middle managers being trained in
coaching - training due to be completed by
June 2016
Board walkabout programme is being redeveloped and strengthened. Proposal will
be circulated to Board members in January
2016.
Equality Diversity Scheme assessment (EA)
Induction programme in place for new board members, including board
handbook. (IC)
Sample audit of appraisals took place in
November 2015 as part of the Quality
Improvement Programme and will be
reported to the Board.
20
8
(4x2)
Minutes of Board meetings showing effective strategic thinking
and decision making by the Board. (IA)
Monitoring of Corporate Objectives to show progress. (IA)
G
Two interim executive
directors,
Recruit substantively at the appropriate
time. Under review on a 6 monthly basis next review September 2015.
BAF and CRR in place. (IA)
Full Board now in place. (IA)
Buddying arrangements introduced. (IC)
31 of 208
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Assurance
RAG
Current Risk
Rating
(mitigated by
controls)
Key controls
Risk score
unmitigated by
controls
objective
Lead
Reference
Gaps in controls or
assurance
12. Positive Leadership and Coaching
12.1 Ensure staff are well trained.
12.2 Strengthen Trust leadership
BAF 12a
There is a risk that we do not have
sufficient capability in leadership (clinical
and non-clinical) to effectively deliver the
organisation's objectives and strategy.
Director of Human Resources and Organisation
Development
Related Care Quality Commission Outcomes:
Regulation 5 Fit and proper persons: directors
Regulation 18 Staffing
Regulation 19 Fit and proper persons employed
Leadership programme funded through Health Education Thames
Valley (IC & EC)
Staff survey results (EA)
Performance coaching programme for all managers (IC)
Appraisal programme with appropriate personal development plans
for individual leaders. (IC)
20
12
Staff Friends and Family Test results (IA)
(4x3)
Workforce performance report metrics (IA)
100 clinical and non-clinical leaders on externally facilitated
leadership development programme in 15/16. (IC)
G
Succession planning for
executive and director
reports has not yet been
fully articulated and
considered. (C&A)
Further succession planning work to be
completed and a consolidated picture
to be reviewed by Nominations and
Remuneration Committee by end
March 2016.
A
Not yet clear how the
impact of the new values
and behaviours will be
monitored in terms of
external assurance.
Embed values and behaviours
throughout the organisation, Phase 1
completion by March 2016.
Rollout plan will include consideration
of ongoing external assurance.
Independent evaluation of first wave leadership programme
by HETV including follow up of individuals who have been
through the programme. (EA)
13. Living our vision, values and behaviours
Embed Trust values and behaviours.
BAF 13a
There is a risk that we will not deliver the
highest quality care if we do not embed
Trust values and behaviours and do not
sufficiently engage with staff to deliver this.
Director of Human Resources
Related Care Quality Commission Outcomes: Regulation 5 Fit and proper persons: directors; Regulation 18 Staffing; Regulation 19 Fit and proper persons employed
4 part Project Plan in place (1. Define organisational values; 2.
identify supporting behaviours; 3. embed agreed values and
behaviours; 4. include values and behaviours element in recruitment
and appraisal processes) with external organisation (Talent Works)
recommended by Health Education Thames Valley. (IC & EC)
Steering Group minutes (IA).
16
Steering Group in place chaired by Director of Human Resources
where membership includes a non-executive director. (IC)
New Board approved values and behaviours have been developed.
(IC)
8
Board Workshop minutes 24 June 2015 showing values
work (IA)
(4x2)
External facilitation of values and behaviours work and
patient involvement. (EA)
Question 4 of the Well-Led Framework reviews culture
including values and behaviours. (IA)
32 of 208
Page 9
Assurance
RAG
Current Risk
Rating
(mitigated by
controls)
Key controls
Risk score
unmitigated by
controls
objective
Lead
Reference
Gaps in controls or
assurance
14. The best use of our hospitals and estates
14.1 Implement phase 1 of Wycombe review
14.2 SMH – refurbish theatres
14.3 NSIC - refurbish reception, and commence bathrooms refurb.
14.4 Review community estate
BAF14a
There is a risk that capital projects will not
be delivered on time, may be over budget
or are not delivered to specification on the
following projects:
• Wycombe Cath Lab
• SMH A&E Phase 2
• SMH NSIC Reception refurbishment
• SMH NSIC Bathrooms refurbishment
• Community Estate review
• SMH Helipad
Consequence is that we run out of cash
and have to curtail the capital programme.
Director of Finance
• Planning and design phase, use of in-house and external
designers/architects (EC) (IC)
• Project Manager assigned to each project (IC)
• Programme of works agreed with contractors and stake holders
prior to commencement (IC & EC)
• Regular project meetings held (IC)
Products sourced from framework contracts.(IC)
Contingency built into plans.(IC)
Monthly Capital Management Group review (IC)
Detailed pre-works assessments (IC)
20
12
(4x3)
• Appointment letter assigning Project Manager (IC)
• Project folder set up to contain all documentation (IA)
• Programme of works agreed with contractors and stake
holders prior to commencement (IA)
• Regular project meetings held(IA)
• Director of Property Services has regular 1:1 meetings
with the Project Managers (IA)
External reports on ground conditions prior to contracts
being agreed. (EA)
A
Previously inadequate
Controls have been strengthened in the
management control on
12 months prior to November 2015 and
major projects resulting in
work is continuing to ensure
time and cost overruns for
compliance with controls.
projects still in progress.
15. Technology and Innovation to drive improvement
15.1 PAS/EPR implementation
15.2 Electronic Discharge Summaries
BAF15a
There is a risk that the Trust will be unable
to replace the two Patient Administration
Systems (Millennium and RiO) before the
National Programme for IT contracts expire
in October 2015 resulting in financial
penalties and operational management
issues.
Director of Strategy and Business Development
EPR/PAS monthly Programme Board with Executive
oversight including detailed risks and issues (IA)
Capital Planning Group minutes. (IA)
Capital Planning Group oversight (IC)
Project implementation overseen by the Clinical Systems
Programme Board (IC)
Overall technical strategy overseen by IM&T Strategy Group (IC)
Use of external consultancy to support the procurement process
(EC)
Full Business Case signed off by TDA (EC).
Joint procurement with other Trusts reduces costs and harnesses
expertise. (EC)
Advance Service Agreement initiated with SystemC in October
2014. Contracts signed with suppliers February 2015 (EA)
20
Trust
successfull
y exited
from
National IT
programme
on the 21
September
Monitoring by Clinical Systems Programme Board (CSPB)
and IM&T Strategy Group. (IA). Also oversight by TMC and
FBP Committee.
Monitoring by the NTDA and HSCIC (EA)
Minutes of CSPB and IM&T Strategy Group. (IA)
Written update reports from the consultancy used to drive
the procurement (EA)
Minutes of Live Sites Exec Group (EA)
A
It is impossible to fully
predict the impact of
change on this scale.
Awareness sessions and
support to train all 3,600
staff in the new systems
by September 2015.
Programme plan in place with clear
milestones for achieving the PAS
replacement both in Community and
Acute Services. Awareness sessions
and Communications launch starting
March 2015 and full training
programme developed for
implementation June 2015. Clinical
working groups in maternity, theatres,
outpatients and A&E report back to
programme Board monthly.
Formal sign-off by TDA and involvement in monthly
EPR/PAS Programme Board (EA)
FBP Committee oversight (IA)
Internal Audit PAS implementation (EA)
33 of 208
Page 10
Assurance
RAG
Current Risk
Rating
(mitigated by
controls)
Key controls
Risk score
unmitigated by
controls
objective
Lead
Reference
Gaps in controls or
assurance
Weekly SLAM reports to identify gaps
in activity and resolve.
BAF15b
There is a risk to income and effective
patient administration if processes are not
robust with the new Medway system.
Embedding data quality overseen by the Clinical Systems
Programme Board (IC)
EPR/PAS programme board continues to steer implementation (IC)
15
20
(5x3)
new
EPR/PAS monthly Programme Board with Executive
oversight including detailed risks and issues (IA)
Capital Planning Group minutes. (IA)
Monitoring by Clinical Systems Programme Board (CSPB)
and IM&T Strategy Group. (IA). Also oversight by TMC and
FBP Committee.
A
Additional script fixes to Medway plus
It is impossible to fully
validation of Referral to Treatment
predict the impact of
position (end November 2015) change on this scale.
completed
Awareness sessions and
support to train all 3,600 Manual validation of RTT post 'go live' staff in the new systems
to be complete by end of November
by September 2015.
2015 - completed
Monitoring of activity and 18 week standards - presented
weekly to executive meeting, monthly to TMC and reviewed
in detail at performance meetings with divisions. (IA)
Manual validation of retrospective
outpatient referrals from 2006 - by April
2016.
16. Maintain financial targets
16.1 Deliver Income and Expenditure plan
16.2 Deliver capital programme
16.3 Deliver CIP plan
16.4 Back office benchmarking
16.5 Explore potential options for joint venture for a nursing home.
Related Care Quality Commission Outcomes: Regulation 13 Financial position
Financial report to Board. (IA)
Monthly financial performance report for the Board (IC)
External audit programme. (EA)
BAF16a
The failure to deliver the annual financial
plan will jeopardise the future of the
organisation.
This has the potential to result in an
adverse impact on quality.
Director of Finance
Signed Service Level Agreements (EC)
Internal audit programme (EA)
Finance and Business Performance Committee review. (IC)
FBP minutes. (IA)
Divisional Performance Management process (IC)
20
Monthly FIMS forms for TDA. (EC)
Bank and Agency reduction plan approved by Trust board in
October 2015 (linked to BAF 11a)
Implementation of Programme Management Office approach to
Cost Improvement Programme
20
(4x5)
Minutes of TDA Integrated Delivery Meeting. (EA)
External review of financial plan. (EA)
TDA review of financial plan. (EA)
G
Cost improvement
programme not yet
delivering to target. (C)
Bank and agency staffing
still running above
affordable levels. (C )
Continued focus on financial control
and accountability at all levels of the
organsiation.
Internal Audit - Estates PFI contract management review
(EA)
Internal Audit - Data Quality review (EA)
Internal Audit - Compliance with HR policies around leave
(EA)
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Recruitment of Programme Management Office (PMO) Lead and
PMO function (IC).
Director of Finance
Monthly financial reporting to Board, divisions, TMC,
corporate services and TDA (IA).
Performance management framework for divisions and corporate
services (IC).
Overview by Finance and Business Performance Committee.(IC).
Gaps in controls or
assurance
Minutes of FBP Committee (IA).
Full governance methodology and process in place for cost
improvement plans (IC).
There is a risk to delivering our financial
duties if we do not deliver the cost
improvement programme and control
expenditure particularly on temporary staff
Annual internal and external audit review (EC)
BAF16b
Assurance
RAG
Current Risk
Rating
(mitigated by
controls)
Key controls
Risk score
unmitigated by
controls
objective
Lead
Reference
Review and enhancement of PMO
function. (linked to 16a)
Reports of internal and external audit (EA).
20
16
Transformation Board minutes. (IA)
(4x4)
G
None
Project Initiation Documents (IA)
Board approved Standing Financial Instructions and Standing
Orders (IC).
Quality Impact Assessment process (IA)
Weekly review of temporary shift spread at Executive Meeting. (IC)
Regular Cost Improvement
Programme meetings with Divisions
and Corporate services chaired by
Chief Operating Officer. These will
continue through the remainder of the
financial year.
Internal Audit - CIPS due to be reported Autumn 2015 Amber Green (EA)
Temporary staff reduction plan (IC)
Planning and documentary evidence of CIPS. (IA)
BAF16c
There is a risk that we will have insufficient
cash to manage working balances and
satisfy payroll, creditor and servicing
historical debt requirements.
Director of Finance
Credit control and debtor management team (IC).
PDC approval by TDA (EC)
Board approved Standing Financial Instructions and Standing
Orders. (IC)
20
20
(5x4)
TDA approved temporary loan (EC).
FBPC approved Treasury Management policy (IC)
Minutes of FBP Committee (IA).
Monthly financial reporting to Board, divisions, TMC,
corporate services and TDA (IA).
G
None
A
Previously inadequate
management control on
major projects resulting in
time and cost overruns for
projects still in progress.
As per controls.
Programme of internal and external audit (EA).
Access to £28m working capital facility (EC)
BAF 16d
Sufficient liquidity is not generated to meet
the Capital Programme requirement (linked
to BAC 16c and 14a)
Director of Finance
Capital Management Group (IC)
Capital Management Group minutes (IA)
Finance and Business Performance Committee (IC)
Financial performance report to Board (IC)
20
Project management approach to capital programme (IC)
Additional capital received from TDA in 15/16. (EC)
Agreed Capital Resource Limit in Financial Plan (IC)
16
(4x4)
Finance and Business Performance Committee minutes
(IA)
Project plans (IA)
As per controls.
Risk assessments (IA)
Internal Audit - Planned Preventative and Reactive
Maintenance (EA)
35 of 208
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Assurance
RAG
Current Risk
Rating
(mitigated by
controls)
Key controls
Risk score
unmitigated by
controls
objective
Lead
Reference
Gaps in controls or
assurance
BAF 17a
There is a risk that if the Trust does not
develop a robust 5 year strategy it will not
be sustainable in the long term.
Director of Strategy
and Business
Development
Overarching risk
12
Board approved five year strategy 2015 - 2020 (IC)
25
(4x3)
new
Monthly Strategic Transformation Committee to monitor
implementation of strategy. (IA)
Trust Development Authority oversight of IBP (EA) through
monthly Integrated Delivery Meetings.
Refresh Integrated Business Plan January 2016.
G
Detailed financial and
workforce planning to
underpin strategic intent.
Board development programme to
focus on key elements of the strategy March 2016
Alignment with Clinical Commissioning Group strategic
intentions through support for Trust IBP (EA)
36 of 208
Page 13
Appendix 2
Risk Profile – Corporate Risk Register moderated by TMC 11 December 2015
CONSEQUENCE
Insignificant Minor Moderate
(1)
(2)
(3)
Major
(4)
Catastrophic
(5)
LIKELIHOOD
(frequency)
Almost Certain
(5)
Likely
(4)
Possible
(3)
CRR 27 – Electrical systems in theatres 
CRR 7 – Insufficient interventional radiology provision 
CRR 32 – Risk to achieving financial targets 
CRR 33 – HSMR 
CRR 39 – Risk that imaging reports are not acted upon new
CRR 21 – Consistent delivery of high quality end of life
care 
CRR 10 – Numbers of nurse vacancies 
CRR 36 – Numbers of cases of Clostridium difficile - 
CRR 29 – PAS replacement
programme 
CRR 34 – Early recognition of
clinical deterioration
CRR 38 – Trust cash position
– new
CRR 40 – delayed reporting
on cellular pathology - new
Unlikely
(2)
Rare
(1)
Key: = risk score has risen; = risk score has dropped; = no change.
37 of 208
Agenda item: 8.1
PUBLIC TRUST BOARD
27th January 2016
Title
Responsible
Director
Purpose of the
paper
Action / decision
required (e.g.,
approve, support,
endorse)
Your Community, Your Care proposal
David Williams
To approve the principle of an engagement programme with the public and key
stakeholders to develop vibrant multipurpose health centres that are connected to the
communities they serve in Buckingham, Chalfont, Marlow and Thame.
The Board is asked to :•
•
Note the proposed timetable for engagement and possible consultation on the
future of community hubs
Approve the governance framework to oversee the programme
Patient Quality
Legal
Financial
Performance
Regulatory/
Compliance
Operational
Performance
Public
Engagement
/Reputation
Strategy
FT Application
Equality &
Diversity
Partnership
Working
New or
elevated risk
Other
Annual Objective
BAF/Corporate Risk 7b
Register Reference
Risk Description
There is a risk if we do not develop out of hospital care that services will not support
patients to keep healthy and well at home.
CQC Reg. Ref.
Author of Paper
David Williams
Presenter of Paper
David Williams
Executive Committee, Strategic Transformation Committee, Reforming Integrated Care, Healthy Bucks Leaders
Date of Paper
20th January 2016
39 of 208
YOUR COMMUNITY, YOUR CARE: Developing Community Hubs
1. Introduction
There is a national and local imperative to move care closer to home, to provide person
centred care that is responsive and supports individuals to remain as independent as
possible for as long as possible.
The research is clear (Monitor review of clinical evidence) that prolonged stays in hospital
environments is often to the detriment of a frail older person and alternative, home based
services would improve their outcomes.
A Five Year Sustainability and Transformation Plan is being developed for Buckinghamshire
which will focus on a radical upgrade in health prevention, new models of care and a plan to
ensure the health and social care system remains in financial balance.
In the light of this, the Trust is keen to engage the community to create vibrant multipurpose health centres that are connected to the communities they serve in Buckingham,
Chalfont, Marlow and Thame.
Our aim is to develop services and sites that have been informed by those who use
them. Gathering the views of key partners, stakeholders and the public will enable us to
better understand local health and care needs and shape services to meet them.
2.
Rationale
2.1
New Models of Care
The model of care for frail older people needs to change to ensure that where possible
people are cared for in their own homes. Strategy documents have been developed across
the health and care system that reflect the drivers outlined above and seek to deliver care
that is person centred and community based. Commissioners are keen to see all services
focused to support care at home whenever possible.
Linked to this is the development of locality integrated team models which will bring together
general practice and community services with support from the third sector and local
government, more rigorously together to address the health and well-being and the self- care
agenda.
2. Scope
In light of the requirement for Five Year Sustainability and Transformation Plans across
systems, this programme of engagement with the public will set the wider context and share
the locally agreed vision for health and care in the future.
Engagement events will take place all over the county between March and May with the first
session likely to be in early March.
3. Process
Following the engagement sessions, the information gathered will be analysed and if
appropriate proposals developed for change, supported by a business case that may require
public consultation. The engagement sessions will support and influence the proposals as
they develop, ensuring that wherever possible the views of the local population are reflected.
40 of 208
4. Governance
An internal project group has been established (with an operational subgroup) to lead this
work that will report to the Reforming Integrated Care Programme Board and the Strategic
Transformation Committee.
5. Recommendation
The Board is asked to note and support the process and timeframes for community hubs
development.
David Williams
January 2016
41 of 208
27 JANUARY 2016
Details of the Paper
Title
Values & Behaviours Communication Plan
Responsible
Director
Purpose of the
paper
Ian Anderson
Action / decision
required (e.g.,
approve, support,
endorse)
The Board are invited to support the plan.
To update the Board on the rollout plans for Values & Behaviours.
Patient Quality
Legal
Financial
Performance
Regulatory/
Compliance
Annual Objective
Operational
Performance
Public
Engagement
/Reputation
Strategy
FT Application
Equality &
Diversity
Partnership
Working
New or
elevated risk
Other
Trust Corporate Objectives
• Well led and actively engaged staff
BAF/Corporate Risk
11b, 13a
Register Reference
Risk Description
11b - If staff are not actively engaged with organisational goals there is a risk that these
objective will not be delivered.
13a - There is a risk that we will not deliver the highest quality care if we do not embed
Trust values and behaviours and do not sufficiently engage with staff to deliver this.
CQC Reg. Ref.
Author of Paper
Natalie Gregory
Presenter of Paper
Ian Anderson
None
Date of Paper
January 2016
43 of 208
VALUES AND BEHAVIOURS: COMMUNICATIONS PLAN
Context
The Trust brought together a cross section of staff and leaders in 2015 to develop organisational values to
guide the way all members of staff work, foster a positive organisational culture and ensure cohesion and
consistency. These values have already been discussed at previous board workshops and the leadership
team has also been involved in developing an implementation plan and design concept.
The values will be embedded into various HR processes such as appraisals and interviews. Some staff will
already be aware of the new values, having been involved in the development process, but there is a
launch and roll out planned, starting in February 2016.
The values are CARE: Collaborate, Aspire, Respect, Enable
Objectives
• Help key stakeholders, especially staff, understand the Trust’s new values and the behaviours
underpinning those values, as well as how this fits with the Trust’s wider and long-term strategy.
• Help give staff a sense of ownership of the values: these were created by a cross section of staff,
they already exist across the organization and they support our mission to deliver safe and
compassionate care, every time
• Support sustained, regular, long-term communication of the values in various formats to help HR
embed these into the day-to-day consciousness of staff
Strategy
• Provide staff with a clear and consistent vision of how the values are part of what they do and what
they mean in practice.
• Promote key milestones and celebrate people living the values.
• Embed the values into our main internal communication channels and other communications, so
they become a regular part of the intranet and staff bulletin
• Demonstrate that the organisation is living the values
• Ensure all corporate communication messages are consistent with the values
Audience
Our key external message continues to be our mission of safe and compassionate care, every time. The
values messages will initially be an internal driver to support organisational development.
All staff: all employees should be living and breathing the new values
Stakeholders: organisations that hold us to account (such as Care Quality Committee, Trust Development
Authority, Health and Adult Social Care Select Committee) and wider health influencers, commentators and
leaders
Summary of communications activity
Teaser campaign – January - February2016
• Intranet and bulletin articles charting how the values have evolved, how they have been created for
staff by staff and that many within the organisation are already living the values
• Launch to managers at leadership sessions w/b 1 Feb
Launch celebration week - w/b 22 February 2016
• Lunch-time drop in celebration and market place event at Stoke Mandeville and Wycombe
hospitals, including give-aways for staff such as branded cupcakes, lanyards, massages from health
and wellbeing team
• Executives and values specialists walk about at all acute and community hospital sites, visiting all
wards and departments to hand out give-aways
• CARE pledge postcards wall or tree in main staff areas (such as education centre)
44 of 208
•
•
Animated video about the values, CARE posters to replace patient promises and service standard
posters
Promote HR’s ‘prove your values’ pen collecting competition
Continuous awareness raising – ongoing
• Create values section on the intranet with key information and space for staff to comment and
discuss
• Value of the month features in staff bulletin and celebration of best team values actions plans
• Photo campaign of staff with their values pledges supporting the initiative
• Quarterly values e-newsletter round-up
• Regular staff blogs
• Promote HR values initiatives, policy and process changes including GEMA (Going the extra mile
awards), annual staff awards, recruitment and appraisals
• Update staff on values through the team brief, chief executive all staff sessions and other internal
meetings
45 of 208
Trust Board
Wednesday 27 January 2016
Title
Responsible
Director
Purpose of the
paper
Workforce Report
Ian Anderson
Action / decision
required (e.g.,
approve, support,
endorse)
Key metrics to note are:
• Nurse recruitment and retention
• The reduction in agency staffing numbers and compliance with TDA rules
• Statutory training compliance at 89%
• Appraisal compliance at 89%
• Doctors’ industrial action
To update the Committee on key people metrics from December 2015
Patient Quality
Legal
Financial
Performance
Regulatory/
Compliance
Operational
Performance
Public
Engagement
/Reputation
Strategy
FT Application
Equality &
Diversity
Partnership
Working
New or
elevated risk
Other
Annual Objective
• Recruit an appropriately skilled, permanent workforce
• Focus on training & development
BAF/Corporate Risk 11a, 11b, 12a, 13a
Register Reference
Risk Description
11a - There is a risk to delivering organisational objectives if we do have not the right
12a - If we do not develop and nurture skilled leadership there is a risk that staff
engagement will be impacted in a negative way and that other corporate objectives
will not be achieved
CQC Reg. Ref.
Author of Paper
Bridget O’Kelly
Presenter of Paper
Ian Anderson
Date of Paper
15 January 2016
47 of 208
1
Executive Summary
Staffing levels
The number of staff employed substantively decreased in December when compared to November.
Challenges remain in recruiting and retaining nursing staff; the UK, EU and non-EU recruitment markets are highly
competitive as all Trusts work to achieve and maintain staffing levels to deliver safe and high quality
compassionate care. A key initiative is the recruitment of nurses from the Philippines; we have made 140 offers of
employment, with individuals joining the Trust in phases in 2016-17.
Nurse attrition rates are high and this has impacted on our nurse vacancy rate, which has increased over this
financial year and now stands at 14.6%. A senior member of the HR team will be leading a task and finish group
to identify causes and early wins.
Temporary staffing
Managing spend on agency staffing remains a Trust priority in order to deliver high quality at best value to the
organisation. Agency numbers were the lowest seen this year and bank staff numbers above average for the year.
Demand for nursing (qualified and HCAs) agency reduced in December, primarily as a result of a reduction of
theatre activity. The proportion of shifts (nursing and HCA) filled by agency workers reduced to 38%, the lowest
ratio in the last 12 months.
We are utilising the TDA/Monitor rules to support management of agency staff:
• The use of framework agencies for nursing staff: we are compliant
• The meeting of an 8% cap on spend for qualified nurse agency spend: we are estimating a December outturn of just over this figure
• The introduction from 23 November 2015 of caps for hourly charge rates for all agency staff: we are
compliant for nursing staff; we are reporting non-compliance in a small number of specialist areas
Statutory Training & Appraisals
We continue to make progress in both these areas and are at 89% for both statutory training and appraisal
compliance, just short of our target of 90%.
Industrial Action
89 Junior Doctors took strike action between 8.00am Tuesday 12 January and 8.00am Wednesday 13 January
(24 hours); emergency care only was covered during this period. Everyone who was expected to turn up for work
did; four operational meetings were held throughout the day.
The next action planned for 26-28 January has been suspended as talks continue between the British Medical
Association and the Government. A full walk out planned for 10 February could still take place depending on how
talks progress.
Organisation Development
A separate paper has been submitted to the Board this month.
48 of 208
2
A separate paper has been submitted to the Board this month.
Trust Values and Behaviours
The soft launch of the Trust’s new Values and Behaviours has started and includes engaging leaders in defining
next steps, which will be incorporated in a formal launch planned for early next month
Multi-professional, multi-divisional Leadership Programme
The 2015/16 Leadership Development Programme (for 125 staff in Bands 8a and senior medical staff) is
underway. The programme is fully subscribed with positive feedback received to date from participants. It includes
core development of leadership theory and application, together with practical application to work through
organised action learning sets. Delegates’ feedback about benefits includes increased opportunities to work with
colleagues across divisions, recognising synergies and opportunities for improving quality of care.
Developing a coaching culture
The coaching programme for staff in Bands 6 -7 is underway, with c200 individuals booked onto the course. It has
been developed to raise understanding and competence to use a range of coaching techniques and also
considers the impact of behaviour on colleagues and direct reports.
Employee Relations
89 Junior Doctors took strike action between 8.00am Tuesday 12 January and 8.00am Wednesday 13 January
(24 hours); emergency care only was covered during this period. Everyone who was expected to turn up for work
did; four operational meetings were held throughout the day. There was a picket outside Stoke Mandeville main
entrance ranging from half a dozen people to about 15 and all were very well behaved.
The next action planned for 26-28 January has been suspended as talks continue between the British Medical
Association and the Government. A full walk out planned for 10 February could still take place depending on how
talks progress.
Substantive Workforce
Staff In Post
Total staff numbers as at 31 December were 5425.1 fte, 10.8 fte under the budgeted establishment of 5435.9 fte.
Staff in Post and Temporary Staff (FTE)
5,600
5,500
5,400
5,300
5,200
5,100
5,000
4,900
4,800
4,700
4,600
4,500
SIP and Temporary
Staff (FTE)
Actual
Apr-15
May-15
Jun-15
Jul-15
Aug-15 Sep-15 Oct-15 Nov-15 Dec-15
Staff in Post
4950.0
4939.5
4945.2
4958.7
4945.9 4969.7 5020.1 5022.9 4992.9
Bank
220.6
209.1
218.3
262.2
258.4
242.6
258.0
269.9
252.0
Agency
227.3
195.3
215.0
234.9
231.0
239.7
235.6
202.6
180.1
Budgeted FTE
5375.8
5394.28
5381.6
5395.0
5408.2 5420.7 5426.8 5432.0 5435.9
The number of staff employed substantively decreased in December when compared to November. Agency
numbers were the lowest seen this year and bank staff numbers above average for the year.
Plans are in place to control agency usage and spend of all staff groups; temporary staff is covered in more detail
below.
49 of 208
3
Turnover
Turnover (all staff groups) was 14.9% in December, an increase of 0.2% from November’s figure of 14.7%.
Turnover of both qualified nurses and healthcare assistants (HCAs) is monitored separately and also increased in
month, which impacted on the overall figure.
Recruitment & Retention
The Trust-wide vacancy rate was 8.1% in December 2015. We are looking to maximise permanent recruitment in
clinical areas as vacancies are the major contributing factor to agency spend.
The challenges we face in attracting qualified nurses, together with high attrition rates has impacted on our
vacancy rate, which has increased over this financial year and now stands at 14.6%. We continue to see high
levels of nurse attrition - in December, 25.7fte left the organisation. Early analysis shows that one third of the
individuals had worked for the Trust for less than three years. A senior member of the HR team will be leading a
task and finish group to identify causes and early wins. Key areas of focus will include identification of hot-spots,
understanding exit data and targeted support for the hot-spot areas.
Key recruitment initiatives are summarised below:
Clinical (non-nursing, non-medical) Recruitment
Representatives from Occupational Therapy and the recruitment team attended a healthcare recruitment event on
the 17 November at the University of Southampton – in previous years we have recruited small numbers of high
quality applicants from the University. The number of individuals registering with us this year was lower than in
previous years, in particular nursing students.
The Trust will be attending the ‘MK JOBs Fair’ taking place at the end of January in Milton Keynes. This is a
multi-sector job fair that we have previously attended and have seen some success in recruiting from.
We have recently started a recruitment initiative for Operating Department Practitioners (ODPs) – an area where
we face challenges in attracting and retaining staff. Vacancies in this area are also a significant contributor to
agency spend.
Nurse Recruitment
We have re-focussed our resources within HR to maximise our ability to recruit in a highly competitive market –
attending recruitment events in the UK, taking forwards overseas recruitment (EU and non-EU) and reducing preemployment times. This has resulted in the recruitment in the final five months’ of the year of 105 nurses – 20
above plan.
During November and December we brought 35.1 fte nurses into the Trust – up from plan in November (by 15
fte), down on plan slightly in December (by 3 fte). We expect to bring in a further 23 fte in each of the next three
months, totalling c70 fte nurses before the end of the financial year. 26 individuals have confirmed start dates,
with the remainder going through pre-employment checks. Of this 70, 58 fte have been recruited from the UK, 12
fte have been recruited from international campaigns.
Activity in the next quarter is to target recruitment for Q1 of 2016-17, in particular in hot-spot areas and we
anticipate recruitment levels of c 20 fte per month.
As described above, we expect the market to remain tight. To help alleviate this major challenge in the mediumterm we have in the past two weeks made offers to 140 nurses from the Philippines, who will join the Trust in
phases from the second quarter onwards.
We remain highly active; a summary of the current actions is set out below:
UK Activity
We have secured 19 newly qualified nurses from the University of Bedfordshire, who will join us in March 2016
(following their completion of their course). This represents 68% of the cohort of 28 individuals
50 of 208
4
We attended the ‘Nursing Jobs Fair’ at Buckinghamshire New University (BNU) on 27 November. 45 adult nursing
students registered with the Trust, the majority of who qualify in July 2016. We are aiming to increase the
numbers we recruit from BNU (whose students’ placements are at other NHS Trusts).
We are attending the RCN jobs fair in London, representing both Health Education Thames Valley and the Trust
on 11-12 February 2016.
International Activity
EU recruitment:
• We have appointed 30 candidates from Portugal as a result of recruitment activity in early December 2015.
We expect these individuals to start with us between January and May 2016.
• We have made offers of appointment to a further 14 individuals following interviews in early January. We
expect them to start working at the Trust between February and April 2016.
• A number of these candidates will be required to go through the new NMC language requirements, which will
extend their individual recruitment timescales.
Non-EU:
• Four representatives from the Trust visited the Philippines in early January; we have made 140 offers of
employment, with individuals joining the Trust in phases during 2016-17 from Q2 onwards. We are making
focussed efforts to explore if any individuals can join us before this.
Bands 2 – 4 Nursing recruitment
The recruitment team continue to recruit Healthcare Assistants through a monthly programme of recruitment
events. In November and December 21.8 fte healthcare assistants joined the Trust. Our current vacancy rate is
8.8%.
We are continuing to actively recruit to Band 4 Assistant Practitioners and are advertising 14 roles across the
organisation through a Trust-wide campaign, utilising social media. To date, we have made 4 appointments; 3
internally 1 externally. We have been disappointed by the low numbers of external candidates that have met the
person specification.
Medical Recruitment
We are currently recruiting to 27 Consultant and locum Consultant posts.
We are also recruiting to 35 other posts for specialty doctors, Locum Appointment for Service (LAS) and Trust
Registrars.
Hard to fill posts are being looked at again to review how many posts are being advertised elsewhere and what
the national picture is showing before a recruitment premia will be considered.
Temporary Workforce
The Trust continues to utilise the TDA/Monitor rules to support management of agency staff. Specific areas of
monitoring are:
• The use of framework agencies for nursing staff
• The meeting of an 8% cap on spend for qualified nurse agency spend
• The introduction from 23 November 2015 of caps for hourly charge rates for all agency staff
Operational reports show a reduction in temporary staffing usage over the past three months, in particular for
qualified nursing.
This is not reflected in December expenditure, as this figure includes a catch up of invoices, which were not
included in November’s expenditure figures. Without inclusion of these invoices, temporary spend would have
been £2.2 million, the second lowest figure this f/y and c£0.5million below April spend.
51 of 208
5
Temporary Workforce Expenditure
£3,000,000
£2,500,000
£2,000,000
£1,500,000
£1,000,000
£500,000
£0
Bank & Locum
Agency
Total target spend
Medical
Demand for and use of medical agency staff remained level in December compared to November with 41.6 fte
locum doctors brought into the trust. Vacancies remain the main driver for use of temporary staff. Total current
vacancy numbers are 62 fte, the highest this year - vacancy levels during the first half of the year stood at c30 fte
each month, and we have seen an increase month on month since October. However, increased controls fortnightly reviews with Bank Partners, review at Deep Dive meetings and implementation of caps – means that
we are predicting that total medical temporary spend will remain flat at £750k per month for the remainder of the
quarter.
TDA Compliance
In the week ending 17 January, we reported three doctors as working with us at rates above the new caps. There
is a plan for each individual to either remove the usage or bring the individual into line with the caps. We are
seeing the impact of the rate cap on the average costs per hour of medical agency staff.
We continue to have fortnightly meetings with Bank Partners and they also attend the Deep Dive meetings.
Nursing (qualified)
• Agency Spend
Based on our operational returns, we are reporting a December out-turn of c£540k, just over target at c8.1% of
spend. This represents a significant improvement from August (when TDA reporting started) when we reported
an out-turn of 12.5%.
In January, the first two weekly reports and look ahead figures indicate that if we book no further agency there
would be an in-month spend of c£560k (c8.5%). However, with the number of unfilled shifts currently on the
system indicate that there is a risk that spend could increase up to c£620k. The primary difference between
December and January demand is almost entirely due to Surgery and we have seen a pick-up in demand as the
organisation reverts to normal working.
In February, if demand remains stable and we maintain fill rates of agency staff following the further reduction of
agency rates, we will see a further saving of c£60k, which would enable us to meet the 8% target. However, there
is a risk, particularly in critical areas, that if agencies withdraw their staff, there will be an impact on patient care.
Our efforts to meet the cap are inhibited by high attrition rates within nursing, which we are working to address (as
described above). Medium to long term mitigation will be helped non-EU recruitment due to impact during f/y
2015/16.
• Framework Agencies
We continue to be fully compliant with the TDA requirement to use only framework agencies for nursing staffing.
(This is reported to the TDA on a weekly basis.) Information from neighbouring Trusts indicates that we are in a
minority of Trusts in this position.
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6
• Price Caps
Since 2 December, no nursing shifts have been filled above the cap (introduced on 23 November). We are not
aware of any other Trust in the region which has achieved this.
On 1 February, the price caps reduce further. We are engaging with our agency suppliers and liaising with
neighbouring Trusts in order to ensure compliance. Whilst we expect to get some financial benefit from this
reduction, there is a risk to patient care if agencies decide to withdraw their staff. We are therefore putting in place
contingency plans.
Clinical non-nursing, non-medical
We are collating use of clinical non-nursing, non-medical agency usage through a weekly manual return from
managers across the organisation. The majority of agency workers (c35 individuals) are working at rates
compliant with the current price caps. In the week commencing 4 January, 5 individuals working in key critical
(patient facing) areas with national shortages were engaged at rates above the cap.
A number of agency staff across the organisation are currently paid at rates which will be above the rates due
come into force on 1 February. We have set up fortnightly meetings set up with AHP/Healthcare Scientist leads to
ensure consistency of approach across the organisation. We are working with suppliers to ensure compliance with
these lower rates. We are also working with our Bank Provider to bring all other temporary staffing onto their
platform. This will facilitate the management of temporary staffing for these staff groups.
2015 NHS National Staff Survey
The 2015 NHS National staff survey closed on 27 November 2015. The benchmarked key findings report which
compares the trust’s results with other organisations will not be available until 23 February 2016. This year, for
the first time, NHS England have introduced a new category of organisation “combined trusts” and so BHT will be
benchmarked against other combined acute and community trusts, rather than compared with just acute
organisations.
Divisions are identifying staff survey leads/champions that will be responsible for sharing divisional results within
their parts of the organisation and for developing divisional action plans.
Quality Health, our new survey partner will present an overview of the trust’s results to TMC on 4 March and we
will share the highlights of the results with Trust Board in March.
Sickness Absence
Overall sickness absence for the Trust remained level at
4.1% in both October and November 2015. Levels for
HCAs remain significantly higher than for other staff
groups, there was an increase in November (6.7%)
compared to October (6.0%). HCA sickness remains
high on the Case Managers’ agendas, and the aim is to
sustain below target levels over the coming months,
supported by the start of the HCA self-care course. HR
Business partners continue to work with managers to
address issues in hot spot areas.
Sickness Absence %
8%
6%
4%
2%
Qualified Nurses
Trustwide
Healthcare Assistants
Target
Dec to Mar - Projected figures
53 of 208
7
Trustwide Statutory Training
Compliance at the end of December was 89% against a
target of 90%, the same as November. (This figure
excludes new starters in December as these staff will be
due to attend Trust induction in the first week of December
and will then complete their statutory training.) This is
disappointing; operational managers and the HR Team
are working hard to achieve the Trust target of 90% as a
priority - face to face training sessions continue and a data
stick has been made available which will increase the
opportunity for slow responders to complete their training.
The HR Team and managers are targeting those
individuals with low levels of compliance which could
include disciplinary action.
Dec-15
Corporate
Integrated Elderly Care
Integrated Medicine
Specialist Services
Surgery & Critical Care
Women & Children
Trust overall
% Compliance
93%
91%
88%
89%
86%
89%
89%
Non-medical Appraisals
The completion rate as at end of December was recorded on ESR as 89%, against a target of 90%.
Appraisal Compliance
100%
80%
60%
40%
Actual
Target
Jan to Mar - Projected figures
Medical Job Plans
In December, 89% of job plans have been signed off on the Allocate Job Plan system against a target of 100%.
This number has reduced from October’s figure as some job plans have been placed back in discussion.
Medical Revalidation
We currently have a doctor who has been referred to the GMC for non-engagement; however the doctor is now
working with the Trust and the GMC to address.
Update on Flu
We reported an uptake of 45.3% (for the period 1 September to 30 November) for the flu vaccine, above the
national average of 44.1% (based on 97% of Trusts). In December, our uptake had increased to 48.6%. (Early
virological surveillance from the UK shows the flu strain A(H1n1)pdm09 is now the main seasonal flu virus
detected this season, and this is well-matched to the current vaccine.) The Occupational Health Team continues
to promote the importance of having the flu vaccination.
54 of 208
8
27 JANUARY 2016
Title
Organisational Development Board discussion paper
Responsible
Director
Purpose of the
paper
Ian Anderson
Action / decision
required (e.g.,
approve, support,
endorse)
To review and comment on the proposed approach and evidence the actions proposed.
To outline the proposed Organisational Development approach and activities to enable
delivery of our Strategic Plan.
Patient Quality
Legal
Financial
Performance
Regulatory/
Compliance
Operational
Performance
Public
Engagement
/Reputation
Strategy
FT Application
Equality &
Diversity
Partnership
Working
New or
elevated risk
Other
Annual Objective
• Recruit an appropriately skilled, permanent workforce
• Focus on training & development
BAF/Corporate Risk 11a, 11b, 12a, 13a
Register Reference
Risk Description
11a - There is a risk to delivering organisational objectives if we do have not the right
12a - If we do not develop and nurture skilled leadership there is a risk that staff
engagement will be impacted in a negative way and that other corporate objectives
will not be achieved
CQC Reg. Ref.
Author of Paper
Ian Anderson
Presenter of Paper
Ian Anderson
None
Date of Paper
January 2016
55 of 208
Organisational Development Board Discussion Paper
Executive Summary
To enable delivery of our ambitious Strategy and the significant change that will require, an
assessment has been made of the Organisational Development needs arising from that
ambition. This paper has isolated the key people elements of OD and outlined the key
activities that need to be undertaken in each. The proposed programme highlights the
substantial activity required and charts the proposed timescales for each activity.
The Board is invited to:
1. Review the assessment and proposed actions
2. Provide feedback and guidance on the proposed plan and the priority assigned to
the proposed activities.
3. Endorse the direction of travel and the proposed plan of action with any
enhancements that may emerge from Board debate.
4. Note the funding challenge
Background
Five Year Forward View
The national Five Year Forward View (FYFV) highlights a dramatic improvement in the NHS in the past 15
years but states that quality of care can be variable, preventable illness is widespread and health
inequalities deep rooted. Growing demand if met by no further annual efficiencies and flat rate funding
will produce a mismatch between resources and patient need of £30bn by 2020/21. The report argues,
to meet this challenge a radical upgrade in prevention and public health is required as well a decisive
steps to break down barriers in how care is provided between primary and secondly care, physical and
mental health and health and social care.
Mission and Vision
We developed our mission and vision through a series of Board sessions and workshops involving
patients and clinicians to identify their aspirations for our services.
Mission
Our Mission which sets out our fundamental purpose is safe and compassionate every time.
Strategic Objectives
Our strategy is translated into seven clear objectives. In January 2015, the Board and
senior leaders within the Trust developed a set of long-term strategic objectives to
take Buckinghamshire Healthcare to 2020. The Board confirmed these strategic
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objectives in August 2015.
Figure 3.3 Strategic Objectives
Strategy
Objective
1
Quality
To reduce mortality, harm and deliver a great
patient experience
2
Integrated Care
To deliver integration of hospital, community and primary
care services which are shaped around the needs of every
adult and child
3
Emergency and
Urgent
To develop emergency and urgent care services for the local
population which maximise the chances of survival and
good recovery
4
Planned
To develop planned services which are seen as some of the
best in the country for patient outcomes, access and
efficiency
5
Specialist
To develop specialist services which are renowned
regionally and nationally as centres of excellence
6
People
To ensure we have a skilled and committed teams who live
our vision, values and behaviours
7
Support
To deliver our financial plans and transform our estate and IT
Our Values
The Trust has undertaken a wide ranging consultation with staff and other stakeholders to review our
values to ensure these align with our mission and vision. A series of focus groups and one to ones were
held with a wide range of staff. Emerging themes were tested with patients.
We COLLABORATE – working together as a team
We ASPIRE – striving to be the best
We RESPECT – everyone, valuing each person as an individual
We ENABLE – people to take responsibility
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Each value has a set of positive and negative behaviours which will help our people and patients
understand what each value means and what can be expected from us.
The values will become an integral part of our organisational development activity including staff
recognition schemes, recruitment processes and communication with our patients to embed a culture of
safe, compassionate care, every time for every patient.
This paper seeks to support the Strategic Plan by charting the organisation Development journey that
will be required to enable the transformation that delivery of the Vision will require.
For the purposes of this paper Organisation Development has been defined by the Exec team as “OD
creates the environment and capability which enables organisations to deliver sustainable
performance”.
The key component parts of an OD approach are highlighted below. This paper will focus on the people
elements of the OD which are summarised below. It is noted that these are separate workstreams
progressing systems and strategy and it is proposed that a further workstream is established to progress
process change reporting to the OD Assurance Committee.
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Whilst there is room for debate about whether these are the exact component parts of an OD Strategy
(several hundred thousand articles have been published debating the point) the intention of this paper
is to identify a framework that will enable real and sustainable progress to be made against the key
objectives that will enable delivery of the Trust Strategy.
This approach is informed by a number of inputs.
1. The clear need for change defined by the Trust Strategy
2. Consultative work undertaken with c300 leaders and staff who were asked to define strengths
and weaknesses of the organisations to deliver the strategy.
3. The work of Michael West and others around the role of people in the future success of the NHS
4. The collective input of the HR Team
5. The authors observations of the current situation v best practice
Summary Assessment of Current Situation
To help prioritise our activity our current state versus best practice has been assessed in each of the
component areas and this is summarised below using a scale of 1-10 where 1 = very poor and 10 =
excellent. This highlights that there is a significant amount of work to be done which will require
dedicated focus and a long term commitment to complete.
Team Development
4
HR Processes
6
Programme Management
3
Learning and Development
5
Leadership Development
6
Coaching and Mentoring
5
Staff Engagement
4
Culture Change
2
Recruitment
5
Organisation Design
2
Talent Management
2
Communications
6
Reward & Recognition
3
A more detailed assessment of each area and proposed Actions follow.
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The Way Forward
Team Development
Current State
A range of activities have been undertaken at Exec, Board and throughout the organisation. Some is
sponsored and supported by ELD and some from other sources and there are pockets where is it very
good. In general there is not strong evidence of effective team working and a low level of ability to
strengthen team working amongst the key Leaders in the organisation.
Recommended Next Steps
That a consistent approach and toolkit for team working is developed and adopted across the Trust Q2
2016.
That training in this tool kit should be compulsory for all managers and leaders and that this should be
rolled out over the next three years 2016-2019.
HR Processes
Current State
HR Processes are fit for purpose and compare adequately with best practice except they are heavily
manual and supporting technology is extremely inadequate. There are likely to be some marginal
financial gains from elements of outsourcing and there are definite opportunities for an extension of
self-service HR and to take advantage of national technology enhancements due to be released next
financial year. There is a further opportunity to benefit from shared HR services with other Trusts that is
likely to lead to process and financial benefits.
Seek early involvement in technology enhancements to National HR systems 2016
Implement HR Self Service 2017 - 2018
Explore opportunities for shared services with other Trusts 2017 - 2018
Implement shared services 2018 - 2019
Performance Management
Current State
There are established processes for managing underperformance and a very unwieldy appraisal process.
Compliance with approved process is much improved with over 90% reporting that they have had an
appraisal. A consistent view from all sources is that beyond that basic level performance management is
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weak with little differentiation between high performance and under performance and limited evidence
of support and challenge on a consistent basis.
We are unlikely to achieve our mission of consistently delivering high quality patient care if we do not
create a high performance environment with much improved performance management.
Work is already underway to simplify the appraisal process and integrate the new values and
behaviours. This work should be completed in 2016/2017 and fully embedded by 2016/2017. All
managers and leaders should attend a compulsory training module in managing performance 2016 –
2018.
Introduce quarterly appraisals from 2016/2017 with non-compliance leading to no incremental
progression. A 10% quality audit to be completed by HR/Appraisal Champions/Internal Audit in the midyear point 2016-2019.
Learning & Development
Current situation – The Trust offers a wide range of Learning and Development activities much of it
funded by HETV and there is a strong bias towards clinical skills although there has been some
rebalancing this year. The quality is good with positive feedback and evaluation from a range of sources.
The key question in this area would appear to be ROI with limited linkage to Personal Development
Plans, Talent and Succession plans and sometimes organisational priorities, and ensuring off the job
learning is translated into improved performance and changed behaviour. The ROI seems particularly
questionable on some of the sponsorship decisions and the use of Academic Half Days. There is also
little evidence that we are progressing towards becoming a truly learning organisation.
1. That we continue to build on the very solid base of learning activity currently in place 20/06/17
onwards
2. That we adopt a more rigorous approach to ensuring that our Programme of activities is fully
matched to TNA, Organisation Priorities, Talent Strategy and Succession.2016/17. Initially this
will be overseen by the OD Assurance Committee
3. That we introduce a more rigourous pre and post course briefing process to ensure learning is
applied to the job. 20/06/17
4. That a comprehensive review of the adequacy of our organisation’s learning approach is
completed in 2016/2017 and a best practice approach is introduced in 2017/2018.
5. That the recommendations to improve the value of Academic half days are fully introduced in
2016/2017 and further improvements are introduced in 2017/2018.
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Leadership and Management Development
Current Situation
Historically there has been very limited investment in Leadership and Management Development which
coupled with a very directive leadership style has generated a very low level of capability and confidence
amongst managers and leaders at all levels. This manifests itself in a number of ways but is particularly
relevant to the weakness highlighted elsewhere in Performance Management and Culture Change.
Over the past year this has been specifically addressed through an extension of the Medical Leadership
Programme and the provision of additional management Development Modules. Additionally we
continue to nominate and support people attend National and Regional high profile programmes.
1. Continue to deliver the current Leadership Programme until all Senior Leaders have completed
the programme 2016/2017, 2017/2018, 2018/2019.
2. Further develop the management development framework and create a further suite of
management development programmes. 2016/2017
3. Develop a Leadership and Management Competency Framework 2016/2017
4. Introduce an assessment process against the framework which is applied to all managers
2017/2018.
5. Introduce a Leadership and Management Development Core Skills Suite which all managers and
leaders must complete to progress along the incremental scale 2017/2018.
6. Use targeted External Leadership forums 2016/2017 onwards
External use of Coaching & Monitoring
Current Situation – Over the past few years a number of Senior Leaders have benefitted from support of
a coach and whilst this may have brought individual benefit it has had a little impact in terms of creating
a coaching culture and capability. This is being addressed through the Leadership Programme where
there is a significant focus on coaching, the coaching to lead programme for Bands 6/7 and the plan to
train 18 accredited coaches within the organisation.
Extend Leadership Programme 2016/2017, 2017/2018, 2018/2019
Extend Coaching to Lead Programme 2016/2017, 2017/2018, 2018/2019
Extend Coach Accreditation 2016/2017, 2017/2018, 2018/2019
Build a Programme of Coaching Support 2016/2017, 2017/2018, 2018/2019
Pilot group coaching sessions 2016/2017
Ensure all Executives and Divisional Board members are qualified coaches by 2017/2018
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Staff Engagement
Current Situation – As of 2014/2015 we are in the lower quartile nationally for staff engagement as
measured by the annual Staff Survey. Whilst we are anticipating some improvement this would support
the management view that there is much to do in this area.
During 2015/2016 there has been significant focus on this area with initiatives which include, Quarterly
CEO Engagement Sessions, Quarterly Leading the BHT Way Sessions, launch of an amended comms
approach including re-launched team brief, and there has been wide engagement in the development of
the Values and Behaviours.
If we were being brutally honest we have a sound approach but it has not yet translated into engaging
hearts and minds.
Recommended Actions
1. Continue, and build on all current initiatives 2016/ - 2019
2. Progress the comprehensive launch and rollout plans for values and behaviours currently in
place.
3. Appoint staff engagement champions in each division with specific responsibility for Staff Survey
Action Plans 2016 –
4. Develop a series of engagement sessions around specific topics that include and engage a wide
range of people.
Start with quality 2016-2017
Other topics 20175. Introduce a hot ideas scheme – 2016
6. Introduce a Shadow Board to give more people an understanding of the challenges of running
the organisation 2017 onwards
7. Introduce a management conference and cascade process to ensure the 5 year strategy and
2016/17 plan is fully understood and bought into Q2 2016/17
Culture Change
Current Situation – Bucks has a very traditional NHS culture and displays many old fashioned traits of
directive leadership, lack of accountability, lack of commercial savvy lack of pace, etc This is a serious
impediment to delivering our strategy and if not addressed will ultimately seriously damage our ability
to deliver the strategy.
This is compounded by a lack of awareness of the problem and hence the absence of an appetite to
drive real change. It is probably also fair to say that there is an absence of experience and skills to
deliver real culture change. Although the platform is burning the pain of change still seems to outweigh
the discomfort of doing what we have always done.
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That we complete a culture assessment to clarify/confirm the gaps we need to address – 2016/2017
That a comprehensive culture change proposal is developed and implemented to address identified gaps
– 2017-2020
That we utilise Values and Behaviours work to roll out a sustained culture change programme with
identified leaders and champions as the catalysts for change – 2016 – 2020. First stage is to embed
values and behaviours during 2016/17
That we identify our people who could be catalysts for change and develop an awareness and education
programme to enable readiness to lead 2016 – 2017.
Recruitment
Current State – The Trust has a technology enabled recruitment system which is largely self-service up
to the point of placing an advert. The process needs to be updated to reflect the new Values and
Behaviours. The specialist recruitment team support line managers through the advertising and
appointment stages. The process works fairly well with KPI’s generally being met. There is limited
quality control over recruitment decisions.
1. Redesign recruitment process to ensure there is a greater emphasis on recruitment to Values
and Behaviours 2015/2016
2. Seek to further streamline vacancy approval process and link to budget 2016/2017
3. Raise the competence and confidence of all managers who recruit through refresher training
2017/2018
4. Undertake a comprehensive review of skills and competence required for the future and
develop resourcing and recruitment strategies to resource these 2016/17
Organisation Design
Current State – The Current organisation design reflects the traditional way of doing things in the NHS
and feels fit for purpose for the current agenda. If we are to create an organisation that is appropriate
for the future it is anticipated that further review will be necessary bearing in mind the need for whole
system working, changed pathway of care, the need to reduce costs by at least 20% over 5 years and
become best of breed in response to Carter etc
1. As part of the emerging strategy for changed approaches to care, a workstream is established to
look at the organisational design impact 2016/2019
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2. That a set of OD principles are established, that are used to test all interim changes to structure
whilst the strategy is fully formed – 2016/2017
3. That on initial Organisational review is completed using simple tools such as spans and layers
and responsibility mapping to generate early cost savings 2016/2018
Talent Management
Current State – Probably one of weakest areas currently with very limited focus, activity or process
completed to date. Consequently there is limited understanding of the depth of talent within the
organisation.
Some limited activity has been undertaken to try to establish the Strategic Workforce Agenda but
progress has been slow. Some work has been completed on Succession Planning at the most senior
levels.
1. Develop a Talent Management Strategy and Approach 2016/2017
2. Refresh the Succession Planning work done at senior levels and share outcomes with the Board
2015/2016
3. Establish first pass workforce of the future framework and implement concrete strategies to
address the management gaps 2016-2018.
4. Build stronger links with wider system partners to progress specific workforce challenges and
improve long term planning 2016 Communication
A recent survey of communication activity has led to a re-launched approach to internal
communications.
1. That we should carefully mentor the effectiveness of the comms approach and review in 6
months’ time what else we need to do – 2016/2017
Reward & Recognition
Current state – Current pay mechanisms are nationally dictated and not highly valued by staff. Whether
good, bad or indifferent the key point is that they are perceived in a fairly negative way and therefore
are not motivational.
Other Reward and Recognition mechanisms are received more favorably with a very positive response
to long service and staff recognition etc
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1. Review and enhance current recognition activity to align more closely with Values and
Behaviours 2015/2016
2. Engage staff to identify additional non-financial tool that would be used 2016/2017 possibly to
enable additional Development activity.
3. Engage managers to use the more powerful recognition tool – say `Thank You’
A Summary Action Plan is attached to Appendix 1
Costs
It is anticipated that the majority of this work can be achieved by reshaping existing HR Budgets (so long
as HETV funding is maintained at current levels). Initial costings suggest that additional costs of up to
£100k could be incurred each year and the proposal is that these will be self-funding by reductions in
attrition sick absence etc. Release of these funds to be agreed with the Financial Director as they arise.
Next Steps
•
•
•
•
•
Develop detailed plans to deliver each action
Socialise and engage key leaders in delivery
Embed into objectives of relevant teams
Develop success measures for each action
Report back to OD Assurance Committee (monthly) and Board ( 3 times a year)
Ian Anderson
Director of HR & OD
January 2016
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Summary Action Plan
Appendix 1
Action
Team
Development
HR Processes
Performance
Management
Learning &
Development
2015/2016
2016/2017
2017/2018
2018/2019
That a consistent approach and
toolkit for team working is
developed and adopted across
the Trust Q2 2016.
That training in this tool kit should be compulsory for all managers and leaders and
that this should be rolled out over the next three years 2016-2019.
Seek early involvement in
technology enhancements to HR
systems 2016
Implement HR Self
Service 2017
Explore opportunities
for shared services with
other Trusts 2017
Implement shared
services 2018
Work is already underway to
simplify the appraisals process
and integrate the new values and
behaviours. This work should be
completed in 2015/2016 and fully
embedded by 2016/2017.
All managers and leaders should attend a compulsory training module in managing
performance 2016 – 2018.
Introduce quarterly appraisals from 2016/2017 with non-compliance leading to no
incremental progression. A 10% quality audit to be completed by HR/Appraisal
Champions in the mid-year point 2016-2019.
That we continue to build on the
very solid base of learning activity
currently in place 20/06/17
2019/2020
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Leadership &
Management
Development
That we introduce a more
rigorous pre and post course
briefing process to ensure
learning is applied to the job.
20/06/17
That a comprehensive review of the adequacy of our organisation is learning
approach is completed in 2016/2017 and a best practice approach is introduced in
2017/2018.
That the recommendations to improve the value of Academic half days are fully
introduced in 2016/2017 and further improvements are introduced in 2017/2018.
Continue to deliver Leadership Programmes until all Senior Leaders have completed
the programme 2016/2017, 2017/2018, 2018/2019.
Further develop the management
development framework and
create a further state of
management development
programmes. 2016/2017
Develop a Leadership and
Management Competency
Framework 2016/2017
External Leadership forums
2016/2017
External Use of
Coaching &
Monitoring
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Introduce an assessment process against the
framework which is applied to all managers
2017/2018.
Introduce a Leadership and Management
Development Core Skills Site which all managers
and leaders must complete to progress along the
incremental scale 2017/2018.
Extend Leadership Programme 2016/2017, 2017/2018, 2018/2019
Extend Coaching to Lead Programme 2016/2017, 2017/2018, 2018/2019
Extend Coach Accreditation 2016/2017, 2017/2018, 2018/2019
Build a Programme of Coaching Support 2016/2017, 2017/2018, 2018/2019
Pilot group coaching sessions
2016/2017
Staff
Engagement
Ensure all Executives
and Divisional Board
members are qualified
coaches by 2017/2018
Continue and build on all current initiatives 2016/ - 2019
Appoint staff engagement
champions in each division with
specific responsibility for Staff
Survey Action Plans 2016 –
Develop a series of engagement
sessions and specific topics that
include and engage a wide range
of people.
Start with quarterly 2016-2017
Other topics 2017Introduce a hot ideas scheme –
2016
Other topics 2017-
Introduce a Shadow
Board to give more
people an
understanding of the
challenges of running
the organisation 2017
Introduce a Management
Conference
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Culture Change
Recruitment
Organisation
Design
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Redesign
recruitment
process to
ensure there is
a greater
emphasis on
recruitment to
Values and
Behaviours
2015/2016
That we complete a culture
assessment to clarify/confirm the
gaps we need to address –
2016/2017
That a comprehensive culture change proposal is developed to address identified gaps – 2017-2020
That we utilise Values and Behaviours work to roll out a sustained culture change programme which
identified leaders and champions as the catalysts for change – 2016 – 2020
That we identify our catalysts for
change and develop awareness
and education programme to
enable readiness to lead 2016 –
2017
Embedding Values & Behaviours
in 2016/2017
Seek to further streamline
vacancy approval process and link
of budget 2016/2017
Raise the competence
and confidence of all
managers who recruit
through refresh training
2017/2018
As part of the emerging strategy for changed approaches to care, a workstream is
established to look at the organisational design impact 2016/2019
That a set of OD principles are
established, that are used to test
all interim changes to structure
whilst the strategy is fully formed
– 2016/2017
That on initial Organisational review is completed using
simple tools such as spans and layers and responsibility
mapping to generate early cost savings 2016/2018
Develop a Talent Management
Strategy and Approach
2016/2017
Talent
Management
Refresh the
Succession
Planning work
done at senior
levels and share
outcomes with
the Board
2015/2016
Communication
Reward &
Recognition
Review and
enhance
current
recognition
activity to align
more closely
with Values and
Behaviours
2015/2016
Establish first pass workforce of the future framework and implement concrete
strategies to address the management gaps 2016-2018.
That we should carefully mentor the effectiveness of the comms approach and review
in 6 months’ time what we need to do – 2016/2017
Engage staff to identify additional non-financial tool that would be used 2016/2017
possibly to enable additional Development activity
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Agenda item: 10.1
27 JANUARY 2016
Title
Patient Story from Respiratory
Responsible
Director
Purpose of the
paper
Chief Nurse
Action / decision
required (e.g.,
approve, support,
endorse)
To share the experiences of patients with Chronic Obstructive Pulmonary Disease
following the respiratory pathway. The presentation aims to demonstrate how the
integrated respiratory services supports patient along the pathway ensuring they receive
safe and effective care at home, improving their quality of life and supporting selfmanagement
For information and discussion
Patient
Quality
Legal
Financial
Performance
Regulatory/
Compliance
Annual Objective
Objective 1:
Operational
Performance
Public
Engagement
/Reputation
Strategy
FT Application
Equality &
Diversity
Partnership
Working
New or
elevated risk
Other
To excel in the delivery of clinical care, safety and patient experience
BAF/Corporate Risk
Register Reference
Not applicable
Risk Description
Not applicable
CQC Reg. Ref.
Author of Paper
Lesley Broad
Presenter of Paper
Lesley Broad
Date of Paper
14 January 2016
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Agenda item: 10.2
Enc: TB2016/011
27 January 2016
Title
Chief Nurse and Medical Director
Responsible
Director
Purpose of the
paper
Action / decision
required (e.g.,
approve, support,
endorse)
This paper provides the Board with an update on the quality of service provided by the
organisation, reducing mortality, reducing harm and ensuring a great patient experience
as well as ensuring we have safe staffing levels.
The Board are asked to note and approve the actions taken
Patient
Quality
Legal
Financial
Performance
Regulatory/
Compliance
Annual Objective
Operational
Performance
Public
Engagement
/Reputation
Strategy
FT Application
Equality &
Diversity
Partnership
Working
New or
elevated risk
Other
This relates to :
Objective 1 - Improving quality, safety and patient experience
Objective 2- Employ, engage and develop high calibre staff
BAF/Corporate Risk BAF 1a - There is a risk that the targeted reduction in mortality as measured by the HSMR
Register Reference
will not be achieved.
BAF 2a - There is a risk that patients will come to harm as a result of preventable falls.
BAF 3a - There is a risk that we will not deliver the targeted improvement in the net
promoter score for patient experience
CRR 21- We do not consistently deliver clinically effective End of Life Care (EoLC) - CQC
review assessed EoLC to be inadequate on both SMH and WGH sites
Risk Description
As above
CQC Reg. Ref.
Author of Paper
Deputy Chief Nurse
Presenter of Paper
Chief Nurse and Chief Medical Officer
Date of Paper
January 2016
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Quality Report
January 2016
Presenting November 2015 data
Carolyn Morrice –Chief Nurse
Tina Kenny- Chief Medical Officer
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Quality Report
Executive Summary
The Quality Report is a review of the progress against quality Improvement and achievements towards the 3 main objectives : Reducing
mortality, Reducing harm and Great Patient experience.
1. Reducing Mortality-Avoidable cardiac arrests continue to decline since June 2015
Appendix 1 has been submitted by the Chief Medical Officer in support of the Mortality Report.
Deteriorating Patient(DP)- 90 day improvement and innovation programme to address the concerns arising from the recent trend in failure to
escalate sick patients and the resultant failure to rescue. Sustained 94% compliance accurate national early warning scores(NEWS) and improved
position documented evidence of escalation from 53% to73%.
2. Reducing Harm
Falls Fall categorised as severe and those leading to death has reduced from 17 last year to 5 (April 2015–December 2015).
Pressure ulcers are on target to meet the 25% reduction of avoidable Grade 3 and 4 pressure ulcers this year with the Trust reporting 7 to date,
as compared to 30 in 2015.
Medication errors- still need for focus on increased reporting , whilst the target in December was met ,there is not yet evidence of sustained
reduction. Improvement work is concentrating on high risk medications ; Insulin and anticoagulant therapy and raising awareness and reducing
omitted doses
End of Life Care (EoLC)
Good progress has been made over the last quarter. 1250 care plans rolled out across the trust. 1,199 clinical staff trained in foundation training on
EoLC. Public engagement with EoLC has been a huge success in helping to shape this work. Divisional Leads will help create divisional ‘heat
maps’ which will identify specific EoL improvements in each division. The challenge is confidence in early conversations regarding end of life care
and using treatment escalation plans to support care if recovery is uncertain.
3. Patient experience
Focussed effort in Quarter 4 to improve the rate of responses from users of the service. Consideration of digital feedback using text services in an
attempt to drive up our response rates is currently being given priority. It should be noted that scores remain high and narrative is overwhelmingly
positive in support of the care received. Rich text data is used to inform improvements and is fed back through to divisional level.
Complaints performance for November is 57% ,root cause and immediate mitigation was discussed in detail at the Quality Committee in January
2016.Future focus must be on how the organisation reaches the 85% response rate and more importantly sustains that position.
The paper highlights the following risks:
•
Delivery of Complaints has not met the 85% compliance target and sustained that position
•
Continued focus is required on improving early recognition of the deteriorating patient
•
EoLC embedding improvement through continued education and ownership at divisional level
To manage this risk
•
Improvement group dedicated to the DP work stream reporting to the Quality and Safety Group
•
Trust and system wide EoLC steering groups to drive improvement
•
Backlog complaints within one division being addressed to improve position by February2016 which will improve overall Trust position
•
Key stakeholder meeting January 2016 to plan a sustainability model for complaint response times to prevent variation in performance
Quality Report
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Reducing Mortality
Crude mortality
• The rolling HSMR is a
benchmark mechanism
that provides high level
comparison, the trust sits
marginally above the
average of 100 . The
crude mortality falls
below the national
average
RED = BHT BLUE = National Average
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Quality Report
90 day Deteriorating patient update
Aim: Reduce avoidable cardiac arrests by 10% by March 2016
The
90 day Deteriorating Patient
improvement plan seeks to use the
following 6 drivers for change:
•
•
•
•
•
•
•
•
Quality Report
Reliable recording of vital signs
Early identification of deterioration
(escalation)
Effective
communication
of
deterioration using SBAR
Escalation to higher level of responder
Escalation to higher level of care
TEP
and
DNACPR
discussions
documented
The deteriorating patient group have
created a 90 day innovation and
improvement programme with a view
to driving a 6 step improvement plan at
pace
An action plan has been developed and
will be fine-tuned by the project group
as they implement and test changes
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Reducing Mortality
Deteriorating Patient & Cardiac Arrest Rate
In terms of milestones :
•
Achievement of reliable recording of vital signs has remained >94% consistently since 2014
•
Audit of escalation of the deteriorating patient has been recorded at 53% in July 2015 and 65% in
September 2015. Data for November 2015 is reflecting an increase to 73% . Predicted reach of 95% by
end January 2016 is challenging.
•
-
The following actions are in train to support the escalation process:
Continued focus on structured SBAR escalation – 100% of staff trained across the 90 day programme
areas
Human factors training for all staff across ward areas in understanding behaviours and team dynamics
Safety huddles to develop thoughtfulness and heightened awareness of patient escalation
Ward leadership and senior support is key
•
SBAR stickers in place across ward areas, with supported training and increased usage and confidence
reported by staff
•
Further work to be focussed on Treatment Escalation Plan (TEP) and documented discussions
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Quality Report
Mortality
Deteriorating Patient
Aim: Reduce avoidable cardiac arrests by 10% from 71
arrests in 2014 to 64 in 2015 ( March ‘15-March ‘16)
•
Avoidable cardiac arrests continue to decline since June
2015
•
48 cardiac arrests reported up to December 2015
•
Monthly review of all avoidable arrests informing
themes and remedial actions for ward teams
•
A continued focus and drive on Learning from cardiac
arrest RCA’s are in place supported by the monthly
open lessons learnt sessions .
•
Treatment Escalation Plans (TEPs) and Do Not Attempt
Resuscitation (DNAR) training in place to support
clinicians with difficult end of life conversations
•
Renewed focus on reducing failure to rescue through the
Deteriorating Patient (DP) work outlined above
•
Consistent themes arising:
•
Lack of DNAR discussions
•
Lack of timely escalation. Both of these are being
addressed through the DP working group. 100%
staff trained in DP principles and
SBAR
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communication (90 day programme)
16
14
12
10
Arrest
8
Peri
6
4
2
0
Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec
Quality Report
Reducing Harm
Harm free care
Safety thermometer
Harm Free Care (corporate objective 2.1)
The Safety Express Programme defines ‘harm free’ care as care free from pressure
ulcers, falls, patients who have an indwelling urinary catheter and a urinary infection
and VTE’. Nationally the NHS target is to eliminate harm from a range of conditions
for 95% of patients. In November our patients received 91.9% harm free care against
a national target of 95%.The graph depicts ‘harm free care’ consistently recorded
above 90% since February 2014.
The predicted reach for 2015/16 in delivery of harm free care is 95%. We are
experiencing challenges in achieving this, therefore focussing on:

Monthly validation exercises to support data assurance processes.

Staff reminded to perform the survey on given date to reduce double counting
of patient data.

Engagement of staff to implement tests of change through the Falls and
pressure ulcer work streams, and to better understand the impact of inter
related harm
Pressure ulcers
Pressure Ulcers (corporate objective 2.1)
The overall ambition of the Trust is to have a zero tolerance to harm from pressure
damage The Board is asked to note the improvements and heightened awareness of
prevention interventions are having a positive impact on harm reduction. Pressure
ulcer management will continue to be a key quality improvement initiative in
2016/17. The ambition over 2 years is to reduce harm from avoidable damage by 50%.
The incidence of hospital acquired pressure ulcers has reduced to below target
through the three quarters of the current year.
Achievement:
•
Baseline 2013/14 = 45 avoidable grade 3 and 4 pressure ulcers
•
Ambition 14/15= 25% reduction (36). Outcome 30 avoidable
•
Ambition 15/16= 25% reduction (26). Current position 7
We continue to support:
•
Supportive debrief sessions with education and training
•
10 x study day s set up from February 2016
•
RCA and trend analysis of root causes with corrective actions
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Quality Report Jan2016
Falls
Reducing Harm
Falls
Falls reduction (corporate objective 2.1)
Reported falls for teams participating in the Falls collaborative have been reducing
steadily since the inception of the collaborative. Overall the number of falls remain
above trajectory. However on the collaborative teams, falls are averaging 57 falls
per month since November 2014, following several tests of change.
•
The target number of falls per month is no more than 100
•
At month 8 we recorded 950 falls, therefore above trajectory by 150
There is a risk to this ambition as the rate of falls has not decreased as expected.
However falls resulting in sever harm have significantly reduced to 5 from 17
2014/15
The high impact interventions summarised below should impact on the falls rate,
however the risk is that the target will remain off trajectory., due to possible
unintended consequence of heightened awareness with resultant increased
reporting- which is encouraged.
Next steps:
•
Roll out of Stay in the Bay as of February 2016
•
Low rise beds distributed for those patients at higher risk are in place
•
Re-launch fall safe care bundle risk assessment approach focusing on high
incident areas l e.g. Ward 1&2, AOU, Ward 7.
VTE
Venous Thrombus Embolism (VTE) Risk assessment update
•
We scored 67% in the 2015 VTE National Scorecard survey.
•
The trust achieved on 4 out of 6 indicators:
•
Written policy √
•
Patient Information √
•
VTE Sanctions √
•
VTE Risk Assessment goal √
•
x No ‘agreed local CQUIN goal for Root Cause Analysis (RCA) or
Hospital Associated Thrombosis (HAT) with our commissioners’
•
x delay in implementation of an effective process for RCA of HAT in
Feb 2015
•
Consistently achieved the national quality requirement (95%) on VTE
risk assessment. The changeover from Care Records Service (CRS) to
MEDWAY has impacted on the process, reports, monitoring and
recording of VTE assessments.
•
Commissioner supported intervention to re-launch RCA process, on
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track and delivering.
Quality Report
Reducing Harm
Medication Errors
Reducing Medication errors group (corporative objective 2.1)
Aim: a) to increase reporting by 5% from 1153 to 1210 reported
incidents. To date there are only 873 reported incidents. b)reduce
severity of errors resulting in moderate, severe harm or death by 10%
The work stream has the following priorities for 2015/16:
•
Insulin – Work has been undertaken to ensure insulin is dispensed
urgently when required. Development of a flashcard to support
staff of the different products available and their properties. This
has been aimed at Junior Doctors to help them with prescribing
•
Anti-coagulant prescribing – Low molecular weight heparins have
been the subject of a patient safety alert this year and therefore
remain an area of high focus
•
A deep dive has been undertaken to further understand why doses
have been omitted or delayed.
•
Discharge – There are a number of reported incidents relating to
poor discharge of patients with regard to their medicines.
Next steps:
Next steps – working hours for pharmacists at weekends have been
extended - there are no plans for this to be extended further.
The deep dive into omitted/delayed doses should enable solutions
to be identified to reduce omitted/delayed doses going forward.
This will be monitored closely.
A further work stream has been set up to review discharge planning
and its impact on community teams in terms of discharge
medication
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Quality Report
Reducing Harm
Learning from Serious Incidents
Learning from Serious Incident (SI) investigations
A Deteriorating patient serious incident identified
learning across the divisions relating to the
importance of managing underlying health
complexity as well as the condition requiring
specialist treatment
Theatres presented an excellent example of learning
from a near miss incident demonstrating that they
had learnt and initiated practice changes across the
whole service. It is vital that we move to a
preventative/predictive approach to safety to further
reduce avoidable harm to our patients.
Never Events
•
There has been one Never Events reported by
the trust within the last 12 months. This is
currently under investigation, a debrief has
been held and immediate mitigating actions
have been put into place.
Serious Incidents (SI) reported in November 2015
and December 2015; key themes
Diagnostic Incidents (4)
• Of the SIs currently under investigation related
to diagnostic incidents 4 reported in this period,
the initial findings indicate a requirement for
improved process monitoring.
• This was a topic for further action discussed at
the SE Group 18th January 2016, an additional
meeting is to be set up with the IT Team and
other clinicians to explore what initiatives can be
implemented to improve monitoring of
diagnostic pathways and the move to a paperless
process.
• The 7 remaining overdue Serious Incidents are
planned to be submitted to the February 2016
SE Group as some were presented on the 18th
January 2016 and required further amendments.
Status
In time
Overdue
Total
No. of SIs open at 12th January 2016
21
7
85 of28
208
Staffing Report
Purpose
Safe Staffing
•
Buckinghamshire Healthcare NHS Trust is committed
to staffing our wards and departments safely. With
registered nurses, midwives and care staff to ensure
that the skill mix and numbers of staff in the clinical
areas are correct: matching acuity and dependency
needs of individual patient groups. Our fundamental
responsibility is to ensure that we have the right skill
mix of staff to provide safe, effective care.
Ward capacity and capability
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Quality Report
•
In November 2015 the total required planned hours
to fill all day and night shift rotas for registered
nurses and midwives for in-patient areas was
111,438 the total actual hours worked was 103,653
which equates to a total 93% fill rate.
•
The total required planned hours to fill all day and
night shift rotas for health care support workers for
in-patient areas was 55,063.5 the total actual hours
worked was 56,362 which equates to a 102 % fill
rate.
•
Overall the Trust delivered 97.3% fill rate for
November 2015
•
A copy of safe staffing levels is published on a
monthly basis on the trust website and uploaded
externally to the DoH via UNIFY. The link
http://www.buckshealthcare.nhs.uk/About/safestaffing.htm provides a breakdown of planned and
actual hours worked
Staffing Report
Triangulation with staffing incidents
•
A Datix search for November 2015 identified 23 nurse staffing incidents that resulted in no harm.
All incidents were recorded as low or no harm
Summary
• It should be noted that there are no correlated Datix incidents where patients came to harm as a
consequence of these incidents.
•
To ensure wards and patients remains safe, flexing of staff across wards and departments is
essential. If required, Matrons base themselves in clinical areas alongside other senior nurses to
provide support.
•
Where the fill rate was above 100%, this reflects the increase in patient care needs, for example
where a patient needed 1:1 nursing (a patient has become more acutely unwell or where a patient
needs constant supervision due to challenging behaviour/confusion).
Quality Report
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Great Patient Experience
Friends & family Test
November - 2015
Friends Family Test (FFT):
Friends & Family Test - Trust Total
Unlikely
Extremely
unlikely
% Not
Recommend
Neither
Likely nor
Unlikely
Don't know
Total
3
1
2.3
4
0
176
% Recommend
Unlikely
Extremely
unlikely
% Not
Recommend
Neither
Likely nor
Unlikely
Don't know
Total
180
95.5
7
15
1.9
26
4
1149
Extremely
likely
likely
% Recommend
Unlikely
Extremely
unlikely
% Not
Recommend
Neither
Likely nor
Unlikely
Don't know
Total
44.9
16
6
100.0
0
0
0.0
0
0
22
66
251.5
136
24
96.4
0
0
0.0
6
0
166
Trust Q3
68
226.5
120
32
98.7
0
0
0.0
2
0
154
Trust Q4
294
4.8
13
1
100.0
0
0
0.0
0
0
14
Trust
477
74.6
285
63
97.8
0
0
0.0
8
0
356
Eligible
Patients
Response
Rate %
Extremely
likely
likely
% Recommend
Unlikely
Extremely
unlikely
% Not
Recommend
Neither
Likely nor
Unlikely
Don't know
Total
11441
14.7
1321
292
96.0
10
16
1.5
38
4
1681
Extremely
likely
likely
% Recommend
Unlikely
Extremely
unlikely
% Not
Recommend
Neither
Likely nor
Unlikely
Don't know
Total
887
277
93.9
6
11
1.4
50
9
1240
% Not
Recommend
Neither
Likely nor
Unlikely
Eligible
Patients
Response
Rate %
Extremely
likely
likely
% Recommend
4337
4.06
119
49
95.5
Eligible
Patients
Response
Rate %
Extremely
likely
likely
6627
17.3
917
Eligible
Patients
Response
Rate %
Trust Q1
49
Trust Q2
A&E
Trust
INPATIENT
Trust
MATERNITY
ELIGIBLE TRUST
TOTAL
Total
Outpatient
Total
Community
Total
INTERNAL SCORE
Total
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Aim: Target 30% Trust response rate; 95% Trust approval
rating 95%
•
The Trust response rate 17% in November 2015,
however the approval rating was recorded at 96%
•
All free text comments are captured and reported
through the organisation by making them available to
operational services on a routine basis for feedback
within teams.
Actions to improve:
•
Meetings held with local operational teams to develop
bespoke processes to implement plans to improve the
FFT response rate to 30% by April 2016
•
•
•
Extremely
likely
likely
% Recommend
Unlikely
Extremely
unlikely
Don't know
Total
34
6
97.6
0
0
0.0
1
0
41
Extremely
likely
likely
% Recommend
Unlikely
Extremely
unlikely
% Not
Recommend
Neither
Likely nor
Unlikely
Don't know
Total
2242
575
95.1
16
27
1.5
89
13
2962
Quality Report
7 departments’ identified requiring support with one
to one assistance being offered.
High risk areas are Out patients and short stay areas
which significantly reduce the trust’s position
To mitigate the high risk areas, dedicated resource
identified to provide additional support with FFT
performance to assist the achievement of the 30%
Trust response rate.
Complaints
Aim: Sustained position of 85% compliance in response rates (Internal target –response time 25 working days)
•
The response rate in October 2015 has improved consistently since the Summer from 53% to 74%. However November recorded a
reduction in response rate to 57% which was predominantly due to a single division managing a challenging backlog of complaints.
Actions to improve:
•
The Patient Experience Manager will give additional focused support alongside the complaints team during February and March 2016
to support improvement in the complaints performance position.
•
The Division with the greatest challenge has committed to improving their complaints performance and clear their backlog by Mid
February 2016.
•
Stakeholder meeting January 2016 to map improvement and sustainability model. Outcome to be presented to the Quality
Committee as well as revised trajectory for improvement up to April 2016.
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Quality Report
PALS
•
There were 349 enquiries made to the PALS in
November, of which 223 were issues for
resolution
•
The Division of Surgery and Critical care received
the largest number of enquiries
•
During the months of October and November
2015 the PALS and complaints team have
continued to provide support with training and
service awareness, specifically around how to
access translation services
•
Specific training and support has also been
provided within our community hospitals
•
Analysis is being completed of Complaints, PALS
and other patient experience feedback to inform
development of further patient experience
improvement actions for February – March 2016
These actions will be supported by the Patient
Experience Manager as part of an additional
focused effort during February – March 2016
•
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Quality Report
Care at the end of life
Aim: 95% of EoL pts with care plan by
March 2016
– Trust-wide roll out started 1 Dec
2015.
– Care plan & patient record now in
use across the Trust except ICU
where we are designing a bespoke
solution
– Case note audit in March 2016
Aim: 85% of pts with a clearly recorded
Preferred Place of Care (PPoC)
– PPoC recorded in 72% of patients
on average over last quarter (down
4%)
– New Macmillan funded post and
care plan should improve this
position in the next quarter
Aim: 45% of clinical staff with
foundational EoL training by March
2016
– Very challenging target but making
good progress. On track to deliver
– 1,199 clinical staff trained since Sept
2015. Topics include symptom
control, identifying EoL, and EoL
communications
Aim: Improve leadership and public
engagement around EoL
– 100 members of the public engaged
in 5 events plus patient panel
– New Division Leads for EoL care will
be supported in developing Divisionspecific EoL heat maps to drive
improvement
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Appendix 1
HSMR Data to
September 2015
January 2016
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CONFIDENTIAL
Rolling HSMR Data to August 2015
•
The graph below shows the rolling 12 month trend in HSMR up to August
15, all periods were within the expected range
2
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Data Issues
•
During the processing of September 15 data, we noticed the Trust had significantly
lower volumes of inpatient (and outpatient) data in comparison to previous months
indicating that there may have been issues with the submission of the data to SUS
•
The table below shows volumes of usable inpatient data for the Trust for the last 12
months, September 15 has 39% less data than the average volume for the
preceding 3 months (June to August 15)
•
The Trust had reduced data submission in September, October and November 2015
meaning that we won’t have a reliable HSMR figure until the February 2016 tools
update when accurate data submitted in December 2015 has come through the
system
3
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Recommendations
• As a result of the data flows, the HSMR figure for
September is subject to change, so we would recommend
ignoring this most recent month of data and focussing on
the HSMR up to August 2015
• The next scheduled Dr Foster tools update is Thursday
18th February 2016
• The following slides focus on data up to August 2015
4
95 of 208
Diagnosis Groups – Stoke Mandeville
•
The table below shows the top ten diagnosis groups (ordered by low 95%
confidence interval) to highlight any groups that have a statistically significantly
higher than expected relative risk for Stoke Mandeville Hospital for the period
September 14 to August 15
•
One group has a statistically significantly higher than expected relative risk;
aspiration pneumonitis. A respiratory meeting to review this has been set up.
5
96 of 208
Diagnosis Groups – Wycombe
•
The table below shows the top ten diagnosis groups (ordered by low 95%
confidence interval) to highlight any groups that have a statistically significantly
higher than expected relative risk for Wycombe Hospital for the period September
14 to August 15
•
No groups have a statistically significantly higher than expected relative risk
6
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Weekend/Weekday Emergency HSMR
•
The table below shows the HSMR for emergency admissions during the weekend
and weekday for the time period September 14 to August 15
•
This is a metric that has historically been monitored by the CQC
•
Both are within the expected range when compared with hospital trusts nationally
Sunday and Friday have the
highest relative risks at 113 and
109 respectively, however, both are
deemed to be within the expected
range statistically speaking. We are
reviewing Sunday in more detail.
7
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Peer Comparison – Weekday
Emergency HSMR
8
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Peer Comparison – Weekend
Emergency HSMR
9
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NHS England – National Changes
• NHS England are working towards a national approach to
a standardised retrospective case record review (RCRR)
• NHS England are intending to procure a supplier to
develop a standardised methodology for RCRR.
• There will be a training roll out to all NHS trusts in England
• It is anticipated that a supplier will be in place and a pilot
will start in Q1 2016/17.
10
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Agenda item: 10.3
Enc: TB2016/012
January 2016
Title
Quality Improvement Plan
Chief Nurse
Responsible
Director
Purpose of the
paper
Action / decision
required (e.g.,
approve, support,
endorse)
This paper provides the Board with an update on the achievements of the Quality
improvement plan, highlights the risk to delivery with mitigation and a predicted position for
year end.
The Board are asked to discuss the progress and note the risks and prediction
Patient
Quality
Legal
Financial
Performance
Regulatory/
Compliance
Annual Objective
Operational
Performance
Public
Engagement
/Reputation
Strategy
FT Application
Equality &
Diversity
Partnership
Working
New or
elevated risk
Other
This relates to :
Objective 1 - Improving quality, safety and patient experience
Objective 2- Employ, engage and develop high calibre staff
BAF/Corporate Risk BAF 1a - There is a risk that the targeted reduction in mortality as measured by the HSMR
Register Reference
will not be achieved.
BAF 2a - There is a risk that patients will come to harm as a result of preventable falls.
BAF 3a - There is a risk that we will not deliver the targeted improvement in the net
promoter score for patient experience
CRR 21- We do not consistently deliver clinically effective End of Life Care (EoLC) - CQC
review assessed EoLC to be inadequate on both SMH and WGH sites
Risk Description
As above
CQC Reg. Ref.
Author of Paper
Deputy Chief Nurse
Presenter of Paper
Chief Nurse and Chief Medical Officer
Date of Paper
January 2016
103 of 208
QUALITY IMPROVEMENT PLAN (QIP): PROGRESS UPDATE
Executive Summary
This paper provides assurance to the Trust Board that there is a robust plan in
place that captures all the recommendations from the Care Quality Commission
(CQC) inspection without losing sight of the overarching aim to reduce mortality
and harm, provide a great patient experience and promote a culture of
continuous improvement.
The Quality and Safety Group continues to drive progress. A monitoring
dashboard is provided at appendix 1 for information on progress. The group
submitted 36 actions for closure to Trust Management Committee in December
2015. The TMC returned 16 actions for further evidence.
Currently 14% of schemes have been completed and signed off with a further
11% of schemes due to be signed off in January 2016. A further 21% of actions
remain in the grey and are being reviewed currently by operational teams.
78 actions in total are due for submission and closure in February. The 48 Must
Do actions are on track to deliver with amber actions addressed and escalated;
allowance has been made by extending delivery dates to meet the final
submission date of March 2016. There are challenges anticipated in terms of
delivery the QIP in its entirety from the following work streams: Mortality including
Deteriorating Patient, End of Life and Works streams owned by partners.
Mitigation is provided in the report below.
For 2016/17, several quality improvement goals will be transferred to the Trust’s
refreshed 3 Year Quality Strategy incorporating the quality priorities from
2105/16. The plan will be to launch this in April 2016 at the Quality Committee.
Page 1 of 4
104 of 208
1.
Purpose
1.1
To update the Trust Board on the progress made on the quality improvement plan
(QIP) and to summarise the achievements to date.
1.2
Assurance is provided that the single quality improvement action plan has enabled
the organisation to focus on the recommendations following the CQC inspection
without losing sight of our overarching improvement goals detailed in the Quality
Improvement Strategy.
1.3
The Project Management Office (PMO) team continue to support robust monitoring
and reporting to help drive progress and highlight where additional support or focus is
needed.
1.4
This paper provides an update to the Trust Board on achievements, predicted
position for year end, outlines the risks to achievement from frontline level to Board,
and forward planning from April 2016.
2.
Achievements
2.1
The Quality and Safety Group (QSG) continue to drive progress with delivery leads.
The group is chaired by the Chief Nurse/Medical Director. There are 12 improvement
sub groups that report to the QSG.
2.2
The Trust Management Committee (TMC) received an update from the QSG in
December 2015 on 36 potential actions for closure. The committee approved and
closed 20 actions. 16 actions were refuted for closure on the basis of insufficient
evidence, and will be re-presented in February.
Currently there are 45 actions with robust evidence awaiting closure and a further
predicted 33 awaiting submission. This means that a total of 78 actions need to be
reviewed in January/ February 2016.
The table below demonstrates overall position of QIP progress to date:
Month Due
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Total
Blue
6
5
1
2
1
0
5
20
Green
2
11
1
2
8
0
5
29
Amber
0
25
8
7
3
0
20
63
Red
0
2
0
0
1
0
1
4
Grey
0
0
5
8
0
2
15
30
Total
8
43
15
19
13
2
46
146
The 30 actions listed under ‘grey’ are all currently being reviewed with a view to
move actions to green rating with the exception of 2 actions which is predicted to
move into amber rating. This is being managed with the delivery lead currently.
Page 2 of 4
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3.
Update on MUST Do actions
The forty eight (48) Must Do actions are categorised below against achievement:
Blue
5
Green
10
Amber
21
Red
0
Grey
12
Total
48
Key
Delivery Rating
Blue
Target or action has either been delivered and is embedded or is guaranteed to do so
Green
Target or action can be forecast to achieve w ith a level of certainty but may not yet be sustained long enough to guarantee change in system
Amber
Target or action is fairly likely to deliver but may have slipped in terms of timescales or may not deliver as much as originally thought
Red
There is concern about the target or action ability to deliver and is a clear flag for senior staff to get involved
Grey
No KPI/milestones due for significant time and target or action has not yet commenced
Green actions are listed for closure as part of the process outlined above.
The 21 actions listed in Amber are distributed across:
• Community Paediatrics=2
• Community Operational=2
• Patient experience Group=1
• Operations=8
• End of Life=2
• Serious Incidents=6
Assurance is provided that amber actions are actively addressed and delivery is on
track, however adequate evidence has not yet been submitted in full support.
Therefore the QSG Chairs have addressed the risk of slippage with these up until
March 2016, where the expectation is submission of robust evidence provided for
final sign off.
2.3
The predicted position for March 2016 is that the 4 partner support actions are very
likely to remain in Red status, if there is no improvement in engagement.
It is extremely likely that all Must Do actions will be met, however to continue to build
sustainability around these, they may be considered for transfer to next year’s QIP.
It is very likely that actions listed under ‘Trust quality objectives’ will be met, however
cannot be closed due to their nature, and will be transferred onto new quality plan.
2.4
It must be noted that 2015/16 Quality improvement plan will be refreshed in March
and developed again for 2016/17, incorporating the Trust quality objectives,
underpinned by the Quality Strategy for the next 3 years. All long term quality
objectives will be transferred and new milestones set.
2.5
The Quality Committee has received an assurance report in January 2016 and this
subcommittee provides assurance to Board.
3.
Risks
Page 3 of 4
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In terms of delivering the QIP plan in its entirety, there are anticipated challenges
across our progress with the following work streams:
• Mortality including Deteriorating Patient
• End of Life
• Works streams owned by partners
Mitigation
4.
5.1 Mortality
•
•
•
•
90 day focused improvement programme focusing on escalation-SBAR tool, sepsis
and point of care education
Mortality reduction group providing close monitoring of mortality review process
Dr Foster data for monitoring crude and weekend mortality
Deep dive into primary diagnosis groups
5.2 End of Life Care (EoLC)
•
•
•
•
•
EoL care plan rolled out across trust with circa 1250 care plans in use. Case note
audit in March 2016
1,199 clinical staff trained in foundation training on EoLC
Trust wide ownership – Divisional champions “end of life care everyone’s business”
Treatment escalation plan – extended pilot to other areas medical ownership and
engagement
System wide EOLC steering group to drive early recognition and early intervention
5.3 Works streams owned by partners- Urgent Care and EOLC
•
Trust and Clinical Commissioning Group (CCG) existing Quality and performance
meetings will monitor the partner’s improvement work streams and report progress
and blocks to success through the existing Trust Governance framework. This
approach agreed at recent joint quality review chaired by the Trust Development
Authority.
6.
Conclusion
6.1
The Quality and Safety Group continues to drive and monitor the impact of
improvement. There is clear sight of risks to delivery and a robust governance
structure to drive improvement and escalate risk to delivery. Due to slippage in
delivery timescales, and insufficient assurance, delivery dates have been extended
and will be transferred to 2016/17 QIP for further scrutiny and monitoring.
7.
Recommendation
The Trust Board is asked to:
Note the achievements to date, discuss the risks and prediction to delivery of the
Quality Improvement Plan, the mitigation summarised and to note the approach for
2016/17.
Page 4 of 4
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Appendix 1: Monitoring dashboard
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Agenda item: 10.4
TRUST BOARD MEETING
27 January 2016
Title
Summary of Quality Committee meeting held on 12th January 2016
Responsible
Director
Purpose of the
paper
Quality Committee Chair
Action / decision
required (e.g.,
approve, support,
endorse)
Consider the level of assurance.
The purpose of this paper is to provide information to the Trust Board about the matters
reviewed by the Quality Committee and the level of assurance gained through discussion
of items on the agenda.
Patient
Quality
Legal
Financial
Performance
Regulatory/
Compliance
Operational
Performance
Public
Engagement
/Reputation
Strategy
FT Application
Equality &
Diversity
Partnership
Working
New or
elevated risk
Other
Annual Objective
BAF/Corporate Risk
Register Reference
Risk Description
All quality related risks on the Board Assurance Framework and CRR
Author of Paper
Liz Hollman, Director for Governance
Presenter of Paper
Mr Graeme Johnston
None
Date of Paper
19 January 2016
109 of 208
Agenda item: 10.4
COMMITTEE DETAILS:
Name of Committee: Quality Committee
Meeting date:
12 January 2016
Was the meeting quorate? Yes.
There were no conflicts of interests declared by members or attendees on the Agenda items due to be discussed.
Apologies were received from: Professor Mary Lovegrove; Professor David Sines
KEY AREAS OF DISCUSSION:
• The Terms of Reference were reviewed and agreed. These will be submitted to the Trust Board in March
with an accompanying work plan for Board approval
• The Chief Nurse highlighted progress in reducing pressure damage and falls and her concerns about the
number of outstanding complaints past the 25 day response rate. Focused action is taking place to clear
the backlog and reduce the time taken to respond to complaints
• The Medical Director brought to the Committee’s attention the upcoming focused visit from Health
Education Thames Valley to review progress with the actions to address the issue of undermining
highlighted in Trauma and Orthopaedics
• Detailed report on Safeguarding. It was noted that due to staff moving on to other roles this will create
some organisational pressure in the safeguarding team in the coming months
• Progress with the Quality Improvement Plan was reviewed with actions starting to be signed off.
• The Director for Infection Prevention and Control alerted the Committee that the Trust has now reached its
annual limit for cases of Clostridium difficile having reported 32 cases.
• A detailed mortality paper was considered by the Committee
• It was reported to the Committee that a programme of CQC ‘mock inspection’ reviews has been started
and findings will be coming to the Committee in future
• Good progress with addressing the backlog of Serious Incident final reports and sign off.
• The Committee received a briefing about the clinical audit work plan.
• The Committee approved a briefing on NHS preparedness for a major incident which is for return to NHS
England
• As the Junior Doctors’ Industrial Action was happening on the day of the Committee the impact of this was
noted.
The Committee reviewed the following sub-committee minutes:
• Quality and Safety Group – October 2015 and November 2015
• Drug and Therapeutics Committee – Oct 2015
KEY ACTIONS:
The main actions from the meeting were :
• Schedule workshop to review Quality Key Performance Indicators
• Written update on Trauma and Orthopaedics ‘undermining’ issues to the Committee in March 2016
• Report on usage of electronic discharge summary to the Committee in March 2016
AREAS OF RISK TO BRING TO THE ATTENTION OF THE BOARD:
• Timeliness of complaints responses
• Clostridium difficile cases
• Workforce pressures in the safeguarding team
ANY EXAMPLES OF OUTSTANDING PRACTICE OR INNOVATION:
New CQC ‘mock inspection’ programme designed internally has now commenced.
110 of 208
Agenda item: 10.5
27 JANUARY 2016
Title
Responsible
Director
Purpose of the
paper
Infection Prevention and Control Report December 2015
Dr Tina Kenny
To convey information on recent trends in Healthcare-associated infections and
hand hygiene compliance.
Action / decision To note.
required (e.g.,
approve, note,
support, endorse)
Patient Quality
Legal
Financial
Performance
Regulatory/
Compliance
Annual
Objective
•
•
Operational
Performance
Public
Engagement
/Reputation
Strategy
Equality &
Diversity
FT Application
New or elevated
risk
Partnership
Working
Other
Limit of 32 avoidable C. diff cases in 2015/6.
Objective of zero avoidable MRSA Bacteraemia infections in 2014/15.
BAF/Corporate
Risk Register
BAF:1A
Reference
Risk Description
CQC Reference Outcome 8 Regulation 12
Author of Paper
Dr Jean O’Driscoll, Director of Infection Prevention and Control
Presenter of Paper
Dr Jean O’Driscoll
None
Date of Paper
January 14th 2015
111 of 208
Infection Prevention & Control Report
for Trust Board 27th January 2016
Month: December 2015
MRSA (Meticillin Resistant Staphylococcus aureus) Bacteraemia
No case was detected.
Clostridium difficile infections
One case attributable to BHT was identified in December. Root cause analysis has failed to identify
any lapse in care which could have contributed to the infection. We await a result from Southampton to
see if the strain resembles 3 earlier strains found on the same ward in November.
MSSA (Meticillin Sensitive Staphylococcus aureus) Bacteraemias
Eleven cases were detected in December. In all 11 cases the infections were already present prior to
admission to BHT. Three cases were healthcare-related (one line infection, one PEG site infection and
one urinary catheter-associated infection).
E.coli (Escherichia coli) Bacteraemias
Twenty cases were detected in December. Of these, only 3 were in patients who had been in-patients
for more than 3 days. One of the cases occurred in patients who were catheterised; he had been
catheterised prior to admission.
Outbreaks
There were no outbreaks in December.
Divisional Hand Hygiene Compliance with cleaning hands prior to patient
contact:
Integrated
Medicine
Surgery &
Critical Care
Specialist
Services
98%
99%
99%
Dr Jean O’Driscoll MB FRCPath
Director of Infection Prevention & Control
14th January 2016
112 of 208
Integrated
Elderly &
Community
Care
100%
Integrated
Women &
Children
100%
Clostridium difficile Trajectory 2015/16
BHT Clostridium difficile Trajectory
2015/2016
35
30
25
20
15
10
5
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
(cumulative) Trajectory Limit
(cumulative) reported on PHE database
(cumulative) BHT cases where lapse in care was identified, but the lapse didn't directly
contribute to the infection
(cumulative) BHT cases where lapse in care was identified and the lapse contributed to the
infection
By the end of December BHT had reported 30 cases as being BHT-attributable, 4 cases above the
trajectory limit for December of 26 cases. The trajectory limit for the full year is 32 cases.
Formal monthly meetings are held with the CCG Infection Prevention and Control Lead to review each
case.
A small Outbreak was identified in November where 3 patients in the same Bay had the same strain
of C difficile. Meetings were held and the main deficiency identified was a defect in the floor of the Bay
which has been rectified.
Dr Jean O’Driscoll MB FRCPath
Director of Infection Prevention & Control
14th January 2016
113 of 208
PUBLIC BOARD PAPER MEETING –
27 January 2016
Title
Responsible Director
Purpose of the paper
To present the integrated operational performance scorecard for December
2015
Action / decision required
To note
Patient Quality
Financial
Performance
Operational
Performance
Strategy
FT Application
New or
elevated risk
Legal
Regulatory/
Compliance
Public
Engagement
/Reputation
Equality &
Diversity
Partnership
Working
Other
Annual Objective
High Quality Emergency Care
Improved access and performance in planned care
BAF/Corporate Risk
Register Reference
BAF7a
CRR1
Risk Description
Redesign of urgent care
Waiting times in the A&E department
Author of Paper
Neil Macdonald
Presenter of Paper
Neil Macdonald
Finance and Business Performance
Date of Paper
January 2016
115 of 208
Executive Summary
1.
This summary outlines the operational performance of the Trust for the
month of December 2015, and identifies the key successes and risks for
the organisation in the responsiveness domain.
2.
Against the three key access performance indicators of cancer, urgent care
and planned care, the performance report highlights that:
3.
•
Compliance against the cancer access standards remains at a high
level. Particularly pleasing to note is the strong performance
against the 2 week wait standard over the holiday period and the
efforts from the clinical teams in retaining most waits for clinic
appointments under 7 days to allow patient flexibility for choice
over this time period.
•
Continued achievement with the Referral to Treatment 92%
standard in light of continuing challenges around maintaining
accurate patient tracking post the implementation of the Medway
system.
•
An improvement in urgent care access standards against the 4
hour standard, but with further ongoing work required (shown
through the attached exception report) in bringing total
performance back to the national standard of 95% and in line with
the recovery trajectory submitted to the Trust Development
Authority.
The board’s attention should be brought to the following risks:
•
Urgent care:
1. Pressures across the system remain high through the winter
period, and although performance is holding at a higher
level than the previous year, further work is required to
ensure sustained improvement to reach the required level.
This work is especially focused on the ongoing efforts to
ensure timely onward transfer of care for patients who no
longer require intervention in an acute hospital setting.
2. Transfer of care waits (those patients awaiting onward care)
reduced in December, especially the later part of the month,
although they remain above the trend from last year. This
relates directly to increase in performance in the final two
weeks of the month.
•
116 of 208
Significant amounts of work are ongoing post-Medway
implementation to ensure data quality issues being driven by the
system changeover are rectified, and the Trust’s overall waiting list
is returned its sustainable size. This work will be ongoing until the
end of March 2016.
4.
5.
To manage these risks the following actions are in place:
•
A revised work plan has been agreed with the system’s Resilience
Group which put greater emphasis on particular work programs to
focus on a joint assessment process with adult social care, the
strengthening of the Integrated Care plan with a focus on building
stronger locality teams, reductions in hospital attendances and
different care models in responding to care homes. These are
happening alongside a series of internal actions launched in
January which have included the launch of a new Rapid
Assessment and Treatment model in the Emergency Department,
and additional capacity in the community healthcare teams. These
should combine to give a recovery trajectory of 93% through
January with a return to overall compliance in February 2016.
•
A specific action plan monitored on a weekly basis to eliminate all
data quality issues being driven by unfamiliarity with the new PAS
system and a trajectory of work to create a single, clean waiting list
by March 2016.
The board is asked to note the achievements and risks against the key
responsiveness standards listed above.
117 of 208
A&E Attendances & Performance
Trust level (all types)
Attendances - Trajectory
Attendances - Actual
4hr Performance - Trajectory
4hr Performance - Actual
95% Target
3000
100%
90%
2500
80%
70%
2000
60%
1500
50%
40%
1000
30%
The 95% performance standard was not achieved in December with a performance of 92.79% for the month though95.2%
performance was achieved in the last week of December.
Attendences remain above plan with paediatrics accounting for 25% of attendences though the number of paediatrics requiring
admission decreased in December to 23.7% from 26% in November.
Overall admissions continued to reflect the trend of the previous month with 30.94% of attendences requiring admission compared to
30.56% in November with high demand for in-patent speciality beds refecting the acuity of patients presenting to ED
The numbers of medical patients requiring a short stay admission improved on the previous month to 19% discharged from the short
stay ward compared to 10% in November but below the 32% reported in the summer months.
The number of patients medically stable for transfer remained above the baseline of 60 (25%) in the first 3 weeks of December with an
improved position in the last week of December to 50 reported transfer of care waits (15% below basline). This improved position
correlates with the delivery of the ED 95% performance in the last week of December.The Trusts year to date ED performance was
94.41%
20%
500
10%
05/04/2015
12/04/2015
19/04/2015
26/04/2015
03/05/2015
10/05/2015
17/05/2015
24/05/2015
31/05/2015
07/06/2015
14/06/2015
21/06/2015
28/06/2015
05/07/2015
12/07/2015
19/07/2015
26/07/2015
02/08/2015
09/08/2015
16/08/2015
23/08/2015
30/08/2015
06/09/2015
13/09/2015
20/09/2015
27/09/2015
04/10/2015
11/10/2015
18/10/2015
25/10/2015
01/11/2015
08/11/2015
15/11/2015
22/11/2015
29/11/2015
06/12/2015
13/12/2015
20/12/2015
27/12/2015
03/01/2016
10/01/2016
17/01/2016
24/01/2016
31/01/2016
07/02/2016
14/02/2016
21/02/2016
28/02/2016
06/03/2016
13/03/2016
20/03/2016
27/03/2016
03/04/2016
0
0%
The number of reportable Delayed Transfer of Care waits (DToCs) continued to be above the baseline of 10 in the first 3 weeks of
December to peaks of 23 :130% increase with an improved position reported in the last week of the month from a peak of 23 to 6-8
reportable delays( 40% decrease against the baseline).
Acute transfer of care waits, Acute delayed transfers of care
& patients in hospital (Working days only)
Transfer of care waits
DTOC
DTOC
100
25
90
80
20
70
60
The number of transfer of care waits remained above the baseline of 60 with a 25% increase in the first half of the month of patients
waiting for onward care to be sourced. In the last week of December the number of patients waiting significantly improved:15% below
the baseline due to an increase in both interim and step-down beds becoming available for adult social care and the commencement
of the night sitting service and the commisioning of the non-weight bearing beds.
15
50
40
10
The number of patients requiring complex check lists and completion of clinical decison tools (DST) continued to be above the baseline of 6, with a 50% increase in month of patients requiring DSTs.
30
20
5
The number of Out of Area patients (OOA) increased from November by 35% and an overall increase of 50% from a baseline of 10
10
T 31/12/2015
W 30/12/2015
T 29/12/2015
T 24/12/2015
W 23/12/2015
T 22/12/2015
M 21/12/2015
F 18/12/2015
T 17/12/2015
W 16/12/2015
T 15/12/2015
M 14/12/2015
F 11/12/2015
T 10/12/2015
W 09/12/2015
T 08/12/2015
M 07/12/2015
F 04/12/2015
W 02/12/2015
T 03/12/2015
0
T 01/12/2015
0
Type 1 attendences conveyed via ambulance in December was in line with the previous month , 33 % of of patients conveyed via
ambulance with peaks of 34-37% on 4 days reflecting the increased numbers of type 1 attendences (247-260) with an associated peak
in ambulance conveyances(66-78)
A&E Type 1 attendances & Ambulance conveyances
Attendances
Conveyances
14/15 Avg Attends (Dec 14)
% attendances via ambulance
40%
300
35%
250
This activity reflects the increased acuity of patients with an associated increase in conversions to admissions:64.0% converting to
admission (in-line with October) compared to 64.5% in November
30%
200
25%
20%
150
100
50
The overall number of daily ambulance conveyances was above our baseline of 48 in November with 17 days of > 60 conveyances
and peaks of 74-78 ambulance conveyances.
15%
The number of conveyances remained higher out of hours ( OOH) with 15-20(average attendences 9-12) arrivals between the hours of
10%
midnight until 08.00 hours on 13 days.
5%
0%
31/12/2015
30/12/2015
29/12/2015
28/12/2015
27/12/2015
26/12/2015
25/12/2015
24/12/2015
23/12/2015
22/12/2015
21/12/2015
20/12/2015
19/12/2015
18/12/2015
17/12/2015
16/12/2015
15/12/2015
14/12/2015
13/12/2015
12/12/2015
11/12/2015
10/12/2015
09/12/2015
08/12/2015
07/12/2015
06/12/2015
05/12/2015
04/12/2015
03/12/2015
02/12/2015
0
01/12/2015
118 of 208
EXCEPTION REPORT - EMERGENCY DEPARTMENT (ED) ACCESS DECEMBER 2015
Summary - The Trust reported a performance of 92.79% against the 4 hour access standard:Year to Date (YTD) 94.41% against the national standard of 95%
Page 1 of 7
SERVIC
CE IMPROV
VEMENT PLAN Action
Im
mplementation of a singgle assessment process; whole system approach
h to managing patients through one asssessment to identify patients early in their pathw
way and reduce he number of duplicatio
ons in the process. th
A
Adult Social Care – SRG funded additional ASC sttaff: increased availabilitty of step‐down beds to provide interim ccare for patients waitingg for Packages of Care to
o start BHT procuring PoC from BUC to support transferr of care waits for patien
nts waiting for onward care across ACHTT, Community Hospitals and Acute: releasing caapacity to increase he number of patients d
discharges requiring onw
ward rehabilitation in th
heir own homes th
Revised Urgent Care Improvement Plan; monitored through SRG. Review
w of staffing ot to increase senior con
nsultant shop floor preseence until 22.00 aggainst demand with pilo
hours in the week and 233.00 at weekends (until 10 substantive ED Consu
ultants from Jaanuary 2016) combined with pilot for ENPs to w
work until 24.00 hours to
o support the m
minor flow OOH. Exxpand clinical cover for the Ambulatory Emergeency Care unit (AEC) 7 days a week. Using th
he expertise of the ED C
Consultants to provide w
weekend cover for this 7 day service , in
ncreasing the number off patients managed on aan ambulatory care path
hway Im
mplementation of Paediiatric escalation plan witth a plan to create extraa capacity through w
winter 119 of 208
Im
mplementation of SAFER
R principles for all inpatiient areas to be monitorred through A
Almanac system to suppo
ort effective decision maaking In
ncrease of Medical cover across the Acute Care Hub in support of 7 dayy working: From D
December there will be aan increase from a 2 PoD
D system at weekends to
o 3 PoDs on rota providing wider cover across the hub and wards .Increased the number of junior Drs to su
upport the Short Stay w
wards, Assessment Unit aand Ambulatory care and additional junior D
Dr for the wards Mondayy –Friday and weekend, improving patient safetty and support for th
he medical rota. Im
mprove the whole hospiital response to pressurees within the ED department – implement H
Hospital wide ‘full Capacity Protocol’ with agreed
d actions from across th
he divisions. ED O
Overcrowding tool in place Pilot GP in Acute Care Hu
ub initiative – providing discharge support to REEACT team, ED ambulatory majors and p
provide education to staaff for alternatives to admission. proved‐ recruitment to tthe posts commenced. Business case to SRG app
To improve the managem
ment of patient on the N
NWB pathway across thee Trust including Community hospitals through the identification of alternatives to acute care. Business case approved.
Im
mplement a Night Sittingg Service – SRG funding agreed.
Pilot from September to March 2016 ment capacity in 3 localitties, Aylesbury, Wycombe and Amersham Exxpand access to reablem
Expected Outcome
e
Date for
completion / ow
wner
ss
Progres
Reeduce lead time to care in place Reeduce number of medically stable patients Im
mprove patient and care
ers experience Reeduction in > 14 day LoS
S tolerance < 80 Reeduce lead time to care in place Im
mprove patient experien
nce Reeduction in > 14 day LoS
S tolerance < 80 Reeduce lead time to care in place Im
mprove patient experien
nce erformance target Delivery of the AE 95% Pe
mproved patient experie
ence Im
Im
mprove staff satisfaction
n December 2015
ADUC December 2015 DD erformance target Delivery of the AE 95% Pe
ence Im
Im
n Delivery of the AE 95% Pe
erformance target mproved patient experie
ence Im
Im
n Delivery of ED performan
nce achievement of 65% of all discharges from shortt stay areas Delivery of the AE 95% Pe
ence Im
Im
n December 2015
ADUC December 2015 DD January 2016
DCNs December 2015
DD Delivery of the AE 95% Pe
erformance target Im
ence Im
n Reeduction in short – stay admissions (KPI 65% ) Delivery of the AE 95% Pe
ence Im
Im
n Reeduction in Communityy Hospital LoS Delivery of the AE 95% Pe
ence Im
A reduction in the total time waits in ED mproved patient and carrer experience Im
Delivery of the 95% Perfo
ormance target December 2015 ADUC January 2016
ADUC December 2015 DD December 2015 ADUC December 2015
ADUC January 2016 DD Page 2 of 7
120 of 208
Caring Domain
Metric
01/04/2014
Caring Domain
Defined
by
Standard
TDA
95%
Quarterly survey
66.0%
Quarterly survey
10.4%
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
FFT - Staff - % recommended as
place to receive care
FFT - Staff - % not recommended
as place to receive care
FFT - Inpatient - % positive
FFT - Inpatient - % negative
FFT - Daycase - % positive
FFT - Daycase - % negative
FFT - A&E/WiC/MIIU - % positive
FFT - A&E/WiC/MIIU - % negative
FFT - Maternity - % positive
FFT - Maternity - % negative
FFT - Community - % positive
FFT - Community - % negative
FFT - Outpatient - % positive
FFT - Outpatient - % negative
L
NA
TDA
L
TDA
L
TDA
L
L
L
TDA
L
L
L
95%
NA
95%
NA
95%
NA
95%
NA
95%
NA
95%
NA
94.8%
3.0%
99.0%
0.0%
97.2%
0.8%
96.6%
0.4%
100%
0.0%
94.0%
4.3%
96.2%
1.7%
100%
0.0%
97.3%
0.7%
94.1%
1.3%
100%
0.0%
95.0%
2.0%
98.4%
0.7%
100%
0.0%
96.4%
1.8%
97.5%
0.7%
90.9%
4.5%
93.1%
3.1%
94.3%
2.0%
100%
0.0%
91.1%
6.0%
98.5%
0.8%
96.7%
0.0%
94.3%
3.3%
94.6%
2.3%
97.9%
0.3%
95.5%
2.3%
97.8%
0.0%
97.6%
0.0%
94.1%
1.3%
95.8%
1.7%
98.9%
0.0%
92.9%
2.6%
98.3%
0.7%
100%
0.0%
95.5%
4.0%
Complaints responded to < 25 days
TDA
85%
83%
53%
63%
74%
57%
NYA
48
40
60
47
66
Q4 14/15 Q1 15/16 Q2 15/16 Q3 15/16 Q4 15/16
71.6%
77.9%
NYA
YTD
73.9%
7.7%
6.1%
NYA
7.1%
98.3%
0.6%
96.6%
2.4%
95.5%
1.4%
98.5%
0.3%
96.5%
0.0%
95.2%
1.8%
96.4%
1.8%
99.6%
0.0%
97.0%
1.1%
96.0%
0.8%
97.1%
1.4%
94.0%
3.2%
94.9%
2.1%
98.7%
0.1%
92.7%
3.6%
98.2%
0.5%
97.8%
0.0%
94.7%
2.7%
96.5%
1.5%
98.5%
0.5%
95.1%
2.0%
97.7%
0.5%
97.1%
0.4%
94.7%
2.6%
60%
70%
66%
NYA
68%
37
156
135
148
47
433
97.7%
0.6%
98.4%
0.8%
Number of complaints received
L
Outstanding complaints
Re-opened complaints
L
L
100
128
8
135
5
135
7
132
12
135
10
125
7
158
30
138
21
135
20
132
29
132
70
TDA
0
0
0
0
0
0
0
0
0
0
0
0
Mixed Sex Accommodation
Breaches
Comments
Lead: Chief Nurse
Defined by TDA - Trust Development Authority (national)
Defined by L - Local Trend or information
Complaints responded to <25 days runs one month in arrears.
Page 3 of 7
Forecast
Safe Domain
01/04/2014
Safe Domain
Metric
C Difficile - number of cases
C Difficile - incident rate per 1000
bed days
C Difficile - variance from plan
MRSA Bacteraemia - incident rate
per 1000 bed days
Never Events - number of
Never Events - incident rate per
1000 bed days
Serious Incidents - number
declared
Serious Incidents - incident rate
per 1000 bed days
Patient Safety Incidents that are
harmful
Medication Errors - number of
Medication Errors - causing
serious harm per 1000 bed days
Medication Errors - number
causing serious harm
Medication Errors - proportion of
errors causing harm
CAS Alerts - overdue alerts
Defined
Standard
by
L
32
TDA
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Q4 14/15 Q1 15/16 Q2 15/16 Q3 15/16 Q4 15/16
YTD
2
3
3
2
6
1
13
8
9
30
0.09
0.13
0.13
0.08
0.25
0.04
0.19
0.12
0.12
0.16
TDA
<=0
-1
0
0
-1
3
-1
4
-1
1
4
TDA
0
0
0
0
0
0
0
0
0
0
0
TDA
0
0
0
0
0
1
0
0
0
0
1
1
TDA
0
0.0
0.0
0.0
0.0
0.04
0
0.0
0.0
0.0
0.0
0.0
L
107
9
11
4
9
5
6
36
31
24
20
75
0.39
0.48
0.17
0.37
0.21
0.24
0.52
0.46
0.35
0.27
0.36
33%
23%
32%
35%
31%
37%
28%
29%
33%
72
85
85
90
-
-
TDA
TDA
35%
L
84
96
TDA
0.00
0.00
0
0
0
1
0
0%
27%
20%
29%
26%
31%
31%
0
0
0
0
0
0
157
134
120
143
138
49.0%
37.8%
43.3%
42.0%
L
0
L
TDA
0
109
per mth
-
322
252
260
834
0.01
0.00
0.01
0.00
1
0
1
2
28%
25%
29%
0
0
0
0
137
384
411
418
1213
33.3%
33.6%
45.6%
42.3%
34.5%
0.04
274
0
0
Patient Falls - total number
L
Acute & Community Patient Falls proportion that cause harm
L
Total Pressure Ulcers
(Category 3 & 4)
L
108
13
13
7
6
4
NYA
33
33
33
10
76
Avoidable Pressure Ulcers
(Category 3 & 4)
L
26
1
0
0
0
0
NYA
2
5
1
0
6
Emergency C section rate
TDA
16.9%
13.2%
13.8%
17.4%
17.0%
17.4%
16.6%
15.1%
14.6%
17.3%
15.6%
VTE Risk Assessment
TDA
95%
95.2%
94.4%
90.4%
NYA
NYA
NYA
% Harm Free Care
TDA
95%
93.1%
92.6%
94.3%
92.8%
91.1%
91.9%
95.5%
95.2%
92.9%
91.9%
93.3%
NYA
91.9%
Forecast
94.0%
92.4%
Comments
Lead: Medical Director and Chief Nurse
N/A - Target not applicable
121 of 208
VTE data is not currently available as validations are ongoing. Reports are expected to be submitted at month end.
Page 4 of 7
122 of 208
Responsiveness Domain
Metric
01/04/2014
Responsiveness Domain
Defined
Standard
by
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Q4 14/15 Q1 15/16 Q2 15/16 Q3 15/16 Q4 15/16
YTD
Referral to Treatment - Admitted
Referral to Treatment - Non
Admitted
TDA
90%
90.7%
91.9%
83.1%
84.4%
84.4%
NYA
90.2%
90.7%
88.6%
84.4%
88.2%
TDA
95%
96.1%
95.5%
95.1%
95.3%
95.3%
NYA
95.3%
95.7%
95.6%
95.3%
95.5%
Referral to Treatment - Incomplete
TDA
92%
92.5%
93.1%
92.5%
92.3%
93.0%
NYA
92.7%
93.5%
92.5%
93.0%
93.0%
Referral to Treatment - Incomplete
52+ week waiters
TDA
0
Diagnostic Waiting Times
TDA
1%
0.0%
0.0%
0.0%
A&E: 4 hour waits (all types)
A&E: 12 hour waits from arrival
A&E: 12 hour trolley waits
TDA
L
TDA
95%
0
0
97.5%
49
0
95.4%
185
0
93.7%
255
0
Two Week Wait Standard
Breast Symptom Two Week Wait
Standard
31 Day Standard
TDA
93%
96.3%
95.2%
94.4%
TDA
93%
98.6%
94.6%
TDA
96%
100%
31 Day Subsequent Drug Standard
TDA
98%
TDA
31 Day Subsequent Surgery
Standard
62 Day Standard
62 Day Screening Standard
Cancer 104 day waits
Elective urgent operations
cancelled for second time
Number of patients not treated
within 28 days of last minute
cancellation
Outpatient cancellation rate Hospital
Outpatient cancellation rate Patient
Delayed Transfers of Care
0
NYA
0.1%
0.5%
NYA
0.2%
0.0%
0.0%
90.4%
378
0
92.4%
285
0
93.0%
290
0
91.2%
934
0
95.9%
453
0
95.6%
489
0
91.9%
953
0
94.5%
1895
0
95.8%
94.9%
94.5%
95.1%
94.5%
95.4%
95.0%
94.9%
94.6%
97.9%
95.3%
97.2%
99.0%
96.1%
96.2%
96.7%
96.4%
98.5%
99.4%
99.3%
98.8%
100%
99.8%
100%
99.4%
99.3%
99.5%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
94%
100%
100%
97.6%
100%
96.7%
100%
100%
99.1%
99.0%
98.9%
99.0%
TDA
TDA
TDA
85%
90%
0
85.6%
89.4%
2
84.2%
93.6%
3
90.2%
94.7%
1
89.3%
91.3%
2
89.7%
95.7%
2.5
94.1%
90.2%
0
85.1%
97.6%
89.9%
97.4%
0
86.9%
92.7%
1
90.8%
92.5%
0
88.9%
93.7%
0
TDA
0
0
0
0
0
0
0
0
0
0
0
0
TDA
0
0
0
0
0
0
0
1
0
0
0
0
TDA
17.2%
18.9%
20.1%
NYA
NYA
NYA
17.8%
16.6%
18.6%
NYA
17.4%
TDA
18.3%
19.1%
21.6%
NYA
NYA
NYA
16.8%
17.8%
19.5%
NYA
18.5%
4.6%
3.3%
TDA
3.5%
0
3.7%
0
4.4%
0
0
2.3%
NYA
0
2.8%
0
3.6%
0
4.2%
0
0.5%
2.9%
Forecast
0
0.5%
3.6%
Comments
Lead: Chief Operating Officer
Cancer figures are provisional for December.
Delayed Transfers of Care data and Diagnostic waiting times data is not yet available due to the change in national reporting deadlines. Reports are due to be submitted at month end.
Cancellation rates and RTT performance are not currently available due to Medway delays and ongoing validation.
Page 5 of 7
Effectiveness Domain
01/04/2014
Effectiveness Domain
Defined
by
Standard
TDA
< 100
HSMR - Weekend
(4 months in arrears)
TDA
< 100
SHMI
TDA
Crude Mortality
(non elective inpatients)
TDA
Metric
HSMR
(rolling 12 months; 4 months in arrears)
SDU Mortality reviews completed
(within 3 months of death)
L
Total Number of SDU Mortality
reviews - Regardless of timescale
to completion
Jul-15
100%
Sep-15
Oct-15
Nov-15
Dec-15
Q4 14/15 Q1 15/16 Q2 15/16 Q3 15/16 Q4 15/16
YTD
103.3
103.0
103
102.7
101.4
101.4
(May - Apr)
(Jun - May)
(Jul-Jun)
(Aug-Jul)
(Sep - Aug)
(Sep - Aug)
105.0
104.0
105.4
107.3
104.7
104.7
(May - Apr)
(Jun - May)
(Jul-Jun)
(Aug-Jul)
(Sep - Aug)
(Sep - Aug)
105
106
106
(Dec)
(Mar)
(Mar)
2.0%
100%
within 3
months
Aug-15
94%
2.5%
2.2%
3.1%
2.5%
2.2%
88%
76%
100%
97%
92%
Quarterly reporting
60.7%
67.3%
69.2%
Quarterly reporting
57%
59%
61%
(Apr dths) (May dths) (Jun dths)
100%
100%
Q1 45%
Q2 60%
Q3 70%
Q4 75%
Q1 50%
Q2 60%
Q3 70%
Q4 75%
2.2%
96%
(Jul dths)
2.3%
2.2%
100%
73%
2.2%
Forecast
2.3%
(Aug dths) (Sep dths)
73%
94%
Health Visitors: % of children
receiving a 12 month development
review
L
Health Visitors: % of children who
receive a 2-2.5 year development
review
L
Health Visitors: % births that
receive a face to face new birth
visit within 14 days
L
95%
92%
92%
93%
91%
93%
92%
92%
92%
92%
92%
New born blood spot screening:
Coverage - % of eligible babies for
whom a conclusive screening
result for PKU has been recorded
on CHIS within 17 days of age
L
95%
98%
98%
97%
97%
97%
97%
97%
97%
97%
97%
Comments
Lead: Medical Director & Chief Operating Officer
Health Visitors: Data for children receiving 12 month and 2-2.5 year reviews is not currently available for Q4 as these are quarterly figures.
123 of 208
Page 6 of 7
124 of 208
Well Led Domain
Metric
Temporary staffing spend as a
percentage of paybill
Staff sickness
Staff turnover
01/04/2014
Well Led Domain
Defined
Standard
by
TDA
Jul-15
Aug-15
13.7%
13.9%
3.2%
13.3%
3.5%
13.2%
Sep-15
13.7%
Oct-15
Nov-15
Dec-15
Q4 14/15 Q1 15/16 Q2 15/16 Q3 15/16 Q4 15/16
14.2%
12.5%
NYA
15.2%
12.2%
3.9%
14.7%
NYA
14.7%
NYA
NYA
13.6%
3.1%
13.3%
3.7%
14.5%
3.9%
14.7%
3.5%
14.7%
Quarterly survey
17.4%
15.7%
3.0%
2.9%
22.2%
10.5%
14.3%
19.5%
51.0%
20.6%
2.4%
NYA
19.2%
2.7%
NYA
17.3%
10.6%
51.0%
18.9%
5.1%
15.4%
<3.5%
<12%
FFT - Staff - Response rate
FFT - Inpatient - Response rate
FFT - Daycase - Response rate
FFT - A&E/WiC/MIIU - Response
rate
FFT - Maternity - Response rate
TDA
TDA
TDA
30%
30%
30%
19.9%
3.2%
20.6%
1.9%
TDA
30%
8.2%
10.1%
9.2%
9.0%
4.1%
15.4%
11.2%
9.2%
9.5%
10.0%
L
30%
13.2%
25.6%
27.1%
36.7%
42.4%
32.2%
28.7%
21.7%
36.4%
27.9%
FFT - Community - Response rate
TDA
30%
0.20%
0.10%
0.10%
0.20%
0.20%
0.10%
0.24%
0.20%
0.10%
0.20%
0.20%
TDA
95%
Quarterly survey
53.0%
53.6%
58.0%
NYA
55.1%
L
NA
Quarterly survey
TDA
>90%
Safe Staffing - Overall fill rate
97.7%
95.7%
93.6%
95.9%
23.2%
97.3%
94.1%
95.8%
19.5%
96.1%
19.5%
95.7%
NYA
96.4%
Forecast
13.1%
TDA
TDA
FFT - Staff - % recommended as
place to work
FFT - Staff - % not recommended
as place to work
3.7%
14.5%
13.8%
YTD
19.5%
96.1%
Comments
Lead: Chief Nurse and Director of Human Resources
Sickness data runs one month in arrears.
FFT Staff data is not available as this is a quarterly survey.
Page 7 of 7
Agenda item: 12.1
TRUST BOARD MEETING
27 January 2016
Title
Summary of Finance and Business Performance Committee meeting held on 17
December 2015
Responsible
Director
Purpose of the
paper
Finance Business Performance Committee Chair
The purpose of this paper is to provide information to the Trust Board about the matters
reviewed by the Finance and Business Performance Committee and the level of
assurance gained through discussion of items on the agenda.
There was a further meeting of the Committee on the 20th January after the issuing of this
paper.
Action / decision
required (e.g.,
approve, support,
endorse)
Consider the level of assurance.
Patient Quality
Legal
Financial
Performance
Regulatory/
Compliance
Operational
Performance
Public
Engagement
/Reputation
Strategy
FT Application
Equality &
Diversity
Partnership
Working
New or
elevated risk
Other
Annual Objective
BAF/Corporate Risk
Register Reference
Risk Description
All financial, operational and workforce risks on the Board Assurance Framework and
CRR
Author of Paper
Presenter of Paper
None
Date of Paper
6 January 2016
125 of 208
COMMITTEE DETAILS:
Name of Committee: Finance and Business Performance Committee
Meeting date:
17 December 2015
Was the meeting quorate? Yes. Mr Rajiv Jaitly and Dr Dipti Amin also attended the meeting.
There were no conflicts of interests declared by members or attendees on the Agenda items due to be discussed.
Apologies were received from: Mrs Rachel Devonshire; Mr David Williams; Mr Mike Naylor
KEY AREAS OF DISCUSSION:
The main focus for discussion was the financial position as at Month 8 and the challenges of the cash position as
follows:
• £8.9m deficit at Month 8 – a £2.8m negative movement from Month 7
• Improvement in nursing pay spend but an increased variance from budget for medical staff. Compliance
for nursing with national agency cap.
• Drop in activity compared to forecast
• Impact of Patient Administration System switchover process to Medway
• Service Level Agreement Monitoring (SLAM) prepared for Month 6 closed and estimate prepared for M7
• Divisional summary bottom up forecast
There had been a lack of assurance around the reliability of numbers presented to the Committee but it was
considered that the presentation at this meeting demonstrated improvement in this area.
A range of year end forecasts based on M8 position were presented to the committee with the best case
projection of £6.7m deficit and the worst case projection of £14.4m deficit.
The Committee recognised the urgency of receiving support on the cash position and supported the submission of
a bid to the Independent Trust Financing Facility (ITFF) for Public Dividend Capital.
The Committee considered a business case for replacement of 10 anaesthetic machines. This was
recommended to the Board for approval.
The Committee received performance reports for operations and workforce and the implementation of Medway.
The Committee received feedback from the Lord Carter review for information.
KEY ACTIONS:
The main actions from the meeting were the actions required to deliver the financial recovery plan.
AREAS OF RISK TO BRING TO THE ATTENTION OF THE BOARD:
• Risk to delivery of the financial plan
• Risks arising from the implementation of the new patient administration system
ANY EXAMPLES OF OUTSTANDING PRACTICE OR INNOVATION:
126 of 208
Trust Board Report - 27th January, 2016
Title
Finance Board Paper, Month 9, December 2015-16
Responsible Director
Dominic Tkaczyk, Director of Finance
Purpose of the paper
To brief the board on the financial performance against plan, inform by exception areas of
concern, and seek approval of corrective actions being taken.
Action / Decision required (E.G.
approve, note, support, endorse)
Board is required to note the position
Patient Quality
Financial Performance
Operational
Performance
Strategy
FT Application
New or elevated risk
Legal
Regularity /
Compliance
Public Engagement /
Reputation
Equality & Diversity
Partnership
working
Other
Annual Objective
Deliver the Financial Plan in a sustainable manner.
Links to BHT Board Assurance framework / Corporate risk register
BAF / Corporate risk register BAF 16a, 16b, 16c, 16d
reference
Risk to the delivery of financial break -even duties if BHT do not deliver CIPs. Failure to deliver the
financial plan would result in insufficient cash to service historical debt.
Risk Description
CQC Reg. Ref.
Regulation 13 Financial Position
Author of Paper
Wayne Preston
Presenter of Paper
Dominic Tkaczyk
Other committees / groups where this paper / will be considered
Finance and Business Performance Committee
Date of Paper
15th January, 2016
127 of 208
Financial Summary - Month 9, December 2015/16
Executive Highlights:
- Reported In month deficit £1.5m. YTD actual deficit £10.4m.
- Efficiency delivery - £12.1m delivery YTD, £1.6m behind plan.
- Cash - £24.6m temporary borrowing accessed to date. Additional £1m approved for draw down in January.
-Income - Income is based upon costed YTD activity levels to November, and indicative activity numbers at average prices for December.
NB. In light of the financial position to date the Trust is reviewing its forecast in discussions with the TDA.
In Month
Actuals
Actual
Variance
%
30,806
277,861
274,503
(3,358)
R
Pay
(19,823)
(173,402)
(177,315)
(3,913)
R
Non Pay
(10,157)
(79,997)
(85,714)
(5,717)
R
Total Expenditure
(29,980)
(253,399)
(263,029)
(9,630)
R
826
24,462
11,474
(12,988)
R
Total Other adjs inc IFRIC
(2,288)
(22,153)
(21,883)
270
R
Surplus (Deficit)
(1,462)
2,309
(10,409)
(12,718)
R
Total Income
Reported
EBITDA £0.8m
in month, £13m
behind plan YTD
Total EBITDA
£10.4m
deficit YTD
Recurrent Efficiency Delivery
Non Recurrent Efficiency Delivery
Total CIP Delivery
Temporary Staffing Costs
1,868
13,650
10,296
(3,354)
R
-
1,790
1,790
G
13,650
12,086
(1,564)
R
186
2,054
(2,505)
Cash balances
5,175
Creditors % invoices paid within 30 days (volume)
75%
Creditors % invoices paid within 30 days (value)
89%
Capital Expenditure
128 of 208
YTD
Budget /
Plan
(1,749)
R
(22,357)
6,195
5,175
(1,020)
95%
83%
-12%
95%
90%
-5%
(9,479)
6,364
(15,843)
R
I&E Graphs - Month 9, December 2015/16
Average No of Shifts per week
Bank Partners Nursing - Average Weekly Shifts filled
1500
1400
1300
1200
1100
1000
900
800
2014-15
2015-16
129 of 208
Narrative - Month 9, December 2015/16
Summary
Income £3.4m behind plan YTD. CIPS £12.1m delivery YTD, £1.6m adverse to plan. Pay £3.9m adverse to plan YTD, non pay £5.7m adverse to plan YTD.
Income
Income is based upon costed YTD activity levels to November, and indicative activity numbers at average prices for December.
Expenditure (I&E Sheet)
Pay
Pay costs total £19.8m for the month. The YTD adverse variance against plan is £3.9m.
Non Pay
Non pay costs total £10.2m for the month, £5.7m adverse variance against plan YTD. Main pressure areas continue to include drugs and clinical consumable spend.
Cash
The Trust received a further £2.6m of its Working Capital Facility in December, which brings the total utilised to £24.6m in year, against its facility of £28.2m. This was
less than applied for, and working balances are being managed on a daily basis, through the deferment of creditors. A longer term application for cash support has been
submitted to the TDA in December for presentation to DH in February.
Debtors
The Q1 position with local commissioners has been 'hard closed' resulting in a cash settlement paid in early December against the agreed position. Bucks County Council
have also settled their account resulting in a cash benefit of £0.5M. The aim is to reduce debtors further through the closure of Q2 with commissioners, but the level of
debt paid will depend upon the negotiated final settlement.
Creditors
Creditor payment have been robustly managed due to the working capital position. This has impacted on BPPC, however the trust prioritises payments in a way to
minimise operational impacts. The BPCC numbers when analysed net of dispute and the impact of short-term cash injections are 65% by value, and 21% by invoice
number.
Capital
Capital expenditure is behind plan. This is due to withholding payments on specific projects until the product is operating to a mutually agreed standard. Together with
slippage on significant schemes such as the CT scanner and radiology equipment £1.5, spinal bathrooms £0.8M and Estates projects £1.2M. The revised forecast year
end spend is £14.5m, £3.3m under plan.
130 of 208
Narrative - Key Financial Risks
Month 9, December 2015/16
Risks Identified
1
2
Containment of
Operational expenditure
within funded levels
Efficiency Plans
Description
The key to achieving this is to manage demand
effectively and deliver productivity gains to deliver
improved quality and where appropriate increased
activity through the same or less resource. It will
require a steady and stable workforce to
significantly reduce the use of agency workers and
the reliance upon temporary staffing. In house
capacity needs to be right sized to balance the
demand need, and be flexible enough to respond to
fluctuations and changes to pathways of care. The
purchasing of goods and services needs to be
continually scrutinised to assure best value for
every pound spent.
The full level of planned CIPs is required to be
delivered recurrently, along with any additional
recovery value to ensure the Trust delivers break
even at year-end.
Potential
Value £'m
£12.4m
£4.0m
Risk (RAG)
M - 50%
M - 50%
Weighted
Value £'m
Mitigation
£6.2m
Recovery plan FBPC 23rd July / 11th August.
Workforce strategy including:
Comprehensive recruitment and retention
plans
Procurement Strategy
Member of DH Procurement Review led by
Lord Carter
Performance Management Framework
PWC Benchmarking
NHS benchmarking club
£2.0m
Continual scrutiny and pressure to deliver
through PMO, FBPC, Deep Dives etc
Continual search for new schemes
Multi-year and future year savings pulled
forward
Corporate over delivery to assist clinical
divisions
Income generating proposals
Estate Strategy
Revised CIP programme
Recovery Plan
3
Income
Potential contract challenge Q2 - Q4
£6.0m
M - 50%
£3.0m
Robust contracting framework
Robust contract management
Clinical involvement and ownership
Expand approach to wider sources of income
Improved coding
Improved Data compliance
4
Commissioner
affordability
Commissioners are facing affordability issues and
increased demand upon their limited budgets.
Contractual management is a legitimate method for
them to attempt to reduce their exposure to
financial pressures.
£3.0m
M - 50%
£1.5m
Commissioner relationship management
Data Integrity and robust recording
Clinical involvement and ownership
5
Cash
If the income and expenditure position of the Trust
is less than the surplus required to service historical
debt repayment, pressure upon cash balances will
be increased. The capital programme will be
required to be limited to that affordable from
depreciation.
£27.1m
M - 50%
£13.6m
Ongoing dialogue with TDA
Restriction of capital programme
Alternative funding structures
Supplier relationship management
Robust treasury management
Access to rolling cash facility
6
Fines
National rules apply
£0.5m
R - 100%
£0.5m
RTT lists to be managed patient by patient
7
Seasonal income
3% to 4% additional income in last 6 months of the
year versus 1st 6 months of the year
£3.0m
M - 50%
£1.5m
8
Capital & Estates
Pressure of capital requirements putting pressure to
over commitment of capital plan. The cash position
may result in the plan being curtailed.
£2.5m
R - 100%
£2.5m
9
Junior Doctors
Ballot on strike action
£1.0m
M - 50%
£0.5m
Detailed disposal plan
Revision of asset register
NB Capital to revenue transfer risk retired.
131 of 208
Income and Expenditure Account - Month 9, December 2015/16
Income
Income From Activities
Other Operating Income
Donated Asset income
Unallocated CIPs
Pay
Nursing
Medical Staff
Non Clinical (A&C/Snr Mgrs)
Professional & Tech
Other Staff
Exec & Non Exec Dirs
Unallocated CIPs / Pay Reserves
Non Pay
Drugs
Clinical Supp Servs
Gen Supp & Servs
Establishment Exps
Premises & F Plant
Miscellaneous
PFI
CNST
Unallocated CIPs
TOTAL EBITDA
Other
Owned Depreciation
Donated Depreciation
Impairment
Interest Paid And Pdc Div
Interest Receivable
Profit/Loss Disposal of Assets
TOTAL
IFRIC 12
Donated Asset Reporting Adj
132 of 208
TOTAL POST REPORTING ADJ
Year to date (£000)
In month
Actual
Budget
Actual
Variance
28,876
1,902
29
0
30,806
262,009
14,988
750
114
277,861
257,465
16,545
492
0
274,503
(4,544)
1,558
(258)
(114)
(3,358)
(8,298)
(5,176)
(2,875)
(2,937)
(441)
(97)
0
(19,823)
(73,431)
(44,181)
(23,118)
(26,793)
(3,824)
(871)
(1,183)
(173,402)
(76,521)
(46,606)
(22,901)
(26,426)
(3,990)
(871)
0
(177,315)
(3,090)
(2,425)
217
367
(166)
0
1,183
(3,913)
(3,168)
(2,596)
(99)
(438)
(1,156)
(666)
(1,532)
(502)
0
(10,157)
(23,410)
(19,897)
(889)
(2,792)
(10,904)
(5,127)
(13,842)
(4,518)
1,381
(79,997)
(25,190)
(21,427)
(862)
(3,485)
(11,371)
(4,855)
(14,035)
(4,490)
0
(85,714)
(1,780)
(1,531)
28
(693)
(467)
273
(193)
28
(1,381)
(5,717)
826
24,462
11,473
(12,989)
(749)
(95)
0
(1,523)
5
0
(2,362)
(7,697)
(750)
0
(13,773)
27
0
(22,193)
(7,484)
(788)
0
(14,007)
27
0
(22,253)
212
(38)
0
(234)
0
0
(60)
(1,536)
2,269
(10,780)
(13,049)
8
66
40
0
74
296
34
296
(1,462)
2,309
(10,409)
(12,719)
Activity Data - Month 9, December 2015/16
133 of 208
Activity Data - Month 9, December 2015/16
134 of 208
Balance Sheet - Month 9, December 2015/16
Statement of Financial Position
NON-CURRENT ASSETS:
Property, Plant and Equipment
Trade and Other Receivables
TOTAL Non Current Assets
CURRENT ASSETS:
Inventories
Invoiced Receivables
Accrued Income and Prepayments
Other Receivables
Other Current Assets
Cash and Cash Equivalents
TOTAL Current Assets
TOTAL ASSETS
CURRENT LIABILITIES
Trade and Other Payables
Other Liabilities
Provisions
Borrowings
Liabilities arising from PFIs/Finance Leases
DH Working Capital Loan - Revenue Support
Capital Investment Loan
Total Current Liabilities
NET CURRENT ASSETS/(LIABILITIES)
TOTAL ASSETS LESS CURRENT LIABILITIES
NON-CURRENT LIABILITIES:
Trade and Other Payables
Other Liabilities
Provisions
Liabilities arising from PFIs/Finance Leases
DH Working Capital Loan - Revenue Support
DH Capital Loan
Total Non-Current Liabilities
ASSETS LESS LIABILITIES (Total Assets Employed)
TAXPAYERS EQUITY
Public Dividend Capital
Retained Earnings reserve
In Year I&E
Revaluation Reserve
Total
Balance at
31st March
2015
£000s
Balance at
30th
November
2015
£000s
Balance at
31th
December
2015
£'000s
268,806
2,183
270,989
270,315
2,183
272,497
270,777
2,167
272,944
1,970
(16)
1,955
462
(16)
447
270,357
2,102
272,459
(42)
81
38
274,431
1,955
276,386
5,699
17,362
6,505
5,852
163
1,771
37,352
308,341
5,551
11,501
14,115
5,269
54
4,965
41,455
313,953
5,573
11,293
15,705
5,249
42
5,175
43,038
315,982
(126)
(6,069)
9,199
(603)
(121)
3,404
5,685
7,640
22
(208)
1,589
(20)
(12)
210
1,581
2,028
5,693
11,292
8,398
9,450
55
6,195
41,083
313,542
(142)
209
5,717
(4,181)
(1)
(1,230)
372
411
5,693
15,953
10,000
7,000
147
6,232
45,025
321,411
(37,288)
(25)
(429)
(2,833)
(1,142)
(41,717)
(4,366)
266,623
(32,206)
(12)
(92)
(22,000)
(1,057)
(571)
(310)
(56,248)
(14,793)
257,705
(33,291)
(151)
(92)
(24,600)
(797)
(571)
(59,502)
(16,464)
256,480
3,997
(126)
337
(24,600)
2,037
571
(17,784)
(12,099)
(10,145)
(1,084)
(139)
(2,600)
260
310
(3,253)
(1,671)
(1,225)
(29,452)
(7)
(268)
(845)
(571)
(310)
(31,453)
9,630
282,089
(2,755)
(5)
176
(22,000)
(212)
(24,796)
(24,424)
(24,385)
(30,914)
(24)
(130)
(15,000)
(2,588)
(1,143)
(900)
(50,699)
(5,674)
270,712
(936)
(361)
(1,353)
(63,763)
(4,574)
(3,100)
(74,087)
192,537
(936)
(361)
(1,353)
(64,398)
(4,574)
(2,790)
(74,412)
183,293
(936)
(361)
(1,353)
(64,398)
(4,574)
(3,100)
(74,722)
181,758
(635)
(635)
(10,780)
(310)
(310)
(1,535)
(820)
(361)
(1,165)
(63,684)
(14,573)
(6,690)
(87,293)
194,796
(116)
(188)
(714)
9,999
3,900
12,881
(11,504)
(547)
(337)
(1,716)
(61,096)
(3,430)
(5,600)
(72,726)
197,986
181,917
(25,799)
181,917
(25,799)
(9,244)
36,419
183,293
181,917
(25,799)
(10,780)
36,419
181,758
(0)
(10,780)
(10,780)
(1,535)
(1,535)
181,917
(25,799)
2,260
36,418
194,796
(0)
(11,504)
181,917
(25,799)
5,450
36,418
197,986
36,419
192,537
Movement
from
Opening
Balance
£000s
Movement
in month
£000s
Plan at 30th
November
2015
£000s
Variance
from Plan
£000s
(11,504)
Forecast at
31 March
2016
£000s
135 of 208
Agenda item: 13.2
27th January 2016
Title
December 2015 Self-Certification return to the NHS TDA.
David Williams
To provide the Board with the proposed self-certification return for December 2015
Responsible
Director
Purpose of the
paper
Action / decision
required (e.g.,
approve, support,
endorse)
The Board will note that there have been no changes since the November return. The
board statements note the Trust’s A&E position and highlight the risk around the financial
position.
The Board is asked to approve the December self-certification return.
Patient
Quality
Legal
Financial
Performance
Regulatory/
Compliance
Annual Objective
Operational
Performance
Public
Engagement
/Reputation
Strategy
FT Application
Equality &
Diversity
Partnership
Working
New or
elevated risk
Other
Links to all corporate objectives.
BAF/Corporate Risk
Register Reference
Risk Description
• There is a risk that, if the organisation does not achieve Foundation Trust status, care
could be compromised through merger/integration with a Foundation Trust that is
struggling with performance.
• There is a risk that, if the organisation does not achieve Foundation Trust status, care
could be compromised through merger/integration with an academic health sciences
organisation resulting in specialist centres of excellence being out of the county.
CQC Reg. Ref.
Author of Paper
Kingsley Grimble
Assistant Director of Business Development and Marketing
Presenter of Paper
David Williams
None
Date of Paper
15th January 2016
137 of 208
TDA Monthly Self-Certification – December 2015
Compliance with Monitor licence requirements for NHS Trusts
Licence Condition
Condition G4 – Fit and proper persons as
governors and Directors (also applicable to those
performing equivalent or similar functions)
Condition G5 - Having regard to Monitor guidance
Compliance
YES
5
Condition G7 – Registration with the Care Quality
Commission
Condition G8 – Patient Eligibility and selection
criteria
Condition P1 - Recording of information
6
Condition P2 - Provision of information
YES
7
Condition P3 - Assurance report on submissions to
Monitor
Condition P4 - Compliance with the National Tariff
n/a
1
2
3
4
8
YES
YES
YES
YES
YES
11
Condition P5 - Constructive engagement
concerning local tariff modifications
Condition C1 - The right of patients to make
choices
Condition C2 - Competition oversight
12
Condition IC1 – Provision of integrated care
YES
9
10
138 of 208
YES
YES
YES
Comment
Board statements
For each statement, the Board is asked to confirm the following:
1
2
3.
4.
For CLINICAL QUALITY, that
The Board is satisfied that, to the best of its knowledge and using its own processes and
having had regard to the TDA's oversight regime (supported by Care Quality Commission
information, its own information on serious incidents, patterns of complaints, and including any
further metrics it chooses to adopt), the trust has, and will keep in place, effective
arrangements for the purpose of monitoring and continually improving the quality of healthcare
provided to its patients.
The board is satisfied that plans in place are sufficient to ensure ongoing compliance with the
Care Quality Commission’s registration requirements.
The board is satisfied that processes and procedures are in place to ensure all medical
practitioners providing care on behalf of the trust have met the relevant registration and
revalidation requirements.
For FINANCE, that
The board is satisfied that the trust shall at all times remain a going concern, as defined by
relevant accounting standards in force from time to time.
Response
YES
YES
YES
RISK
The Trust shall remain a
going concern, as per
guidance in the NHS Manual
for Accounts, subject to the
continued support of the TDA
for its funding requirement.
The Trust is working closely
with the TDA regarding
access to its Working Capital
Facility, and to longer term
financing, to ensure that the
Trust continues to meet its
financial obligations.
Timescale for compliance:
31st March 2016
139 of 208
5
6
All current key risks to compliance with the NTDA Accountability Framework have been
identified (raised either internally or by external audit and assessment bodies) and addressed –
or there are appropriate action plans in place to address the issues – in a timely manner.
7
The board has considered all likely future risks to compliance with the NTDA Accountability
Framework and has reviewed appropriate evidence regarding the level of severity, likelihood of
a breach occurring and the plans for mitigation of these risks to ensure continuing compliance.
8
The necessary planning, performance management and corporate and clinical risk
management processes and mitigation plans are in place to deliver the annual operating plan,
including that all audit committee recommendations accepted by the board are implemented
satisfactorily.
9
An Annual Governance Statement is in place, and the trust is compliant with the risk
management and assurance framework requirements that support the Statement pursuant to
the most up to date guidance from HM Treasury (www.hm-treasury.gov.uk).
The board is satisfied that plans in place are sufficient to ensure ongoing compliance with all
existing targets as set out in NTDA oversight model; and a commitment to comply with all
commissioned targets going forward.
10
140 of 208
For GOVERNANCE, that
The board will ensure that the trust remains at all times compliant with the NTDA Accountability
Framework and shows regard to the NHS Constitution at all times.
NO
The 4-hour A&E standard
was not met in November
although the year to date
position at 94.5% is just
below the standard.
31st March 2015
RISK
YTD and forecast positions
flag red against financial
indicators.
31st March 2016
RISK
indicators.
31st March 2016
RISK
indicators.
31st March 2016
YES
RISK
There is a risk to ongoing
compliance with the targets in
the oversight model, as per
5,6,7,8 above.
Timescale for compliance
31st March 2016
11
12
13
14
The trust has achieved a minimum of Level 2 performance against the requirements of the
Information Governance Toolkit.
The board will ensure that the trust will at all times operate effectively. This includes
maintaining its register of interests, ensuring that there are no material conflicts of interest in
the board of directors; and that all board positions are filled, or plans are in place to fill any
vacancies.
The board is satisfied that all executive and non-executive directors have the appropriate
qualifications, experience and skills to discharge their functions effectively, including setting
strategy, monitoring and managing performance and risks, and ensuring management capacity
and capability.
The board is satisfied that: the management team has the capacity, capability and experience
necessary to deliver the annual operating plan; and the management structure in place is
adequate to deliver the annual operating plan.
Print Name
YES
YES
YES
YES
Date
Signed on behalf of the Trust
CEO
141 of 208
Chair
Date submitted to the TDA:
142 of 208
Agenda item: 13.3
Public Board meeting
27th January 2016
Title
Responsible
Director
Purpose of the
paper
Working Capital Policy
Dominic Tkaczyk, Director of Finance (interim)
Action / decision
required (e.g.,
approve, support,
endorse)
For ratification
To update Trust Board on the Policy approved by Finance and Business Performance
Committee, and enable Board ratification of the Policy
Operational
Strategy
FT Application
Patient Quality Financial
Performance
Performance
Legal
Regulatory/
Public
Equality &
Partnership
Compliance
Engagement
Diversity
Working
/Reputation
New or
elevated risk
Other
Annual Objective
To deliver the Financial Plan in a sustainable manner.
BAF/Corporate Risk BAF 16a, 16b, 16c, 16d
Register Reference
Risk Description
Risk to the delivery of financial break-even duties if BHT do not deliver CIPs. Failure to
deliver the financial plan would result in insufficient cash to service historical debt.
CQC Reg. Ref.
Regulation 13 Financial Position
Author of Paper
Presenter of Paper
Finance & Business Performance Committee
Date of Paper
18th January 2016
143 of 208
Policy on Cash and Working Capital (Treasury) Management and
Associated Procedures
V.1.0
This document is supplemental and subordinate to Buckinghamshire Healthcare NHS Trust
Standing Orders and Standing Financial Instructions and does not supersede the governance
provided by them either in part or in whole.
This document does not cover treasury management arrangements for Charitable Funds
Once printed off, this is an uncontrolled document. Please check the intranet for the
most up to date copy.
Version:
1
Issue:
0
Approved by:
Date approved:
Ratified by:
Board
Date ratified:
144 of 208
Author:
Nicky McKechnie, Head of Financial Control
Lead Director:
Mike Naylor, Director of Finance and Deputy Chief
Executive
Name of Responsible Individual/
Committee:
Consultation:
Trust Development Authority, Trust Policy and Strategy
Group
BHT Document Reference:
BHT Pol 216
Department Document Reference
N/A
(if applicable):
Date Issued:
September 2015
Review Date:
April 2016
Target Audience:
Trust Directors, managers and finance staff
Location:
Intranet
Equality Impact Assessment:
September 2015
Document History
Title
Version
Issue
1
0
Reason for change
Authorising body
Date
Associated documents
BHT
Ref
BHT
Pol
089
Title
Location/Link
Standing Orders http://swanlive/sites/default/files/sos_and_sfis_v8b_march_2014.pdf
and Standing
Financial
Instructions
2
145 of 208
CONTENTS
Page
1.
Introduction
3
2.
Objectives of Treasury Management Function
3
3.
Treasury Controls
4
4.
Summary of Roles and Responsibilities
4
5.
Banking Arrangements
5
6.
Temporary Surplus Investments
5
7.
Borrowing
5
8.
EFL
8
10.
Treasury Management under the Foundation Trust regime
9
11.
Review of Policy
12
12.
Contacts
12
.Appendix A Operational Procedures
13
3
146 of 208
1. INTRODUCTION
This document has been prepared to provide details of the policies and procedures for the
management of cash, including short to medium term financing and working capital management,
for Buckinghamshire Healthcare NHS Trust.
The Trust Board needs to ensure that cash and working capital is managed in such a way to
generate adequate liquidity to support the Trust’s operational requirements, discharge its
obligations and remain a ‘going concern’. The Director of Finance and Deputy Chief Executive
has the overall responsibility for the fulfilment of this requirement under the Trust’s Standing
Orders and Standing Financial Instructions.
Treasury management consists of the efficient management of liquidity and financial risks in a
business and the actions to manage these risks will vary as their nature changes over time. This
policy is designed to provide a clearly defined risk management framework for those responsible
for treasury operations. In order to fully realise the benefits, the policy will be reviewed not less
than biannually to reflect any changes in the Trust’s operation.
This Treasury management policy has been written to address the current requirements for
Buckinghamshire Healthcare as an NHS Trust and to comply with administrative duties set by the
Department of Health such as the External Financing Limit (EFL) (see section 8). Section 9
outlines the key changes and greater freedoms which the Trust will experience when it achieves
Foundation Trust status.
The Trust’s goal is to put in place a number of enablers which it believes will help prepare for its
transition. Key to this is the move to more active cash and treasury management.
2. AIMS
The aims and objectives of this policy are:
•
To support the delivery of the Trust’s objectives by ensuring short and longer term liquidity.
•
To ensure that the Trust accesses short to medium term financing, whether investing or
borrowing, in an efficient and timely manner.
•
To ensure that working capital is effectively managed and cash is reported appropriately.
•
To ensure that the Board and senior management receive adequate oversight of the
current cash position to enable them to make the most appropriate decisions, given the
current circumstances.
3. SCOPE
The Policy covers the following areas:
•
Roles and responsibilities in relation to the Policy.
•
Key objectives of the Policy.
4
147 of 208
•
Forecasting, monitoring and reporting arrangements for cash.
•
Borrowing and investing procedures.
There are a number of linked Policies and Procedures which may also be relevant, including:
Standing Orders and Standing Financial Instructions (BHT089)
Limits of Delegation Policy (BHT061)
Procedure on the follow up of unpaid invoices.
Procedure on obtaining goods and services for the Trust
The scope of this Policy does not cover the following areas, which are subject to other Policies
and Procedures :
•
The management of patient’s monies.
•
Petty cash or security of cash receipts procedures.
•
Charitable funds banking and working capital arrangements (although the overarching
principles of this policy will also be appropriate for those funds).
.
4. ROLES AND RESPONSIBILITIES
a. Trust Board of Directors
The Trust’s Board of Directors are responsible for approving external funding arrangements
and the overall Plan that supports the financial strategy of the Trust. The Trust Board
delegates responsibility for the approval of most Trust Policies to Finance and Business
Performance Committee, with ratification by the Trust Management Committee. However, it
retains the responsibility for the approval of some Policies, such as this.
b. Finance and Business Performance Committee
Monitor’s guidance to Foundation Trusts recommends the setting up of a Cash Committee for
reporting to the Board. As the Trust has not yet achieved Foundation status and, given that it
is subject to constraints in the scope of its Treasury function, this role is undertaken by the
Finance and Business Performance Committee.
Finance and Business Performance Committee review the Trust’s plans, budgets and
significant Business Cases, which impact on the Trust’s working capital position. They receive
reports on the Trust’s cash position.
c. Audit Committee
The Audit Committee provide assurance to the Board that there are processes in place to
appropriately record the risks associated with the delivery of the Trust’s corporate objectives,
including risks to the cash position. They also receive reports on the Trust’s aged receivables
and payables position.
5
148 of 208
d. Director of Finance and Deputy Chief Executive
The Director of Finance and Deputy Chief Executive has the following responsibilities:
•
Recommend revenue and capital budgets to the Board that support the working capital
management of the Trust
•
Report variances to revenue and capital budgets and the Cost Improvement
Programme that lead to issues regarding the delivery of the working capital plan.
•
Approving cash management systems.
•
Ensuring approved bank mandates are in place for all accounts and for the auctioning
of agreed financing facilities. These mandates need regular review for any changes in
signatories and authority levels.
•
Receive regular reports and updates from the Deputy Director of Finance and Head of
Financial Control, discuss issues and consider any points that are needed to be
brought to the attention of the Audit Committee and Finance and Business
Performance Committee.
e. Deputy Director of Finance/Head of Financial Control
The Deputy Director of Finance and Head of Financial Control manage the wider financial
services team in ensuring:
•
Reports on Treasury activities are prepared and provided on a regular and timely basis.
•
Key banking arrangements are managed.
•
Working capital and treasury activities are undertaken within key Policies and
Procedures.
•
All applications for permanent and temporary financing are submitted in a timely way,
and subsequent reporting on cashflow to the TDA/DH is made within agreed
parameters.
•
Detailed cashflow forecasts are produced on a daily, monthly and annual basis to aid
operational decision-making.
•
Sufficient cash is maintained to ensure that any operational issues from payables
management, if required, are minimised.
The Policy and Procedures supporting this Policy on Working Capital management are subject to
periodic review by both internal and external auditors as part of their assurance work. Any
improvement in processes recommended will be incorporated, as appropriate, within these
procedures. In particular they will review the controls included within those processes.
6
149 of 208
The treasury controls are designed to ensure the Trust’s treasury activities are undertaken in a
controlled and properly reported manner.
The key components of the overall treasury operating environment include the following:
•
clearly defined roles and responsibilities in treasury activities for the Trust Board, the
Director of Finance and Deputy Chief Executive, Deputy Director of Finance, Head of
Financial Control and the wider Financial Services team;
•
regular reporting of treasury activities; controls on who can operate bank accounts and
authorisation limits;
•
segregation of duties between those who deal, those who initiate payment and those who
account for treasury activities.
5. BANKING ARRANGEMENTS
The Trust operates its banking arrangements in line with the directions issued by the Secretary of
State for Health. These specify where the Trust can hold cash and investments, and the
maximum amount the Trust can deposit in any investments or class of investments.
The Trust holds a bank account with RBS under the Government Banking Service (GBS)
umbrella. At this time it does not hold any commercial bank accounts. However, a maximum
average annual cleared balance of up to £50,000 in total can be held with other approved
institutions for operational reasons (as per DoH guidance)
The Trust cannot become overdrawn on its bank balances and, should this happen; GBS will
contact the Trust to insist that the account is brought back into credit. Interest rates payable on
overdrawn balances are significantly higher than those for credit balances.
6. TEMPORARY SURPLUS INVESTMENTS
NHS Trusts only have the power to invest any surplus funds with the National Loans Fund
Temporary Deposit facility operated by HM Treasury, subject to them not being in receipt of any
short-term or revolving temporary borrowing.
This allows the Trust to invest surplus funds of a minimum of £1million for periods from 7 days to
6 months.
If any surplus funds are to be invested, the following points need to be considered:
•
What is the Trust’s current borrowing? Surplus funds cannot be invested where temporary
borrowing is in place; the temporary borrowing would have to be repaid.
•
What is the likely impact on liquidity from the temporary borrowing? Once invested the
funds cannot be withdrawn, so an operational cash balance of at least the most prudent
7
150 of 208
view on the call on cash will need to be maintained.
•
What will be the I&E benefit in terms of increased interest received? At times of low
interest rates the potential gain is likely to be negligible, and the risk to the liquidity position
will need to be taken into account when looking at the wider picture.
7. BORROWING
The following routes are available to the Trust:
7.1 Interim Revolving Working Capital Support Facility
This is a revolving maturity loan facility to support interim working capital requirements in the
advance of the development of a Recovery Plan. It provides the flexibility to cover short term and
fluctuating cash requirements. The facility is available for 30 days equivalent operating
expenditure and interest is charged at 3.5% based on daily outstanding balances. This facility is
not subject to the agreement on the Independent Trust Financing Facility (ITFF).
The agreement is based on a rolling 2 year maturity and is renewable, but subject to an agreed
maturity date. Once the facility is drawn against, cash balances must be forecast to be held above
a minimum amount on a daily basis, and under a maximum amount at month end. To support this,
the TDA must be provided with a 13 week cashflow each month. If cash falls under the minimum
at any point, a further draw down will be expected to be made. If it goes above the maximum
amount, the DH will direct debit surplus funds. However, these can be redrawn against if
necessary.
The Trust has negotiated a facility of £28.2 million from April 2015. The Agreement has been
supported by a Board Resolution. It is required to hold cash balances between £1.9m and £9.4m
over the two year period, and can draw down against this facility on the submission of a Utilisation
Request, signed by the Head of Financial Control, Deputy Director of Finance or Director of
Finance and Deputy Chief Executive.
7.2 Interim Revenue Support Loan
This is a maturity loan to support interim working capital requirements in the advance of the
development and agreement, by the TDA, of a Recovery Plan, which is a condition of the
borrowing. This facility is subject to the agreement of the ITFF. Interest is charged at 1.5% based
on daily outstanding balances.
The agreement is based on a rolling 2 year maturity and is renewable, but subject to an agreed
maturity date. The principal is repayable on maturity. There is no facility to re-borrow any amounts
repaid.
8
151 of 208
7.3 Interim Revenue Support Public Dividend Capital
This is a PDC product to support interim working capital requirements in the advance of the
development and agreement, by the TDA, of a Recovery Plan, which is a condition of the
borrowing. This facility is subject to the agreement of the ITFF. As no interest is chargeable, a
commitment fee of 1% of the facility is payable to DH at the point of the first drawdown.
At the point that the Recovery Plan is agreed, the PDC may become repayable. The potential for
repayment will also be considered at each second anniversary of the facility.
Interim Revenue Support Loans and Interim Revenue Support Public Dividend Capital are interchangeable products and the TDA will work with Trusts accessing these on the ability to repay as
part of the agreement of the Recovery Plan process.
7.4 Interim Capital Support Loan
The primary source of cash for capital investment is through internal sources. However, as if
addition investment is required, as part of the development of a Recovery Plan, this amortising
loan product is the default facility to support capital expenditure requirements that can be
reasonably expected to be part of the Trust’s normal business commitments.
The loan is subject to the agreement of the ITFF and the interest rate will be the prevailing
National Loans Fund rate on the date the agreement is made. Interest is payable to DH every 6
months, and amounts will be confirmed subsequent to any drawings on the facility.
Principal is repayment in agreed instalments over an agreed term, which will not be longer than
the life of the assets that will be financed using the facility.
The Trust has agreed a £9m loan, with £3.1m drawn in 2014/15, with the remaining £5.9m to be
drawn in 2015/16.
7.5 Interim Capital Support PDC
This will now only be provided in exceptional circumstances, and not for capital requirements that
could be considered as part of the Trust’s usual business. It is serviced through the usual PDC
dividend charge and, although no routine repayment will apply, ability to repay may be determined
where necessary by the Department.
7.6 Planned Term Support
Longer term financial assistance may be considered by the TDA and ITFF where Trusts have
clear and robust recovery plans to return to a sustainable position over a reasonable and realistic
time frame. The Recovery Plan will need to demonstrate that investment is in the taxpayer’s best
interests and will be subject to it carrying substantial assurance to the TDA that the Trust can
deliver its forecast improvements to financial performance.
Planned Term Support may be provided as either a loan or PDC to deliver capital investment or
restructuring.
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7.7 Guidance/forms
Guidance and template business cases is held in the Trust’s cash ‘pigeonhole’ which is
maintained by the Department of Health. Access to the pigeonhole is maintained by the Financial
Accounts team and Head of Financial Control.
8. EXTERNAL FINANCING LIMIT (EFL)
The External Financing Limit (EFL) is a limit on the amount of external finance
which a Trust may access in any one year.
The target EFL, which is set by the Department each year can be positive, neutral or negative,
reflecting the balance between internally generated resources, such as depreciation, retained
surplus, sales of fixed assets and the planned application of resources such as capital
expenditure.
The difference between the EFL and cash outflows from financing which comprise loan
repayments and the capital elements of finance leases and the PFI agreement represents the
required increase in cash holdings during a financial year.
Cash management techniques need to be employed during the weeks leading up to the 31st
March each year in order to ensure that the Trust achieves this administrative duty of meeting its
EFL.
Trusts are permitted to ‘undershoot’ their EFL i.e. permitted to have higher cash holdings at 31st
March. Overshooting this limit i.e. having lower cash holdings represents a failure against the EFL
target.
9. TREASURY MANAGEMENT UNDER THE FOUNDATION TRUST REGIME
Under section 17 of the Health and Social Care Act (Community Health and Standards), NHS
Foundation Trusts have wide discretion to invest money for the purposes of, or in connection with,
their functions. While this freedom offers a greater opportunity to improve patient care, it needs to
be managed carefully to avoid financial and / or reputational risks.
The objectives of the Trust’s treasury operations under the FT regime in addition to those outlined
in section 2 will be:
•
ensuring that sufficient liquidity is maintained to cover business cash flows and to provide
reasonable flexibility for seasonal cash flow fluctuations and capital expenditure;
•
ensuring that flexible and competitively priced funding is available at all times;
•
ensuring a competitive return on surplus cash, within an acceptable risk profile;
•
monitoring the Trust’s exposure to foreign exchange risk
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9.1 Working Capital Facility
The Trust will be required to negotiate a working capital facility with a commercial bank. It is
anticipated that this will equate to 30 days operating expenditure. The Trust will incur associated
set up fees and any utilisation of this facility will incur interest charges and, possibly, draw down
fees.
9.2 Investment of Surplus Cash
Monitor’s guidance is that Trust’s should only invest surplus operating cash in ‘safe harbour’
investments to ensure adequate safety and liquidity.
The following criteria define ‘safe harbour’ investments:
•
they must be held at a permitted institution. These are institutions that have been granted
permission by the Financial Services Authority to do business with U.K. institutions and the
UK Government or an executive agency thereof;
•
they must meet permitted rating requirements issued by a recognised rating agency. Only
the following agencies are recognised:
○ Moody’s Investor Service;
○ Standard and Poors;
○ Fitch Ratings Ltd;
They must be within the preferred concentration limit. Concentration limits are as follows:
•
clearing banks have a limit of £15 million
•
other banks:
○ rated AAA at Moody’s have a limit of £10 million;
○ rated AA1 at Moody’s have a limit of £5 million;
○ rated AA2 and AA3 at Moody’s have a limit of £3 million;
○ rated A1 at Moody’s have a limit of £2 million;
•
they must have maximum maturity dates. Cash balances should remain in a comparatively
liquid form and all investments resulting from them should be realisable and have maturity
not exceeding 3 months;
•
they must be denominated in sterling with any payments or repayments in sterling;
•
they must pay interest at a fixed, floating or discount rate;
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•
investments may include money market deposits, money market funds, Government and
Local Authority bonds and debt obligations, certificates of deposit and sterling commercial
paper.
9.3 Banking Relationships
The Trust will need to develop long-term relationships with a core group of quality banks thus
establishing a high degree of confidence and commitment between the parties. This should
ensure that funding requirements at crucial times and at short notice will be met sympathetically.
9.4 Key Responsibilities
Board of Directors
•
approve external funding arrangements;
•
approve overall treasury policy;
•
delegate responsibility for approval of the Trust’s treasury procedures, controls and
detailed policies to the Investment or Funding Committee.
Investment or Funding Committee
Monitor’s guidance recommends the setting up of an Investment or Funding Committee to report
to the Board. The suggested responsibilities of this Committee in relation to treasury management
are:
•
ensure the Trust’s investment and borrowing strategy retains a minimal risk profile;
•
approve and monitor relevant benchmarks for performance;
•
ensure proper safeguards are in place for security of the Trust’s funds by:
○ agreeing a list of permitted institutions;
○ setting investment limits for each institution;
○ agreeing permitted investment types;
•
monitor compliance with treasury policies and procedures.
Director of Finance & IT
•
approves cash management systems;
•
ensures approved bank mandates are in place for all accounts and that they are updated
regularly for any changes in signatories and authority levels;
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•
holds regular meetings with the Assistant Director of Finance (Financial Control) to discuss
issues and consider any points that should be brought to the attention of the Audit
Committee.
Assistant Director of Finance (Financial Control) and the Financial Accounts team
•
defines the Trust’s Treasury approach for approval by the Investment or Funding
Committee
•
reports on the Treasury activities on an accurate and timely basis;
•
manages key banking relationships;
•
manages treasury activities within agreed policies and procedures;
•
maintains accurate and timely accounting records of treasury activities.
The Trust’s Treasury procedures will become subject to periodic review by both the internal and
external auditors as part of their audit undertakings and any significant deviations from agreed
policies and procedures will be reported, where appropriate, to the Audit Committee or Trust
Board.
10. REVIEW OF POLICY
This policy once approved shall be reviewed annually with regard to working capital management
requirements for that financial year or within 3 months of authorisation as a Foundation Trust.
11. MONITORING
The Finance and Business Performance Committee and Trust Board will have overall oversight of
the management of cash and working capital, and will raise issues with the Director of Finance
and Deputy Chief Executive, who has overall responsibility in this area.
As the actions required under this Policy consist of normal operating procedures for the finance
team, performance of these actions will take place within the Trust’s performance management
framework.
12. CONTACTS
Should any staff member have any questions on the content of this policy then they should
contact the Trust’s Head of Financial Control on 01494 734786.
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Appendix A
OPERATIONAL PROCEDURES
The overall objective of the procedures set out below is to ensure that treasury activities are
undertaken in a controlled manner, thereby ensuring that the Trust is not exposed to undue
operational risks. In particular:
•
The trust minimises its reliance on external financing by maximising liquidity internally. This will
be achieved by minimising the amount of debt that it holds, together with managing inventories and
creditor payments.
•
cash flow forecasts will be prepared for the year ahead with detailed weekly forecasts being
prepared and reviewed by the Head of Financial Control.;
•
regular comparisons will be made between forecast and actual cash-flows;
•
segregation of duties is specified between those who initiate payments, those who authorise
payments and those who account for transactions;
•
all transactions will be recorded by the Treasury Management Team and will be supported by
an instruction/confirmation document;
•
all payment instructions/confirmations will require two authorised signatories, in accordance
with approved bank mandates;
•
mandates will be regularly reviewed and sent to all counterparties.
1.1 Working Capital Management
Receivables
The TDA target is for less than 5% of outstanding receivables to be over 90 days old. The Trust has
historically reported a percentage significantly in excess of this. In order to maximise cash inflows from
receivables and improve performance, the following actions are required:
•
Aged debt reports are produced every two weeks and meetings held between the Accounts
Receivable Manager, Head of Financial Control and Head of Contracts to agree actions to recover
debt, or escalate issues where necessary.
•
Outstanding debts are followed up using the approved Procedure, which includes referral to
outside agencies for recovery action where appropriate.
•
A list of the top 20 overdue debts, with current status, to be provided to the Deputy Director of
Finance on a monthly basis for review.
•
Reporting included ‘Deep dive’ reports which are produced monthly on the level of debt for
each division, percentage of overdue debt is reported to Finance and Business Performance
Committee and Board.
Payables
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The Trust is required to pay 95% of its undisputed invoices within 30 days of receipt. Historically it has
achieved approximately 90% compliance. Factors impacting on performance are:
•
Cash availability to make scheduled payment runs, which currently take place twice a week.
•
Internal processes, including the timely receipting of goods and services.
In order to improve performance, the following actions will be undertaken:
•
The Trust will identify requirements to utilise part of the Revolving Interim Working Capital
Facility, to ensure that cash is available to service its obligations on creditor payments.
•
Processes will be reviewed and strengthened internally.
Payments will take place twice a week, where cash allows, of all invoices up to the point of due date
being equal to the date that cleared funds would be available in their bank account (allowing for the 3
days BACS processing cycle). Where possible, payments will allow for early payment discounts to be
taken. The payment run will be authorised by the Head of Financial Control, or alternative senior
finance manag er, before the payment is processed to ensure that sufficient funds are available. As
stated above, the Trust is not allowed to go overdrawn on cleared balances at any time.
Where it becomes clear that insufficient cash is available to service the Trust’s obligations, the finance
team will prioritise payments to minimise any operational issues that may arise if the provision of
goods and services to the Trust are suspended for non-payment. In outline this prioritisation is likely to
resemble:
1st call – Payroll and associated statutory deductions e.g. tax and NI.
2nd call – Payments to the suppliers (NHS and non-NHS) of goods and services which will have an
impact on operational performance and where there has been a history of issues or where goods and
services are currently being deferred
3rd call – Payments to suppliers (NHS and non-NHS) where there are contractual obligations
regarding payment e.g. Bunzl, NHS Supply Chain, Bank Partners.
4th call – Payments to small suppliers (non-NHS), such as sole traders, where late payment may
cause cashflow issues.
Last call – all other payments.
Where short-term cashflow issues are identified, these will be reported immediately to the Deputy
Director of Finance.
Inventories
The Trust procures most of its ‘consumables’ through ‘Just in Time’ means through (currently)
contracts with Bunzl and NHS Supply Chain. These are managed through the Procurement
Department who will work with wards and departments with balancing the need of ensuring there are
sufficient supplies readily at hand with minimising the amount spent on Purchases.
Where other departments hold significant amount of stock, such as Pharmacy, Radiology, Cardiology
and Theatres, the Procurement team will work with them on minimising stock holdings and maximising
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cash. Any significant reductions in stock-holding will need to be advised to the finance team to ensure
that the impact on I&E is taken into account.
1.2 Cash-flow Forecasts
The Trust Board requires, as part of the standard reporting information, an annual forecast of cash
flow. This is used as part of the business planning cycle of the Trust, with a monthly 12 month rolling
cash flow forecast forming part of the Finance Board Report.
Responsibility for the preparation of these documents lies with the Head of Financial Control or
nominated deputy.
The Treasury Manager, will, each day, update the cash flow forecast with actual receipts, payments
and estimated cleared balances for the financial year. In the absence of the Treasury Manager, the
updates will be prepared by a nominated delegate.
In addition, the bank account reconciliation between the bank statement, cashbook and general ledger
will be undertaken by the Treasury Manager on a monthly basis and reviewed by the Financial
Accountant.
It is the responsibility of the Deputy Director of Finance and the Head of Financial Control to plan
effectively the use of liquid resources available to the Trust, giving due regard to the Treasury Policy of
the Trust at all times.
1.3 Confirmation/Payment Instructions
All confirmation/payment instructions will be signed by two authorised signatories and in accordance
with the limits under the bank mandate as approved by the Board.
1.4 Bank Mandates
The Trust has approved mandates as to authorised signatories and appropriate limits, and copies are
sent to all counterparties together with specimen signatures
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Agenda item: 13.4
27 January 2016
Revised Risk Management Strategy and Risk Management Policy
Title
Responsible
Director
Purpose of the
paper
Action / decision
required
To request that the Board ratifies the revised Risk Management Strategy and Risk
Management Policy
Approve
Patient Quality
Legal
Financial
Performance
Regulatory/
Compliance
Annual Objective
Operational
Performance
Public
Engagement
/Reputation
Strategy
FT Application
Equality &
Diversity
Partnership
Working
New or
elevated risk
Other
Risk management affects all the corporate objectives.
BAF/Corporate Risk No specific risk entry.
Register Reference
Risk Description
CQC Reg. Ref.
Assessing and monitoring quality of service provision
Author of Paper
Liz Hollman
Presenter of Paper
Liz Hollman
Audit Committee
Executive management Committee
Date of Paper
19 January 2016
161 of 208
RISK MANAGEMENT STRATEGY AND RISK MANAGEMENT POLICY REVISION
1.
PURPOSE
The purpose of the paper is to ask the Board to ratify the revised Risk Management Strategy and Risk
Management Policy. These documents are appended to the paper. Track changes has been used to
show the amended text.
2.
BACKGROUND
Each year the Risk Management Strategy and Risk Management Policy undergo a review to confirm
that they are fit for purpose. These are core documents underpinning governance processes across the
organisation, from Board to ward and from ward to Board.
The strategy sets out the organisation’s intentions in relation to risk management while the policy sets
out how this will be accomplished in practice.
The Board and sub-committees see the evidence of these documents in action at every meeting.
3.
KEY ELEMENTS
The documents have been written with the goal of making them accessible to the reader and to explain
a very complex process in a straightforward way. The Audit Committee reviewed these documents at
the meeting on the 7th January 2016 and supported the amendments.
The Equality Impact Assessment has been completed.
4.
RECOMMENDATION
Members of the Board are asked to approve the amendments to the Risk Management Strategy and
Risk Management Policy.
Liz Hollman
19 January 2016
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Once printed off, this is an uncontrolled document. Please check the intranet for the most up to
date copy
RISK MANAGEMENT STRATEGY
Version 6.0
.
BHT Strategy No:
S012
Version:
6
Issue:
10
Author:
Lead Executive
Director:
Elizabeth Hollman, Director for Governance
Anne EdenNeil Dardis, Chief Executive Officer
Consultation:
Trust Executive Management Committee
Audit Committee
Trust-wide Policy and Strategy Subgroup
Approved by:
Date Approved:
Review date:
EQIA:
Location:
Trust Board
December 2015January 2017
March 2009 Reviewed July 2011. Reviewed October 2014.
Swan Live Intranet/ Policies and Guidelines/ Policies and Strategies/
Corporate/Quality & Safety/ Healthcare Governance
Page 1 of 30
Risk Management Strategy v 6.10
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Document History
Risk Management Strategy- BHT S012
Version Issue
Reason for change
1
Author: Jill Henderson,
Clinical Governance
2
Author: Dorothea Reid, Associate
Director Governance & Elizabeth
Hollman, Patient Safety Manager
3
Author: Dorothea Reid, Associate
Director Governance & Elizabeth
Hollman, Patient Safety Manager
3
1
Author: Elizabeth Hollman, Patient
Safety Manager
Strategy updated to reflect
changes in the organisation
4
Author: Elizabeth Hollman,
Associate
Director Healthcare
Governance & Elizabeth
Palmer, Company Secretary
4
1
Amended compliance monitoring
and
merger with Community Health
Bucks in April 2010.
4
2
Minor amendments to Trust Name
&
Logo.
5
Author: Elizabeth Hollman,
Director Healthcare
Governance.
Formal review-June 2011
EIA review-July 2011
5
1
5
6
2
0
6
1
Date
06.04.04
Trust Board
26.05.05
Governance Committee
23.02.07
Accepted by Trust Board
March 2007
October
2007
Healthcare Governance
Committee
May 2009
Ratified : Trust Board
27.05.09
Approved
26.07.10
18.03.11
Risk Monitoring Group
22.06.11
12.07.11
Ratified: Trust Board
Trust Board
Version 5 updated to reflect
changes
agreed by the Audit Committee in
March 2012, and in the light of
feedback from the NHS Litigation
Authority. The changes constitute
amendments rather than entirely
Trust Board
Annual review of strategy
Full Review of Strategy undertaken Trust Board
Annual Review of Strategy
(informed by Trust Board Seminar
November 2015)
Page 2 of 30
164 of 208
Authorising body
Trust Board
05.10.11
May 2012
May 2013
October
2014
Trust Board
Formatted Table
BHT Ref Title
Location/Link
BHT Intranet/Trust Policies/ Corporate Policies, &
CHB Intranet/Policies, Guidance & Procedures
BHT Pol 079
Risk Management Policy
Swan Live Intranet/ Policies and Guidelines/
Policies
and Strategies/ Corporate/Quality & Safety
Page 3 of 30
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Contents
1.
EXECUTIVE SUMMARY
8
2.
INTRODUCTION
8
3.
OBJECTIVE AND SCOPE OF THE STRATEGY
10
4.
DEFINITION OF RISK AND RISK MANAGEMENT
10
5.
PRINCIPLES OF SUCCESSFUL RISK MANAGEMENT
10
6.
CORPORATE AND INDIVIDUAL ACCOUNTABILITY FOR MANAGING RISK
10
6.1.
The Trust Board
10
6.2.
Chair and Non Executive Directors
11
6.3.
Executive Directors
11
6.3.1.
11
6.3.2. Chief Operating Officer/Deputy Chief Executive
11
6.3.3.
The Medical Director
11
6.3.4.
The Chief Nurse
11
6.3.5.
The Director of Human Resources (HR) and Organisation Development
11
6.3.6.
The Director of Finance
12
6.3.7.
The Director of Strategy and Business Development
12
6.3.8.
12
6.3.9.
Associate Director Healthcare Governance
12
6.4.
7.
The Trust Chief Executive
Divisional Chairs
12
6.5. Trust Risk Advisers
12
6.6.
Trust Senior Managers
13
6.7.
All employees
13
6.8.
Care Quality Commission (CQC) Regulations and Outcomes management leads.
13
GOVERNANCE STRUCTURE
14
7.1.
Trust Board
14
7.2.
Executive Management Committee
14
7.3.
Audit Committee
15
7.4.
Quality Committee
16
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7.5.
16
7.6.
Nominations and Remuneration Committee
16
7.8.
Charitable Funds Committee
16
8.
RISK MANAGEMENT PROCESS
8.1.
16
The Approach
16
Diagram 1 Risk Communication Process for Board Assurance Framework
18
Diagram 2 Risk Communication Process for Corporate Risk Register
21
8.2.
Board Assurance Framework
23
8.3.
Corporate Risk Register
23
9.
RISK MANAGEMENT TRAINING AND INFORMATION
23
10.
STAKEHOLDER INVOLVEMENT
24
11.
PERFORMANCE FRAMEWORK AND MONITORING
24
11.1.
Risk Management Strategy
24
11.2.
Indicators
24
12.
APPROVAL AND REVIEW OF THE RISK MANAGEMENT STRATEGY
APPENDIX 1
GOVERNANCE STRUCTURE FLOWCHARTS
25
26
Trust Board and sub-committees
26
Quality Committee and sub-committees
27
Executive Committees
28
1.
EXECUTIVE SUMMARY
5
2.
INTRODUCTION
5
3.
6
4.
6
5.
6
6.
6
6.1.
The Trust Board
6
6.2.
Chairman and Non Executive Directors
7
6.3.
Executive Directors
7
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6.3.1.
8.
7
6.3.2. Chief Operating Officer/Deputy Chief Executive
7
6.3.3.
The Medical Director
7
6.3.4.
The Chief Nurse and Director of Patient Care Standards
7
6.3.5.
The Director of Human Resources (HR) and Organisation Development
7
6.3.6.
The Director of Finance
8
6.3.7.
The Director of Strategy and Business Development
8
6.3.8.
8
6.3.9.
Associate Director Healthcare Governance
8
6.4.
7.
The Trust Chief Executive
Divisional Chairs
8
6.5. Trust Risk Advisers
8
6.6.
9
6.7.
All employees
9
6.8.
9
9
7.1.
Trust Board
10
7.2.
Trust Management Committee
10
7.3.
Audit Committee
10
7.4.
Quality Committee
11
7.5.
11
7.6.
11
7.7.
11
8.1.
11
The Approach
11
12
13
9.
8.2.
14
8.3.
14
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14
10.
15
11.
15
11.1.
15
11.2.
Indicators
15
12.
APPENDIX 1
16
18
18
19
Executive Committees
20
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1.
EXECUTIVE SUMMARY
There are risks in everything the Trust does and each member of staff must learn how to identify risks
in their work environment and their practice, and how in order to reduce the impact of such risks on
patients, staff, visitors and themselves. The Trust Board has overall responsibility for ensuring that
everything possible is being done throughout the Trust to reduce risks as far as possible and to
deliver high quality, safe and effective patient care. The Risk Management Strategy describes the
Trust’s framework for achieving this.
Corporate and individual accountability for managing risk is set out in this strategy as follows:
•
•
•
The Trust Board’s role in reviewing the management of extreme risks
The Audit Committee’s role in monitoring the effectiveness of the system for managing risks
The Quality Committee and Finance and Business Performance Committees’s role in monitoring
the content of the Corporate Risk Register
The Trust Management CommitteeExecutive Management Committee role in moderating the risk
scores
The Trust Chief Executive’s role as the person with overall responsibility for managing risk.
The responsibilities of each executive director in relation to specific areas of risk in the Trust
The requirement for D i v i s i o n a l a n d Service Delivery Unit leads, senior nurses and senior
managers to carry out r i s k assessments, ensure that divisional staff are trained and
competent to do the jobs asked, and to maintain essential services in times of emergency.
The responsibility for all staff to take reasonable care for their own safety and the safety of all
others that may be affected by the Trust’s business.
The scope and range of advice the Board and Trust staff can call upon.
•
•
•
•
•
•
A separate document – the Risk Management Policy – describes the process of risk identification and
reduction which all staff are expected to follow.
2.
INTRODUCTION
Buckinghamshire Healthcare NHS Trust is exposed to a wide range of potential risks, including:
Clinical risks e.g. unavoidable and avoidable risks in treatment.
Health and safety risks e.g. accidents involving patients, staff or visitors.
Workforce and recruitment risks e.g. insufficient staff, or skill shortages.
Financial and business risks e.g. not achieving the corporate objectives.
Estate and environmental risks e.g. poor maintenance or faulty equipment
Information Governance risks e.g. breaches of confidentiality.
Risk assessment is implicit in every activity in the Trust, and the Trust Board must manage its risks in
such a way that people are not harmed and losses are minimised to the lowest acceptable levels.
The priority is to ensure that and clinical and organisational quality are maintained at all times.
Building the Assurance Framework: A Practical Guide for NHS Boards details the requirement for
Trust Boards to be confident that the systems, policies and people they have in place are operating in
a way that is:
Effective
Focused on key risks
Driving the delivery of the Trust’s objectives and meeting the national healthcare standards.
Page 8 of 20
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To meet the requirements of the Annual Governance Statement (AGS) Trust Boards are required to
have in place:
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Clear objectives, which provide the framework for all the Trust’s activity.
Structured risk identification systems covering all possible risks to the Trust.
Robust controls for the management of risk.
Appropriate monitoring and review mechanisms that provide information (assurance) to the Board
that the system of risk management across the Trust is effective.
3.
The objective of the Risk Management Strategy is to promote a consistent and integrated approach
across all parts of the organisation embracing clinical, organisational and financial risks. It aims to do
this through a robust governance structure, sound processes and systems of working, and an open
and fair, blame-free culture that is focused on patient and staff safety and high quality care.
The strategy applies to every employee of the Trust and contractors or other third parties working
within the Trust. Managers at all levels are expected to make risk management a fundamental part of
their approach to clinical and corporate governance.
4.
A risk is the chance of something happening that will have an adverse impact on the achievement of
the Trust’s objectives and the delivery of high quality patient care.
Risk management is the proactive identification, classification, communication and control of events
and activities to which the Trust is exposed.
5.
An open, objective and supportive culture encourages staff to report potential risk issues.
An acknowledgement that there are risks in all areas of the Trust’s work.
It is the role of the Trust Board, and in particular the Chief Executive, to lead and support risk
management.
It is the role of all managers at all levels to identify and reduce risks.
Staff working in the Trust are best placed to recognise the risks and should be actively
encouraged to be involved in reducing those risks.
Good communication aids reduction of risk.
There is always learning from mistakes.
6.
6.1.
The Trust Board
The Trust Board is responsible for setting the ‘risk appetite’ for the organisation. Risk appetite can
be defined as ‘the amount and type of risk that an organisation is willing to take in order to meet their
strategic objectives.’
The Trust Board is responsible for reviewing the effectiveness of its internal control systems through
its Board Assurance Framework (BAF). The Board is required to seek assurance that it is doing its
reasonable best to ensure the Trust meets its objectives and protects patients, staff, the public, and
other stakeholders against risks of all kinds.
The Board must sign a declaration of compliance with the Care Quality Commission Essential
Standards of Safety and Quality every year.
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The Annual Governance Statement (AGS) made by the Trust Chief Executive in the annual
accounts must demonstrate that the Trust Board has been informed through the Board Assurance
Framework about all risks, not just financial ones and has arrived at its conclusions on the totality of
risk based on all the evidence presented to it.
6.2.
Chairman and Non Executive Directors
The Trust Chairman and Non-Executive Directors responsibility for monitoring risk is effected through
attendance at Board and sub-committee meetings. In addition there is a non-executive director lead
for each of the following areas in the Trust:
•
•
•
•
•
•
6.3.
Whistleblowing
Security
Counter Fraud
Health and Safety
Organ and Tissue Donation Committee
Equality and Diversity
Executive Directors
6.3.1. The Trust Chief Executive
As Accountable Officer, the Chief Executive has overall responsibility for ensuring that governance
and risk management systems are adequate within the Trust to cover all its activities. The Chief
Executive is required to sign an Annual Governance Statement on behalf of the Board to provide
stakeholders with an assurance that the Trust has met its governance responsibilities.
6.3.2.Chief Operating Officer/Deputy Chief Executive
The Chief Operating Officer has overall responsibility for the delivery of all operational clinical
and clinical support services. S/he has specific responsibility for risks in the following areas:
Radiation Protection Advisor
24 hour access to emergency services
Major incident coordination
(Note: this list is not exhaustive).
6.3.3. The Medical Director
The Medical Director has joint lead responsibility for healthcare governance with the Chief Nurse and
Director of Patient Care StandardsChief Nurse. This includes lead responsibility for clinical performance
of the medical workforce, clinical audit, medical innovation, research governance, Caldicott Guardian
issues, Licence Holder for the Human Tissue Act and medical education.
6.3.4. The Chief Nurse and Director of Patient Care StandardsChief Nurse
The Chief Nurse and Director of Patient Care StandardsChief Nurse has joint lead responsibility for
healthcare governance with the Medical Director. This includes lead responsibility for Patient
Safety, Health & Safety, Risk Management, Claims & Litigation, Complaints and Safeguarding and
medicines management. The Chief Nurse also coordinates the Care Quality Commission
Registration and the maintenance of compliance with the regulations and outcomes that apply to the
Trust.
6.3.5. The Director of Human Resources (HR) and Organisation Development
The HR Director is the lead director for strategic risks related to employment law, organisational and
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personal development, and training.
The HR Director is the Board lead for Health and Safety.
The HR Director is the Board lead for Equality and Diversity.
6.3.6. The Director of Finance
The Director of Finance is the lead director for financial risks, risks related to procurement and risks
related to information governance. (This is in the office of Senior Information Risk Owner [SIRO]).
S/he is professionally accountable for financial practice and
development and the coordination of the internal audit function which provides the Trust with
independent assurance.
Formatted: Right: 0.19 cm, Space
Before: 0.1 pt, Line spacing: Exactly
12.7 pt, Tab stops: 6.75 cm, Left
Through line management of the Director of Property Services s/he has responsibility for providing a
safe and secure environment for patients, staff and visitors including environmental controls, fire,
security, food safety, hospital transport, decontamination, and cleanliness. This director is responsible
for risks to the delivery of the capital programme.
6.3.7. The Director of Strategy and Business Development
The Director of Strategy and Business Development is the lead director for risks to marketing,
equality legislation in respect of access to services, service modernisation and communications.
Through line management of the Director of Property Services s/he has responsibility for providing a
safe and secure environment for patients, staff and visitors including environmental controls, fire,
security, food safety, hospital transport, decontamination, and cleanliness. This director is responsible
for risks to the delivery of the capital programme.
6.3.8. Director for Governance
The Director for Governance is responsible for ensuring that there is a process in place for risk to
be identified in the organisation, escalated through the risk register and Board Assurance
Framework and top risks reported to the Board.
The Director for Governance is responsible for ensuring that the Directors on the Board, organisational
clinical leads and managers receive risk training on an annual basis.
6.3.9. Associate Director Healthcare Governance
The Associate Director Healthcare Governance is responsible for supporting the Director for
Governance in risk communication and risk management through his/her facilitative work with the
clinical divisions and corporate departments.
6.4.
Divisional Chairs
Divisional Chairs have specific responsibility for identifying significant clinical risks in the Trust
and taking action to manage and reduce them to an acceptable level. Risks assessed as
medium to– extreme and the actions being taken to reduce them should be recorded on divisional risk
registers.
They are supported in this by the Assistant Chief Operating Officer Divisional Directors and
Associate Divisional Chief Nurse for each Division. In addition the Head of Midwifery leads on risks
associated with maternity services.
In addition eEach Service Delivery Unit clinical lead is responsible for ensuring that risks are
identified and reported to the Division through the risk assessment and risk register process.
6.5.Trust Risk Advisers
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The Trust receives advice on a comprehensive range of risks from a number of advisers which
include (list not exhaustive):
•
•
•
•
•
•
•
•
•
•
•
The Director of Infection Prevention and Control, and the Control of Infection Team
The Head of Occupational Health
The Health and Safety Facilitator
The Fire Safety Advisers
The Radiation Protection Adviser
The Chief Pharmacist
The Child Protection Designated Nurse and Designated Doctor
The Human Tissue Act Designated Individuals
The Trust Security Adviser – Local Security Management Specialist
The Data Quality and Information Governance Manager
Emergency Planning Officer
Local Counter Fraud Service
6.6.
Trust senior managers must ensure that:
•
•
•
•
•
•
•
Patient and staff safety is given the highest priority.
Staff are working within their level of competence.
Staff are enabled to attend training appropriate to their role particularly mandatory training.
Sufficient staff are available in the Division to carry out formal risk assessments and to
determine adequate control measures within the working environment.
Formal risk assessments are incorporated into a Departmental or Divisional Risk Register that
informs the Trust Corporate Risk Register.
Fire and other emergencies are appropriately dealt with
There are contingency plans in each division to maintain an acceptable level of service
following any unplanned interruption of essential services.
6.7.
All employees
It is essential that if a member of staff considers that a serious concern which they have raised
through the line management route has not been resolved, they should report this to a more senior
level of management.
All staff must:
• Co-operate fully with departmental and Trust guidelines, protocols and policies in the interests
of health and safety and risk management.
• Report any incident, defect or other concern directly to their manager and complete an
incident reporting form promptly.
• Follow prescribed working practices and all information and training provided.
• Attend training as identified by their manager or by the Trust (e.g. induction and new
procedures, s t a t u t o r y a n d mandatory training: induction, fire safety, moving and
handling and personal safety).
• Participate actively in the process of risk assessment and risk escalation. Comply
with, and implement control plans that arise from assessments.
• Promptly report to their manager or local Risk Assessor, any changes that might affect
assessments / working conditions.
6.8.
Formatted: Bulleted + Level: 1 +
Aligned at: 0.83 cm + Indent at: 1.47
cm
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The Trust has designated leads for each of the Care Quality Commission’s regulations and
associated outcomes. The leads are responsible for coordinating the evidence for compliance in each
case and for identifying to the appropriate Executive Director where this is not available. The Trust
Management Committe eExecutive Management Committee (TMC) and Quality Committee
review compliance and ensure Board members are aware of any non-compliance and that there are
appropriate action plans in place.
7.
The Trust is committed to delivering excellent services for its patients. To ensure this is managed in a
fair and transparent way, the Trust has implemented a governance structure that ensures quality is
the responsibility of all staff and risks are minimised as much as possible. The Trust’s governance
structure which identifies all the Trust’s committees and their relationship to the Board is appended.
(Appendix 1) The purpose of each Board Committee and t h e Trust Management
CommitteeExecutive Management Committee in relation to this strategy is set out below:
7.1.
Trust Board
The Trust Board is responsible for reviewing the effectiveness of its internal control systems – clinical
and non-clinical. The Board is required to receive and analyse statements of assurance to
confirm that it is doing its reasonable best to ensure the Trust meets its objectives and protects
patients, staff, the public and other stakeholders against risks of all kinds. The Board reviews the
Board Assurance Framework at least three times a year. The Board discharges some of these
responsibilities through two of its sub- committees (the Audit, Finance and Business Performance and
Quality Committees. See below). It receives reports from them, through presentations by their
respective Chairs at Board meetings.
The Trust Board receives routine reports throughout the year which identify how risks are being
managed and quality maintained. Considerable importance is placed on the quality of the information
the Board receives. The Trust Executive directors have the ultimate responsibility for ensuring the
information that that Board receives is accurate, appropriate and comprehensive. Examples include
regular financial reports, complaints and incident reports, reports on performance, reviews of the
corporate risk register, updates on national guidance and minutes of all the Board Committees.
At the end of each Board meeting the Director for Governance identifies the risks which have arisen
through information presented to the Board and ensuring discussions and this is recorded in the
minutes. This summary is then used to check that the Board Assurance Framework and Corporate
Risk Register are accurately reflecting the emerging risks.
The Annual Governance Statement (published with the Annual Accounts) summarises the Board’’s s
review of its system of risk management.
7.2.
Trust Management CommitteeExecutive Management Committee
The Trust Management CommitteeExecutive Management Committee is the operational
management group that ensures that all management processes and systems are in place and are fit
for purpose. It is the committee with the responsibility for moderating the Board Assurance
Framework and the Corporate Risk Register to ensure consistency in the way risk is communicated
in the organisation.
All executive directors and Divisional chairs are members of this committee. The Chair Chief
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Executive Officer reports to the Board.
The Strategic Leadership Forum comprising Divisional leads and executive directors provides
information to the Executive Management Committee to support the moderation process.
7.3.
Audit Committee
The purpose of the Audit Committee is to
Review the establishment and maintenance of an effective system of integrated governance, risk
management and internal control across all the Trust’s activities
Ensure this system supports the achievement of the Trust’s objectives, through its
bimonthly scrutiny of the Board Assurance Framework and raise any specific concerns to the
Board as necessary..
The Audit Committee seeks assurance from internal and external auditors, including external bodies
that inspect the Trust.
The Audit Committee receives the minutes of the Quality Committee and the Finance
and Business Peformance Committee..
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7.4.
Quality Committee
The purpose of the Quality Committee is to oversee the oversee the quality of the care
provided by the trust by reviewing the delivery of the Quality Improvement Strategy and
other quality measures, including the Corporate Risk Register.
The Quality Committee reviews the quality related risks on the Corporate Risk Register at least
six times a year and escalates any concerns both to Audit Committee and Trust Board.
The Quality Committee reviews each of the five Divisional Risk Registers in full on an annual
basis. This works on a rolling programme where each Division presents its register annually.
7.5.
The purpose of the Finance and Business Performance Committee is to review assurance
from the executive team around financial, operational and workforce performance.
The Finance and Business Performance Committee reviews risks relating to finance,
operational delivery and workforce and escalates any concerns to Audit Committee and Trust
Board.
Each Division is invited on an annual basis to present to the Committee their risks and controls
relating to finance, operational delivery and workforce. This is both to provide assurance to
the Committee and to give an opportunity for the Committee to provide feedback on the
management and presentation of risk.
Corporate Risk Register and draw significant risks to the Board’s attention.
The Quality Committee reviews changes to the Corporate Risk Register bi-monthly and
receives a comprehensive corporate quality report and a quality report from each Division
on a bi-monthly basis.
7.6.
The purpose of the Nominations and Remuneration Committee is to ensure that senior
managers are fairly remunerated for their individual contribution to the organisation, with
consideration of affordability and public accountability.
7.7.
The purpose of the Finance and Business Performance Committee is to receive assurance
from the executive team around financial, operational and workforce performance. This
assurance is then passed on to the Trust Board.
7.8.
The purpose of the Charitable Funds Committee is the governance and management of the
Trust’s Charitable Funds on behalf of the Trust Board.
8.
The Approach
8.1.
Buckinghamshire Healthcare NHS Trust has a structured approach to risk management.
This process is described in detail in the Risk Management Policy and involves
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•
A pro-active approach to the identification and management of principal risks that
may threaten the achievement of strategic and divisional objectives.
•
A reactive approach to the identification and management of risks that may
threaten the achievement of the Trust’s risk management systems and processes.
•
Progress reports to the Board.
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Formatted: Normal
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8.2.
The Board Assurance Framework is the key document enabling the Board to understand the strategic
risks facing the organisation.
The risks identified from the Board Assurance Framework cover the full range of corporate objectives
and include consideration of present risks, future risks, risks arising from within the organisation and
risks occurring as a result of external pressures and changes.
The Board Assurance Framework is a live document updated by the Executive leads for each of the
corporate objectives at least quarterly and more often if appropriate. It provides the basis for both
the assurances and gaps in control reported in the Annual Governance Statement.
8.3.
The Trust’s Corporate Risk Register is at the centre of the risk management process and is a „living
document. It changes continually to reflect the dynamic nature of risk and the Trust’s management of
it.
The Corporate Risk Register captures top risks identified from Divisional risk registers and risk
registers associated with some corporate services such as Property Services. All risks scored at 15
or above showing on divisional and corporate service risk registers are considered by the Executive
Management Committee for inclusion on the Corporate Risk Register. In addition, risks which
emerge from within Divisions at a lower score but clearly having an organisation wide impact are
considered by the Executive Management Committee for inclusion on the Corporate Risk Register.
Extreme risks (risk score of 15 or above) are recorded on the Trust’s Corporate Risk Register.
Each division has its own risk register which captures in one place how divisional risks are being
managed. The Divisional Boards are accountable for the assessment, communication and
management of risks within their area of responsibility.
In addition there is a corporate service risk register incorporating risks from Finance, Information
Technology and Property Services, managed by the Executive Director responsible for these areas
of risk. Extreme risks (scored 15 or above) from these registers appear on the Corporate Risk
Register.
Any other risks within the portfolio of individual Executive Directors are communicated through the
Divisional Risk Registers where appropriate, and the Board Assurance Framework.
9.
Training and information are key elements in the development of a positive risk management culture.
They provide staff with the necessary awareness, knowledge and skills to work safely and to minimise
risks at all levels. The Trust’s Education Training and Development Strategy sets out a framework
that enables all staff to access education, training and development so that they achieve the level of
competence required to deliver service needs and provide safe and high quality patient care.
The Risk Management Strategy is made available to staff via the intranet, and risk management
training is available to all divisions through the training department and where request is made to the
Associate Director Healthcare Governance to provide such training.
General awareness-raising for staff is also undertaken through staff briefings, induction programmes
and various newsletters.
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10.
It is good practice to involve stakeholders, as appropriate, in all areas of the Trust’s activity, including
the Risk Management Strategy and any significant risks. The Trust must ensure that it has and
maintains a range of communication and consultation mechanisms with relevant stakeholders, both
internal and external.
It is the role of the Trust Board to ensure that the Trust is working in partnership with the following
stakeholders.
•
•
•
•
•
•
•
•
•
Patients and the general public
Members of staff and the Joint Management and Staff Committee
Healthwatch England
Buckinghamshire Health and Adult Social Care Select Committee
Buckinghamshire Safeguarding Children Board
Buckinghamshire Safeguarding Vulnerable Adults Board
Voluntary Organisations and public interest groups
Local Councillors, MPs and the Secretary of State
Neighbouring healthcare
organisations
• Trust Development Authority
• Clinical Commissioning Groups
• Local and national media
(this list is not exhaustive)
11.
11.1.
The Trust Board has overall responsibility for overseeing the implementation of this strategy, and of
taking actions associated with risk management.
The Audit Committee has responsibility for monitoring the risk management system, and providing
appropriate verification to the Chief Executive and the Trust Board. The Trust is required to develop
an Annual Governance Statement that confirms that action has been taken to manage risk, and to
publish this statement in its annual report. The work of internal audit provides assurance to the Audit
Committee of compliance with the risk strategy.
The Quality Committee monitors the risks emerging through the corporate risk register in the
context of quality assurance. The Chair of the Quality Committee highlights any concerns about
particular risks to the Audit Committee and Trust Board.
11.2.
Indicators
Success with managing risk will be assessed by using the following standards as benchmarks,
combining internal self assessment against external assessment where appropriate to do so.
12.2.1. An annual internal audit of the Board Assurance Framework to provide either green or
amber green level of assurance.
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12.2.2. A review of governance processes including risk to be included in the rolling Internal
Audit programme
12.2.3 Annual review of the Annual Governance Statement by the Trust’s external auditors to
confirm that it accurately reflects the risk position of the organisation.
12.
The Risk Management Strategy has been developed in the light of currently available information,
guidance and legislation that may be subject to review.
Any revisions to the Strategy will be considered at the Audit Committee and require the approval of
the Trust Board.
The Chief Nurse and Director of Patient Care StandardsDirector for Governance will ensure that the
strategy is communicated to Trust staff.
References
Building the Assurance Framework: A Practical Guide for NHS Boards (DOH March 2003)
Assurance – The Board Agenda (DOH July 2002) Building the Assurance Framework: A Practical
Guide for NHS Boards (DOH March 2003)
Health and Social Care Standards and Planning Framework 2005/06-2007/08 (DOH July 2004).
Linked Policy: Risk Management Policy- BHT Pol 079
Linked Policy: Being Open Policy BHT Pol 007
Linked Strategy: Maternity Risk Management Strategy
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APPENDIX 1
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Executive Management Committees
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Once printed off, this is an uncontrolled document. Please check the intranet for the most up to date
copy.
RISK MANAGEMENT POLICY
Version 5.1
Version:
Issue:
5
1
Comprehensive review of version of 4.2 to update to V5.0
Consultation:
Executive Management Committee; Audit Committee
Date:
Approval by:
Trust Board
Date approved:
Author:
Elizabeth Hollman, Director for Governance
Lead Director:
Neil Dardis, Chief Executive Officer
Name of responsible
committee/individual:
Trust Board
Document reference:
BHT Pol 079
Date issued:
Review date:
January 2017
Target audience:
All Trust staff
Equality Impact
Assessment
Consistency Panel approved 24/03/09
Review July 11
Review October 2014
Location:
BHT Intranet Trust Policies/Corporate Policies CHB
folder of the PCT Intranet/Policies
Swan Live Intranet/ Policies and Guidelines/Policies and
Strategies/ Corporate/Quality & Safety
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Document History
Risk Management Policy- BHT Pol 079
Version
1
Issue
Reason for change
Author: John Hilton
New Policy
Authors: Elizabeth Hollman, Patient
Safety Manager, Dorothea Reid,
Associate Director of Governance,
Mary Klaus & Sarah Langan-Hart
Authorising body
Date
1
Amendment to Version 2 to update the
policy to reflect the changes in the
organisation.
October
2007
2
2
3
Authors:
Elizabeth
Hollman, Executive Management
Associate
Director
Healthcare
Governance, Mary Klaus & Sarah Healthcare Governance
Langan-Hart
Committee
17.04.09
12.05.09
3
1
Authors: Elizabeth Hollman,
Associate Director Healthcare
Governance & Catherine Brown,
Board Assurance Facilitator
Re-issued
30.07.10
3
2
Minor amendments to Trust name and
Logo. Board Assurance Administrator
Full review. Elizabeth Hollman,
Associate Director Healthcare
Governance & Catherine Brown,
Board Assurance Facilitator
Re-issued
18.03.11
26.06.11
Committee
Trust Board
12.07.11
Issued
24.05.11
Trust Board
30.05.12
Audit Committee
Committee
Trust Board
Trust Board
16.05.13
17.03.13
07.05.13
4
4
1
4
2
Version 4 updated to reflect changes
agreed by the Audit Committee in
March 2012, and in the light of
feedback from the NHS Litigation
Authority. These changes constitute
amendments to these versions rather
than entirely new versions.
Formal Review
5
0
Full Review
5
1
Update to reflect organisational
changes
05.10.11
29.05.13
November
2014
Trust Board
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BHT Ref
BHT S012
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Title
Location/Link
BHT Intranet/Trust Policies/ Corporate Policies, &
CHB Intranet/Policies, Guidance & Procedures
Swan Live Intranet/ Policies and Guidelines/
Policies and Strategies/ Corporate/Quality &
Safety
Contents
INTRODUCTION
6
Definitions
7
SECTION ONE: OPERATIONAL RISK MANAGEMENT
9
THE CORPORATE RISK REGISTER
9
1.
9
Identification and Control of Operational Risks
1.1.
Identifying Potential Risks
9
1.2.
Risk Assessment and Evaluation
9
1.3.
Reducing the Risk
Table 1: Timescales for action
2.
Recording Risks on a Risk Register
Diagram 1: Hierarchy of risk registers
10
10
10
11
2.1.
Service Delivery Unit Risk Registers
11
2.2.
Divisional Risk Registers
11
2.3.
Corporate Service Risk Registers
12
2.4.
12
SECTION TWO: STRATEGIC RISK MANAGEMENT
13
THE BOARD ASSURANCE FRAMEWORK
13
3.
13
Identification and Control of Strategic Risks
3.1.
Assessing Strategic Risk
13
3.2.
Moderating the Board Assurance Framework
13
3.3.
Communicating Strategic Risk
13
TRAINING
14
4.
14
Levels of risk training available to staff
4.1.
Training for Board members
14
4.2.
Training for Senior Managers
14
4.3.
Training for Risk Assessors
14
4.4.
Training for All Staff
14
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MONITORING THIS POLICY
15
APPENDICES
15
APPENDIX A: RISK ASSESSMENT TOOL
15
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INTRODUCTION
The Trust is required (by statute and Department of Health guidance) to systematically
identify and control all significant strategic and operational risks. These arise across the
organisation and include clinical services and corporate services. The Board is required to
ensure that robust systems exist and be assured that there are systems in place to control
and reduce risk.
This involves both the proactive identification and management of principal risk that may
threaten the achievement of Trust objectives and the response to adverse events or learning
from audits.
The purpose of the Risk Management Policy is to set out the process for achieving the Risk
Management Strategy. The Risk Management Strategy sets out the overall plan and
direction for Risk Management in the Trust.
This policy describes the mechanisms and responsibilities for:
•
Identifying risk
•
Assessing and evaluating risk in a consistent manner using the Trust’s Risk
Assessment Tool (RAT)
•
Controlling risk
•
Recording risk within the Trust’s risk documents – namely the Board Assurance
Framework, Corporate Risk Register and Divisional Risk Registers.
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Definitions
Acceptable /
Tolerable Risk
Tolerability is a willingness to live with risk to secure certain benefits but
with the confidence that it is being properly controlled. To tolerate risk
does not mean to disregard it, but rather that it is reviewed with the aim of
reducing further risk. This may also be referred to as ‘risk appetite’.
It is a fundamental principle that no person should be exposed to serious
risk unless they agree to accept the risk.
It is reasonable to accept a risk that under normal circumstances would
be unacceptable if the risk of all other alternatives, including doing
nothing, is even greater.
Adverse Event
Any event or circumstance leading to unintentional harm or suffering.
Co-employer
Another employing organisation which has links with the Trust (e.g.
Sodexo, Medirest, Clinical Commissioning Groups, South Central
Ambulance Foundation Trust, Oxford Health NHS Foundation Trust etc.)
Control
A procedure or arrangement that is implemented to prevent a risk, reduce
the potential impact of such a risk, or detect a failure of internal or
external control when it happens.
External
Refers to activities or documents which do not originate in the Trust
Internal
Refers to activities or documents within the Trust.
Patient Safety
Incident
Any unintended or unexpected incident which could have harmed or did
lead to harm for one or more patients receiving healthcare. It is a specific
type of adverse event.
Residual Risk
The lowest possible level of risk remaining after reasonable control
measures / actions have been implemented.
Risk
A risk is the chance of something happening that will have an adverse
impact on the achievement of the Trust’s objectives and the delivery of
high quality patient care. It comprises a combination of adverse
consequence and likelihood.
Risk
Assessment
Identification of significant hazards which arise out of Trust activities and
a judgement of the likelihood and severity of harm which might occur as a
result of exposure to the hazard.
Risk
Assessment
Training
Training delivered either by the Healthcare Governance Team or by the
Director for Governance.
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Risk Assessor
Member of staff (manager or other) who has received risk assessment
training.
Risk
Management
Risk Management is the proactive identification, classification,
communication and control of risks to which the Trust is exposed through
its day to day activities and through pressures from external sources.
Risk
Moderation
This is a mechanism whereby a designated group reviews risks recorded
on a risk register and takes a view as to whether the risk has been scored
at the right level and scored consistently when compared with other risks.
The group can make the decision to adjust the risk score on the basis of
the review.
Senior
Manager
Someone who plays a significant role in making decisions regarding the
management of the whole or a significant part of the organisation’s
activities and those who carry out those activities. This includes, but is
not limited to, all managers who report to a Director.
Trust
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SECTION ONE: OPERATIONAL RISK MANAGEMENT
THE CORPORATE RISK REGISTER
1.
Identification and Control of Operational Risks
1.1.
Identifying Potential Risks
Potential risks can be identified from a variety of sources for example:
•
Internally generated information such as departmental meetings, internal audits,
external audits, clinical audits, incidents reports, complaints, claims
•
Externally generated information such as guidance from the Department of Health,
the Care Quality Commission, the Health and Safety Executive and the Royal
Colleges
•
External inspections
Senior Managers should note that they have a duty within their areas of responsibility to:
•
Identify risk
•
Assess risk
•
Establish risk management processes
•
Allocate appropriate staff and resources to manage risk
•
Control risks where possible and escalate to Executive Management Committee
where risks are not controlled
•
Maintain a risk register ensuring that it reflects a full range of risks and is up-to-date
•
Communicate risks to staff
1.2.
Risk Assessment and Evaluation
Risks must be assessed and graded using a common matrix (the National Patient Safety
Agency [NPSA] risk matrix shown in Appendix A). Grading shall take into account all
existing controls (e.g. fire alarm detection, maintenance, contracts, protocols, training etc)
and the effectiveness of these controls (e.g. how up-to-date the training is, when the last fire
drill took place).
Grading requires skill and relevant knowledge, and involves the following process:
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i)
Determine the potential adverse consequence (also known as severity or impact) as
objectively as possible and identify the most appropriate consequence score
ii) Determine the likelihood of this adverse consequence taking place, as objectively as
possible, and identify the most appropriate likelihood score
iii) Multiply the consequence score by the likelihood score to give the risk score.
Risk Assessments are carried out in two parts using the Risk Assessment Tool. Part 1 can
be completed by any member of staff with the support of someone who has received risk
assessment training. Part 2 of the assessment will be undertaken by a Senior Manager or
an Executive Director who will verify Part 1, make a decision as to whether the risk should
be included on a risk register, and where necessary produce an action plan to address the
risk.
Where a risk has been confirmed by a senior manager as ‘Extreme’ with a score of 15 or
above this should be immediately brought to the attention of the appropriate Executive
Director at the time of recording the risk on the risk register.
The Trust’s Risk Assessment Tool is shown in Appendix A.
Copies of the completed RAT’s should be held by the senior manager responsible for the
area where from which the risk has emerged.
1.3.
Reducing the Risk
The purpose of identifying and assessing risk is to ensure that measures are put in place to
reduce the risk to the residual risk level.
Table indicating level of risks and acceptable timescales for commencing action:
Table 1: Timescales for action
Level of Risk
Target time for Initiating Controls
Extreme (15-25)
Immediately or within 48 hours
High (8-12)
Up to two weeks
Moderate (4-6)
Up to 6 weeks
Low Risk (1-3)
Up to 12 weeks
2.
Recording Risks on a Risk Register
Following identification, assessment and initial control of a risk, the risk and its related action
plan will be included within the relevant risk register. To minimise administration ‘low’ risks
do not need to be included in the register. There is a hierarchy of risk registers used in the
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organisation as shown on the diagram below. More detail about the management of these
registers is shown in the following sections.
Diagram 1: Hierarchy of risk registers
2.1.
Service Delivery Unit Risk Registers
Risks identified at Service Delivery Unit (SDU) or ward level should be recorded by a Senior
Manager on a Service Delivery Unit Risk Register. There is a standardised format for this
register. Review of the SDU Risk Register should take place at the SDU clinical governance
meeting and therefore is included on the standardised agenda template for these meetings.
The SDU lead is accountable for ensuring that there is a process within the SDU for
identifying and managing risk.
2.2.
Divisional Risk Registers
The Divisional Chair, Divisional Directors and Divisional Chief Nurses should have sight of
the SDU risk registers and ensure that risks scored at 12 or above are recorded on the
Divisional Risk Register. Other risks may also be recorded if the Divisional Board deems
this to be appropriate. The Divisional leads may delegate the function of managing the risk
registers to the Divisional Governance Lead but remain accountable for ensuring that risks
are being identified and managed across the Division.
Divisional Risk Registers should be moderated at Divisional Board meetings. The work
associated with this may be carried out in Divisional Quality Meetings but the Divisional
Board should be aware of the range and scale of risks in the Division.
Page 11 of 26
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The Divisional Risk Registers will be included in the Divisional Performance Reviews as one
mechanism to ensure the quality of the document.
Divisional Risk Registers are accessible to all senior managers, clinical governance leads,
lead clinicians and matrons on the shared drive entitled ‘directorate risk registers’. Access
and administration of this drive is managed by the Director for Governance.
Each Division will present their Divisional Risk Register to the Quality Committee on an
annual basis as part of a rolling programme.
Each Division will present risks relating to finance, operational delivery and workforce to the
Finance and Business Performance Committee on an annual basis as part of a rolling
programme.
2.3.
Corporate Service Risk Registers
Each Executive Director is accountable for assessing and managing risk associated with
their corporate service. By nature of their business many of these risks will be strategic and
this is covered in Part 2 of the risk policy. However some corporate services have very
specific operational risks such as Finance, Property Services and Information Technology.
These risks shall be recorded on the Corporate Service Risk Register.
2.4.
The Director for Governance will on a monthly basis identify all risks scored at 15 or above
on the Divisional and Corporate Service risk registers and will bring these to the attention of
the Executive Management Committee for consideration as to whether the risk should be
included on the Corporate Risk Registers. Other risks not at the extreme level but having a
wider organisational impact will also be considered by the Executive Management
Committee.
The Corporate Risk Register will be moderated on a monthly basis by the Executive
Management Committee (EMC). The EMC will consider information and advice coming from
the Strategic Leadership Forum in their risk discussions.
The moderated version of the Corporate Risk Register (CRR) will be submitted to the Quality
Committee and the Audit Committee on a bi-monthly basis.
Top risks from the Corporate Risk Register will also be reported to the Trust Board at least
four times a year.
In some cases it is clear that an operational risk showing on the CRR has significant
implications for the delivery of a Trust Objective. In these cases consideration will be given
by EMC as to whether a related strategic risk should be recorded on the Board Assurance
Framework.
Page 12 of 26
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SECTION TWO: STRATEGIC RISK MANAGEMENT
THE BOARD ASSURANCE FRAMEWORK
3.
Identification and Control of Strategic Risks
3.1.
Assessing Strategic Risk
The Board agrees a set of Corporate Objectives on an annual basis as the means by which
the overall Vision and Strategy of the organisation will be achieved. Each of these
Corporate Objectives is allocated an Executive Director lead.
Working with the Director for Governance each Executive Director will identify the controls in
place to ensure delivery of their Corporate Objectives and the sources of assurance that
these controls are working effectively. This information should be recorded on the Board
Assurance Framework for each Corporate Objective.
In consideration of the relevant controls and assurances the Executive Director will then
determine the risk to delivery of the Corporate Objectives for which they are the lead and this
shall be recorded on the Board Assurance Framework.
3.2.
Moderating the Board Assurance Framework
The Board Assurance Framework will be moderated by the Executive Management
Committee at least 4 times a year.
3.3.
Communicating Strategic Risk
The Board Assurance Framework (BAF) will be submitted to the Audit Committee at least
four times a year for consideration. As part of the review process individual Executive
Directors will be invited to the Audit Committee to present a ‘deep dive’ on the assurances
recorded against individual Corporate Objectives.
The Trust Board will receive the Board Assurance Framework at least four times a year.
Page 13 of 26
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TRAINING
4.
Levels of risk training available to staff
4.1.
Training for Board members
Risk training for Board members will be provided through the Board Development
Programme at least annually and will be reinforced through risk discussions at Board and
sub-committees.
Where individual members of the Board have not attended risk training within a 12 month
period the Director for Governance will liaise with the individual Board member to provide
training.
The Director for Governance is available to provide training on an individual basis to any
member of the Board on request.
4.2.
Training for Senior Managers
Training for senior managers will be provided by the Director for Governance at the request
of any of the Divisional leads or the Governance Co-ordinator. This training will focus on risk
assessment and communication. At least two senior managers from each Division are
expected to attend risk training each year.
The Director for Governance will monitor compliance with this and in the case of non
compliance with attendance at training the Director for Governance will escalate this to the
Chief Operating Officer to deal with through the performance monitoring route.
4.3.
Training for Risk Assessors
Risk assessors will be trained through the Risk Assessor Training Course run by the
Healthcare Safety Team with the support of the training department.
Divisional leads will be asked to confirm on an annual basis to the Director for Governance
that they have sufficient numbers of trained risk assessors to identify, assess and report
risks.
In the case of non compliance with attendance at training the Director for Governance will
escalate this to the Chief Operating Officer to deal with through the performance monitoring
route.
4.4.
Training for All Staff
All staff will receive risk related training as part of induction and annual statutory training.
This will be monitored through annual appraisal.
Page 14 of 26
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MONITORING THIS POLICY
The Director for Governance will meet with at least one of the Divisional leads for each
Division at least twice a year to go through the relevant Divisional Risk Register to provide
feedback and to reinforce risk messages. The Director for Governance will keep a schedule
to confirm that these meetings have taken place.
The Board Assurance Framework will be the subject of an Internal Audit on an annual basis.
A register of the trained and up-to-date risk assessors will be maintained by the Healthcare
Safety Team.
The induction and statutory training records for all staff will be collected by the Education,
Training and Development team and reported through the workforce report.
This policy will be reviewed every year.
APPENDICES
Available on request
Page 15 of 26
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Agenda Item: 14.1
25 NOVEMBER 2015
Title
Responsible
Director
Purpose of the
paper
Action / decision
required (e.g.,
approve, support,
endorse)
Private Board Summary 25 November 2015
Trust Chair
The purpose of this report is to provide a summary of matters discussed at the Board in
private on the 25 November 2015. The matters considered at this session of the Board
were as follows:
• Serious Incident Report
• Whistleblowing
• Strategic Objectives
• TDA Board Observations
• Finance
• Ratification of a Pharmacy Business Case
The Board is asked to note the contents of this report.
Patient
Quality
Legal
Strategy
FT Application
Operational
Performance
Partnership
Public
Equality &
Working
Engagement
Diversity
/Reputation
Annual Objective
Relates to all objectives
BAF/Corporate Risk n/a
Register Reference
Risk Description
CQC Reg. Ref.
Relates to Outcome 4, Care and Welfare of Persons using our service
Author of Paper
Financial
Performance
Regulatory/
Compliance
New or
elevated risk
Other
Presenter of Paper
No other committees
Date of Paper
18 January 2015
203 of 208
Agenda Item: 14.2
27 JANUARY 2016
Board Attendance Record
Title
Responsible
Director
To keep the Board informed of the attendance of Board members at Board meetings and
sub-committees.
Purpose of the
paper
The Board is asked to agree the following mechanism for changes of meeting dates which
will form part of the Standing Orders when they are next revised:
Action / decision
required
‘Every effort should be made to avoid changing dates of Board meetings and subcommittees once these are set for the year. However, in the event that a change is
unavoidable any new date must be agreed by the chair of that meeting with consideration
of quoracy and after making every effort to ensure that as many members of the Board or
Committee can attend as possible.’
Patient Quality
Legal
Financial
Performance
Regulatory/
Compliance
Annual Objective
Operational
Performance
Public
Engagement
/Reputation
Strategy
FT Application
Equality &
Diversity
Partnership
Working
New or
elevated risk
Other
This affects all the annual objectives
BAF/Corporate Risk Not applicable
Register Reference
Risk Description
CQC Reg. Ref.
Well led Domain
Author of Paper
Liz Hollman
Presenter of Paper
Liz Hollman
None
Date of Paper
18 January 2016
205 of 208
Board Attendance Record: August 2015 to January 2016
Finance and Business
Quality Committee
Trust Board Seminars
Audit Committee
11Aug
28Sep
22Oct
19Nov
17Dec
15Sep
03Nov
12Jan
12Aug
26Aug
09Sep
28Oct
11Nov
09Dec
13Jan
Hattie
LlewelynDavies,
Trust Chair *






x


x


x

Neil Dardis,
Chief
Executive *









x

x
x




x

x
x









x
Dipti Amin,
NED
Ian
Anderson,
Director of
Human
Resources



Les Broude,
NED *
Rachel
Devonshire,
Ass. NED
x



x
David
GarmonJones, NED
designate
x







Rajiv Jaitly,
NED *
206 of 208



17Sep
30Sep
25Nov











x


x







x


x







x






x

x











x



12Nov

07Jan
Trust
Board

Finance and Business
11Aug
Graeme
Johnston,
NED *
28Sep
22Oct
19Nov
Quality Committee
17Dec

Tina Kenny,
Medical
Director *
Trust Board Seminars
Audit Committee
Trust
Board
15Sep
03Nov
12Jan
12Aug
26Aug
09Sep
28Oct
11Nov
09Dec
13Jan
17Sep
12Nov
07Jan
30Sep
25Nov




x

x




















Mary
Lovegrove,
NED *
x
x
x
x


x
x

x


x

x

x
Neil
Macdonald,
Chief
Operating
Officer
(interim) *

x





x


x



x


x





x


x





Carolyn
Morrice,
chief Nurse
*
Director of
Finance *
Dominic
Tkaczyk as
of Jan 16

David Sines,
Associate
NED
David
Williams,
Director of
Strategy
x
x



x

x





x


x
x



x





NB: greyed out fields indicate committees the individual would not be expected to attend. NED = Non-Executive Director. A * indicates a voting member of the Board
207 of 208

Public Board Papers Buckinghamshire Healthcare NHS Trust 27

Transcription

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