Public Board of Directors 1 May 2019 · Board with a detailed overview of her families experience of poor patient care from attending A&E and then across Wards 19 and 23. There were

Public Board of Directors

1 May 2019

MEETING OF THE BOARD OF DIRECTORS ON WEDNESDAY 1 MAY 2019

COMMENCING AT 9AM IN THE BOARD ROOM

EDUCATION CENTRE, ARROWE PARK HOSPITAL

AGENDA

1 Apologies for Absence Chair

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2

Declarations of Interest Chair

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Chair’s Business Chair

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4 Key Strategic Issues

Chair v

5 Board of Directors

5.1 Minutes of the Previous Meeting – 3 April 2019 5.1.2 Board Action Log Board Secretary

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Page 1

Page 13

6 Chief Executive’s Report

Chief Executive d Page 14

7. Quality and Safety 7.1 7.2

Patient Story Head of Patient Experience Quality Strategy Director of Quality & Governance

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Page 17

8. Performance & Improvement 8.1

Integrated Performance Report 8.1.1 Quality and Performance Dashboard and Exception Reports Chief Operating Officer, Medical Director, Chief Nurse, Director of Workforce, Director of Governance & Quality 8.1.2 Month 12 Finance Report Acting Director of Finance

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9. Workforce

9.1

Review of Freedom to Speak Up Guardian Report Director of Workforce

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Review of Healthcare Flu Vaccination Programme and Lessons Learnt Director of Workforce

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10. Governance

10.1

10.2

10.3

10.4

10.5

Report of Trust Management Board Chief Executive Report of Audit Committee Chair of Audit Committee Report of Programme Board External Programme Assurance / Delivery Director CQC Action Plan Progress Update Director of Quality & Governance Review of Board Assurance Framework

Director of Quality & Governance

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Page 102

11. Standing Items

11.1 Any Other Business Chair

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11.2 Date and Time of Next Meeting

Wednesday 5 June 2019 v

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BOARD OF DIRECTORS UNAPPROVED MINUTES OF PUBLIC MEETING 3rd APRIL 2019 BOARDROOM EDUCATION CENTRE ARROWE PARK HOSPITAL

Reference Minute Action

BM 19-20/001

Apologies for Absence Noted as above.

BM 19-20/002

Declarations of Interest There were no Declarations of Interest.

BM 19-20/003

Chair’s Business The Chair welcomed all those present to the monthly Board of Directors meeting. In opening the meeting, the Chair informed the Board of Directors that following recent discussions culminating in a very positive Board to Board meeting with the CCG. The positive step change in views from all parties will

Present Sir David Henshaw Chair Janelle Holmes Chief Executive Jayne Coulson Non-Executive Director Dr Nicola Stevenson Medical Director Sue Lorimer Non-Executive Director Anthony Middleton Chief Operating Officer John Sullivan Non-Executive Director Gaynor Westray Chief Nurse Helen Marks Director of Workforce Chris Clarkson Non-Executive Director Karen Edge Acting Director of Finance Paul Moore Director of Quality and Governance (Non voting) Mr Mike Ellard Associate Medical Director, Women & Childrens Dr Ranjeev Mehra Associate Medical Director, Surgery In attendance Andrea Leather Board Secretary [Minutes] Mike Baker Communications & Marketing Officer John Fry Public Governor Steve Evans Public Governor Ann Taylor Staff Governor Jane Kearley* Member of the Public Matthew Burch Member of the Public Joe Gibson* Project Transformation Sally Robers* Member of the Public / Patient Story Marsha Parton-Murphy* Patient Experience Team Apologies John Coakley Non-Executive Director Steve Igoe Non-Executive Director Paul Charnley Director of IT and Information Dr Simon Lea Associate Medical Director, Diagnostics & Clinical Support

Dr King Sun Leong Associate Medical Director, Medical & Acute *Denotes attendance for part of the meeting

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enable the Trust to build on and work through the changes required across the local health economy and therefore provide better outcomes for patients.

BM 19-20/004

Key Strategic Issues Board members apprised the Board of key strategic issues and matters worthy of note. Chief Nurse – informed the Board that the ‘Patient Information Bank’ has been rebranded to ‘Patient Experience Hub’ following feedback from patients and carers. NHS Improvement has recently established a Matrons network with the first engagement event being held today and 2 matrons are representing the Trust. The Chief Nurse congratulated Radio Clatterbridge who won ‘best promotion’ at Hospital Broadcasting Association's annual conference for its special day commemorating the life and legacy of the Liverpool comic Ken Dodd who was patron of the charity with the judges deciding the CGH radio ‘Doddy Day’ trailer was the best of the year. In support and celebration of national Autism awareness day the Trust is hosting a Learning Disability and Autism awareness session on Tuesday 9th April, Board members are invited to attend. The Chief Nurse apprised the Board of a number of forthcoming charity events including an abseil of the hospital that the Chief Executive, Medical Director and herself are undertaking, suggestions for fancy dress were sought from the Board. Director of Quality & Governance – apprised the Board that following the recent unannounced CQC inspection the formal draft report has been received for review and factual accuracy. Associate Medical Director, Surgery – Dr Mehra apprised the Board of the impact of winter pressures from a divisional perspective for 2018/19 and the development programme on the Clatterbridge site to maximise use and support winter pressures in future years. Director of Workforce – Mrs Marks advised the Board that two reviews have been commissioned, one in the HR business service and the other in medical staffing process and systems. In turn these reviews will strengthen vacancy and non contractual pay control processes including agency medical spend. The reviews will explore alternatives such as job plans for medics and specialist nurses so the Trust has a clearer picture of spend against activity and highlight any gaps. Associate Medical Director, Women & Children’s– Mr Ellard apprised the Board that two consultants have been appointed to national posts and work was underway to support the cancer two week waits within the breast specialty. Mrs Sue Lorimer – Non-Executive Director – informed the Board that she had recently attended the Wirral Audit Chairs meeting to discuss ‘Thinking

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differently about independent assurance in a system setting’. In conclusion it was agreed to hold another meeting later in the year to discuss a shared understanding and approach to assurance framework including risks regarding the Healthy Wirral Programme. Chief Operating Officer – Mr Middleton advised that a review of Soft FM services is underway and will consider the benefits of alternative models such as collaborative working. Following the recent tender process for the additional car parking facility, the unsuccessful bidder has raised a challenge and the Trust has sought legal advice regarding the matter. Medical Director – advised the Board of the retirement of Dr Mark Lipton, Deputy Medical Director at the end of March 2019. Recruitment for his replacement is underway. The Board thanked Dr Lipton for keeping the ship steady in period of instability. The rapid improvement project to improve patient flow has reset the model in relation to patient assessment, referrals to specialist wards and discharges earlier in the day. This also has positive impact on reduced length of stay, corridor care and ambulance waits. The project is to be extended to enable the processes to be embedded and will enable a review of the metrics to provide Board assurance. Acting Director of Finance – informed the Board that the procurement team was leading support regarding national policy in relation to new procurement models and security of supply following Brexit. The Board noted that although some members did not have detailed updates there were themes across a number of reports such as leadership, accountability and possible skills gap of middle managers.

BM 19-20/005

Board of Directors Minutes The Minutes of the Board of Directors Meeting held 6th March 2019 were approved as an accurate record. Action Log In agreeing the Board Action Log, Board members also gave assurance that actions would be reviewed, addressed and actioned as required.

BM 19-20/006

Chief Executives’ Report The Chief Executive apprised the Board of the key headlines contained within the written report including:

• Millennium Upgrade

• EU Brexit Planning

• Leadership structure of NHS England and NHS Improvement

• Local elections – Purdah

• NHS Improvement – new provider directory.

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CQC unannounced inspection – recently took place in AMU and A&E. The formal draft report has been received for review and factual accuracy. The final report, the Trust’s response and appropriate actions will be formally reported to Board once completed. Wirral A&E Delivery Board – at the last meeting it was agreed that Wirral A&E Delivery Board would lead the Health Economy Urgent Care Improvement Work. It was suggested that the A&E Delivery Board change its name and report of progress, around the Transformation programme, to Healthy Wirral Partners Board. In recognising that the transformation programme requires support from all Health Economy Partners, the proposal for the Director of Commissioning and Transformation, as deputy Chair, was seen as advantageous in driving activity and performance. The Board noted the information provided in the March Chief Executive’s Report.

BM 19-20/007

Patient Story The Board was joined by Mrs Sally Rodgers, daughter of Mrs Kay Gibbings who had been a patient. Sally stressed that this experience was not a formal complaint but an opportunity for the hospital to learn lessons from this. She provided the Board with a detailed overview of her families experience of poor patient care from attending A&E and then across Wards 19 and 23. There were however at times evidence of real care and compassion shown to Mrs Gibbings. Sally provided examples of numerous incidents and observations during Mrs Gibbings time as an inpatient; incorrect general administration, lack of staffing, general care and attentiveness. There were also incidents of misinformation around a fall whilst an inpatient and the family not being involved in the MDT meeting. Having intervened, the family spoke very highly of Julie Reid, Associate Director of Nursing, for stepping in, listening and implementing changes for Mrs Gibbings. These changes were also highlighted when Sally’s mother-in-law was an inpatient, and noted improvements pertaining to treatment and care. In conclusion, Sally’s view was that the poor practices were mainly due to inadequate leadership. In response the Chief Nurse apprised that Board that Ward 19 in winter 2017 was introduced as a temporary ward to address winter pressures and was most likely to have been staffed with some temporary staff. She assured the Board that the staff involved had been dealt with appropriately and explained the changes implemented since then to address concerns such as those raised. On behalf of the Board, the Chair expressed his thanks and appreciation to Sally for sharing her experience. The Board noted the feedback received from Mrs Rodgers and acknowledge the changes that had been implemented subsequent to this.

BM 19-20/008

Lessons from Learning from Deaths The Board were provided a report in line with national guidance which requires Trusts to review 100% of deaths in care to gather learning and improve patient experience.

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Dr Stevenson reported that subsequent to the introduction of a revised process reviews are more robust and there had been significant improvement and learning disseminated across the organisation. The Board were advised that when reviewing the performance data contained within the Quality & Performance Dashboard they should be mindful that mortality data is collected from 90 days post month of death (i.e. January data is closed in April). Consequently there is a three month lag after which the performance level will be locked and rated. The Board noted the learning from deaths report and the main learning points which are delivered by direct e-mail, safety bites bulletin, patient safety summit, druggles bulletin, local clinical governance meetings, safety huddles and audits by Governance Support Unit.

BM 19-20/009

Productivity Efficiency Priorities The Chief Executive presented a high level summary of the change programme outlining the priorities and highlighted the focus needs to be on fixing key issues with operational grip and delivery which is currently 80% of the job and will allow the organisation to, over time, grow from a 20% transformation focus. As previously agreed the areas of focus would be:

• patient flow - redesign of acute take, redesign discharge, pathways and nurse led discharge

• outpatients and theatre – job plans (nurses and doctor’s), rotas, leave, theatre efficiency, activity and income, programmed investigations / daycase.

It was acknowledged that as enablers IT and system improvement programmes are to be aligned to the three priority areas. Regarding the Healthy Wirral future models of care the Trust will lead on planned care to include outpatients and electives and urgent care encompassing health economy flow and the emergency village. From an IT perspective support will be provided for the patient portal, health economy EPR and service line reporting. A discussion took place regarding the leadership actions as described below:

• The need for an 80% focus on creating solid foundations

• Agreement that the 3 priority projects for improvement at pace are: Flow, Outpatients and Theatres

• Providing SROs with the mix and level of capabilities they require to assure delivery

• Sponsoring governing meetings (project boards) that make timely decisions and meet at the tempo needed to deliver

• Absolute focus on delivering action plans that shift the dial

• Engaging well and communicating our success effectively To ensure pace is implemented across all programmes both operationally and a transformation basis, there are a number of controls that have been introduced with Executive oversight to ensure delivery and timeframes are met.

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It was recognised that in order to achieve the changes outlined there may be areas of work that are no longer a priority and therefore may be stopped this would evolve over time and would be communicated to staff. The Board noted the presentation and endorsed the leadership actions identified.

BM 19-20/010

Quality & Performance Dashboard and Exception Reports The report provides a summary of the Trust’s performance against agreed key quality and performance indicators. Of the 56 indicators with established targets or thresholds 34 are currently off-target or failing to meet performance thresholds. The Director of Governance & Quality stated that although there is improvement from the January position, performance against many of the indicators is not where the Trust needs to be. The updated metrics and thresholds across a range of indicators were highlighted The lead Director for a range of indicators provided a brief synopsis of the issues and the actions being taken. Areas of focus for discussion were:

• Infection Prevention Control (IPC) indicators - NHS Improvement site visit undertaken with recommendations to be incorporated into IPC action Plan.

• Sickness – targeted review of departments with high instances to be implemented.

• Nutrition and Hydration (MUST) – as at today performance was 94% and expectation is that from March onwards the threshold would be met.

• Discharges – patient flow programme reviewing metrics to implement change.

• Vacancy rate – focus on attrition rate being higher than recruitment rate. Alternative flexible working opportunities and improved career pathways to be considered.

• Appraisal – roll out of revised process imminent including alignment with mandatory training compliance which will require a lead in time to ensure availability of training.

• FFT response rate – additional volunteers recruited to support process.

Whilst there was disappointment that a number of the indicators had seen a decline in performance there were some indicators that had improved, namely: VTE, CAS alerts, serious incidents and complaints. The Chief Nurse informed the Board that by way of support to address ongoing concerns relating to the IPC indicators staff resources have been moved from non clinical areas to clinical with a more focused oversight of performance. The Director of Workforce advised that to address departments with high instances of sickness absence a pilot of an external management attendance solution to be undertaken starting in Estates and Facilities. In addition a

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‘deep dive’ will be considered at the Workforce Assurance Committee and a review of the HR business partner role is underway. The Chief Operating Officer reported that with the exception of A&E 4 hour waits it was expected that all indicators would be ‘green’. The Board recognised that whilst the revised dashboard has now been in place for a period of time and provides greater clarity, Board members were asked if they were confident it captures the right indicators and has the appropriate metrics. It was agreed that future discussion is required to determine areas for focus against the three priorities patient flow, outpatients and theatre ie leading indicators rather than emphasis on outputs. The Board noted the current performance against the indicators to the end of February 2019.

Exec’s

BM 19-20/011

Month 11 Finance Report The Acting Director of Finance apprised the Board of the summary financial position. At the end of month 11, the Trust reported an actual deficit of £30.6m versus planned deficit of £24.3m and includes non-current support of £2.4m which means the underlying position is £8.7m worse than plan. In month, the Trust reported a deficit of (£4.0m) against a planned deficit of (£2.7m) and a forecast of (£3.0m). This being (£1.0m) worse than the forecast position. The key driver of the variance is the under-performance in elective activity in both surgery and medicine, non elective both activity and case mix and outpatients worse than forecast. In addition, there were some pay pressures due to the cost of escalation capacity over the above winter plan and additional support to the Emergency Department The Acting Director of Finance reported that cash is better than plan at £7.7m as a result of capital slippage and working capital movements. There were no significant balance sheet variances – in line with cash management approach and capital slippage. Capital expenditure is £5.0m YTD against full year programme of £12.5m. Significant schemes in progress include MRI scanner, GDE, PACS, Estates backlog and medical equipment. Additional key aspects apprised to the Board included:

• Elective income which continues to under-perform against plan although the run rate has improved from Q1. However, bed pressures in Jan/Feb have impacted on elective activity.

• Non-pay pressures associated with out-sourcing both elective activity and diagnostics, noting that elective outsourcing has reduced significantly in Q4 as expected.

• Pay pressures in medical pay and acute care nursing have been mitigated with vacancies in other area’s, predominately corporate and non medical and acute nursing.

• CIP is £0.8m below plan YTD with a delivery of £8.7m, as expected performance has deteriorated as a result of the high profile in Q4 and in

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addition a proportion of the delivery (£2.9m) is non-recurrent against vacancies/non-pay.

The Trust committed to a forecast deficit position of (£27.3m) with NHSI at the meeting in January following the December meeting where delivery of the planned position of (£25.0m) was sought. The current forecast is (£31.4m) deficit and a view with regard to the exposure to a retrospective VAT claim of c£3.5m was highlighted. The Acting Director of Finance advised the Board that negotiations with the CCG regarding the 2019/20 contract are reaching conclusion with agreement to rebase non elective forecast to the most recent lower activity level and the CCG are to underwrite the gap in income. This approach would be in the best interests of the Wirral Health Economy. Assurance that the capital expenditure programme would not be rear year end loaded was sought which could risk value for money decision making. Significant work has been undertaken with the Divisions and Estates regarding a draft three year plan with an emphasis to approve the annual programme earlier than in previous years. 2019/20 has been approved and schemes are being mobilised. The three year plan will be reviewed again by Finance, Business, Performance & Assurance Committee and Trust Management Board following receipt of the 6 FACET survey. The Board noted the M11 finance performance.

BM 19-20/012

Operational Plan 2019/20 The Acting Director of Finance provided a brief overview of the Operational Plan 2019/20 for submission to the regulator. The plan had been considered in detail by the Finance, Business, Performance & Assurance Committee (FBPAC) at its meeting on 26th March 2019 prior to the Board. The key points discussed were:

• Most Pressures can be managed within Divisions, except £1.7m in Medicine & Diagnostics with some corporate control measures to be put in place as mitigation

• CIP programme has been scoped with £12.3m of the £13.2m challenge being identified. Plans on Page for all schemes have been produced with profiles and RAG ratings. Additional oversight meetings are to be introduced.

• Internal Audit on Budgetary control has been completed with Significant Assurance

• Implementation plan for Bed closures received and approved. In addition, Mark Brearley of Unique Health Solutions had presented his report and verbal update to FBPAC that supported the internal assurance work and the acceptance of the Control Total with recommendations for contingent control measures which will be implemented. The finance elements of the Operational Plan has been updated which summarises a budget of £0.0m break-even with a 3.5 % (£13.2m) Cost Improvement Programme (CIP). Contract negotiations have progressed such that there is no misalignment of contract values and work in progressing of the finer points of a risk-share

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arrangement that mitigates against significant variation in income as a result of activity movements is underway. A potential risk was disclosed on depreciation charges (c£1.5m) which it was agreed was not material in comparison to the benefits of accepting the control total. The Board noted and approved the Operational Plan 2019/20 and accepted the NHSI notified control total.

BM 19-20/013

Report of Finance, Business, Performance & Assurance Committee Ms Sue Lorimer, Non-Executive Director provided a summary report of the FBPAC meeting on 26th March 2019 which covered:

• 2019/20 Operational Plan

• Critical Care Service Line Reporting (SLR)

• Pharmacy Dispensing Robot business Case

• Board Assurance Framework 2018/19 – Year end report

• Quality Performance Dashboard

• Bed Closure Option Appraisal The Committee approved:

• Pharmacy Dispensing Robot business case The Committee recommendation to the Board the approval of the Operational Plan 2019/20. In relation to the SLR item, it was recognised that the layout of the Critical Care Unit was sub-optimal and consequently a review of cost drivers and the strict network standards in respect of staffing requirements indicates that the size of the unit is adversely impacting on cost. The Medical Director advised that there was more work to complete on delayed discharges, medical staffing and peer cost structures that would be presented to the committee at a future meeting. The Board noted the report of the Finance, Business, Performance & Assurance Committee and the items approved.

BM 19-20/014

Report of the Quality Committee Mr Chris Clarkson, Non-Executive Director, apprised the Board of the key aspects from the recent Quality Committee, held on 26th March 2019 which covered:

• Serious Incidents and Duty of Candour

• Nutrition & Hydration Report

• Mortality Review and Learning from Deaths

• Resuscitation Report

• CNST

• Medicines storage

• Infection Prevention and Control Report

• CQC Action Plan Report

• Wirral Individualised Safe-Care Everytime (Ward Accreditation)

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In reviewing the Ward Accreditation report the Committee raised concern regarding leadership capability which would support the observations raised within the patient story discussed earlier in the meeting. It was noted that the Chief Nurse would review the questions behind this elements of the programme to establish if there is a sustainable issue. The Board noted the Quality Committee report and the opportunity to adapt the ward accreditation model for other sections of the Trust ie creating a departmental accreditation.

BM 19-20/015

Report of Trust Management Board The Chief Executive provided a summary report of the Trust Management Board (TMB) meeting on 28th March 2019 which covered:

• Quality & Performance Dashboard

• GDE Position

• Clinical Review of NHS Access Standards

• Outpatient Update

• Health & Safety Management

• 2019/20 Budget Update

• Referral to treatment standard

• CQC Inspection feedback The Board noted the report of the Trust Management Board.

BM 19-20/016

Report of the Workforce Assurance Committee (WAC) Mr John Sullivan, Non-Executive Director, apprised the Board of the key aspects from the recent Workforce Assurance Committee, held on 27th March 2019 which covered:

• Staff story

• Medicine & Acute Workforce agenda

• Workforce Planning update

• Update on the Organisational Development Plan

• 2018 NHS Staff Survey – next steps

• Evaluating the current recruitment campaign

• Gender Pay Gap Report 2018

• Workforce Disability Employment Standards (WDES)

• Organisational Development Implications of the NHS Long Term Plan

• Workforce KPI’s dashboard The Director of Workforce advised that following the success of the new recruitment campaign the focus will now move to retention including flexible working and alternative career pathways such as introduction of junior sister role. The next WAC will focus on one of the Trust’s Corporate Division’s as the core competencies required are inevitably quite different from the clinically based competencies required in the other divisions of the Trust. A representative from Estates and Facilities is to be invited to discuss how they will develop their workforce performance going forward.

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The Board noted the report of the Workforce Assurance Committee.

BM 19-20/017

Report of Programme Board Joe Gibson, External Assurance provided a summary of the Trust’s change programme and the independent assurance ratings undertaken to assess delivery as discussed at the Programme Board on 20th March 2019. He advised that in response to the direction set at the March Trust Board, the Executive Team have agreed and initiated enhanced focus on three areas of the Programme; Patient Flow, Outpatients and Theatres Productivity. Each area has reviewed and reset plans to respond to this greater focus and these are being reviewed. The framework of the assurance report is to be triangulated with other report provided to assurance committees. For priority projects, plans and benefit/finance trajectories will be finalised, supporting and enhancing work already underway. Work to allocate corporate function, transformation team and operational resource to support work on the priority programmes is already underway. In order to improve assurance ratings for all programmes it was agreed that Senior Responsible Owners (SRO’s) are to direct their projects to improve confidence in delivery by:

• Ownership of standards

• Monitor project plans on a regular basis (suggested weekly) to enable all members of the team to understand progress.

The Board noted the Trust’s Change Programme assurance report and confirmed the programme priorities as Patient Flow, Outpatients and Theatres productivity.

BM 19-20/018

CQC Action Plan progress Update The Director of Quality & Governance apprised the Board of the improvements pertaining to the CQC Action Plan. The Director of Quality & Governance emphasised the challenges in relation to the overdue actions which mainly concern patient flow management, ED assessment protocols and medicines storage. Updates for these actions were provide as follows:

• Patient flow management - as socialised earlier in the meeting

• Medicines storage - temperature control for room, clarification that this work has been actioned to be provided to the Chairman.

• ED assessment protocols - triage only process is being launched with consultants.

The Board noted the progress to date of the CQC Action Plan.

BM 19-20/019

Annual Review of Declaration of Interest and Fit & Proper Person Declaration The Trust Secretary provided a summary of the annual declarations of interest and provided assurance that all directors and director-equivalent posts are compliant with the requirements of the Fit & Proper Persons test.

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Two minor amendments of the declaration for Non Executive Director, Sue Lorimer and Chief Nurse, Gaynor Westray were provided for inclusion in the register. The Board noted the declaration of interests and compliance for all directors against the Fit & Proper Persons requirements.

BM 19-20/020

Any Other Business There was no other business to report.

BM 19-20/021

Date of next Meeting Wednesday 1st May 2019.

…………..………………………… Chair ………………………………….. Date

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Board of Directors Agenda Item 6

Title of Report Chief Executive’s Report

Date of Meeting 1 May 2019

Author Janelle Holmes, Chief Executive

Accountable Executive

Janelle Holmes, Chief Executive

BAF References

• Strategic Objective

• Key Measure

• Principal Risk

All

Level of Assurance

• Positive

• Gap(s)

Positive

Purpose of the Paper

• Discussion

• Approval

• To Note

For Noting

Data Quality Rating N/A

FOI status Document may be disclosed in full

Equality Impact Assessment Undertaken

• Yes

• No

No

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This report provides an overview of work undertaken and any important announcements in April 2019. Serious Incidents

In April 2019 there was one incident that crossed the threshold for reporting as a serious incident. The incident declared relates to a patient who presented at ED on 3 occasions over a 24 hour period who subsequently died. Full investigation and duty of candor is underway. Navajo Merseyside & Cheshire LGBT Charter Mark

The Trust has successfully passed the assessment process and will be awarded with a Navajo Merseyside and Cheshire LGBT Charter Mark. The Charter Mark is an equality mark sponsored by In-Trust Merseyside & Sefton Embrace and supported by local LGBT Community networks – a signifier of good practice, commitment and knowledge of the specific needs, issues and barriers facing lesbian, gay, bisexual, and transgender (LGBT) people in Merseyside. Assessors praised the Trust for the commitment shown in identifying and improving services and support for LGBT+ staff and patients. Navajo will continue to support the organisation on its improvement journey. Anyone wanting to get involved in this exciting agenda can contact Sharon Landrum, Diversity & Inclusion Adviser on 0151 678 5111, ext 7475 – you can join a staff network or newly developing LGBT+ patient forum (to be led by patient experience). The awards ceremony is to be held on Friday 17th May 1 – 4.30pm at John Moore’s University. Millennium Upgrade

Work continues on fixing the issues with viewing and reporting on images since the Millennium upgrade. A solution in radiology will be tested w/c 29th April and if successful will be live within a week. Daily interactions with Cerner’s Senior Management continue to ensure it remains a high priority with them. Work is also progressing on the new Carestream PACS. In recognition of the issues, Cerner UK have agreed to provide the integration software needed for this free of charge and also compensate the Trust for any radiology reporting work we have had to outsource. A meeting with Cerner’s Managing Director will take place on 20th May 2019. It was agreed at Trust Management Board to publish weekly updates to the Organisation on progress. The lead for Business Continuity has also reviewed remaining issues to ensure that there is a clear Business Continuity plan in place. There are only a very small number of issues remaining but these are also receiving active attention by Cerner.

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NHSI Bulletins – April 2019 NHS England and NHS Improvement

NHS England and NHS Improvement have now come together formally to act as a single organisation. Their aim is to better support the NHS and help improve care for patients. As local health systems work more closely together, the same needs to happen at a national level to achieve the vision of care set out in the NHS Long Term Plan. 2019/20 will be a transitional year as they implement their new ways of working. Janelle Holmes Chief Executive May 2019

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Board of Directors

Agenda Item 7.2

Title of Report Quality Strategy


Author(s)

Janelle Holmes – Chief Executive Nikki Stevenson – Executive Medical Director Gaynor Westray – Chief Nurse Anthony Middleton – Chief Operating Officer Paul Moore – Director of Quality & Governance

Accountable Executive Paul Moore, Director of Quality & Governance

BAF References


• Key Measure

• Principal Risk

This strategy, when implemented in full, will support a positive patient experience, enable safer care, support clinical effectiveness and improve CQC ratings. Implementation of this strategy will make a positive contribution to further strengthening the control framework for the following risk scenarios:

• Demand that overwhelsm capacity to deliver care effectively

• Catastrophic failure in standards of safety and care

• Fundamental loss of stakeholder confidence

Level of Assurance

• Positive

• Gap(s)

Not applicable


• Discussion

• Approval

• To Note

Approval Required

Data Quality Rating Bronze - qualitative data



• Yes

• No

Yes

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Quality Strategy 2019-22: not just great care, but the best care that can be provided for the people of Cheshire & Merseyside

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Contents

EXECUTIVE SUMMARY ............................................................................................................................ 3

OUR QUALITY CAMPAIGNS ..................................................................................................................... 7

A Positive Patient Experience ............................................................................................................. 8

Care is Progressively Safer .................................................................................................................. 9

Care is Clinically Effective and Highly Reliable .................................................................................. 11

We Stand Out .................................................................................................................................... 13

WHAT COULD STOP US FROM ACHIEVEING OUR QUALITY GOALS? .................................................... 15

BUILDING OUR TEAM OF IMPROVEMENT PIONEERS ........................................................................... 16

HOW WE IMPROVE QUALITY ................................................................................................................ 16

THE QUALITY IMPROVEMENT PLAN ..................................................................................................... 18

Page 19 of 120

3

EXECUTIVE SUMMARY It gives us great pleasure to outline our Quality Strategy for Wirral University Teaching Hospitals NHS Foundation Trust. We recognise that every day all our staff, no matter where or how they contribute within the organisation, demonstrate their commitment to patient-focussed care and strive for excellence in often very difficult circumstances. We are proud to be a part of this great organisation and also proud to be part of this journey with you as one talented team. Together we have the potential to transform the quality of healthcare for all service users and, in doing so, become an outstanding provider in the eyes of those who use our services, those who work in them and those who inspect them. By 2022 we aspire to be rated outstanding for quality by the Care Quality Commission. We understand this represents an ever-increasing challenge as we learn to balance rising demand for healthcare alongside intensifying financial, quality and workforce risks. This Quality Strategy reflects our ambition for sustainable, high value, high quality services delivered in partnership with other health and social care providers across Cheshire and Merseyside. As we move forward we will witness a much closer alignment between quality, activity and financial planning to boost our combined efforts to deliver safe, effective and financially sustainable services in the longer term. The challenges that lie ahead are demanding and will require creative adaptation within the Trust and across the wider health and social care system in order to meet them. By investing in improvement expertise to advance quality and developing our teams to lead, learn, and continuously improve we are positioning the Trust to act as system leader for quality. The driving force behind our new approach to quality is partnership: (i) united by shared quality goals - a partnership which brings about much closer integration across the health and social care system to deliver safer and more sustainable clinical services; (ii) a partnership with patients which seeks to put them more in control of their own care – promoting self-management and involving them in service developments and decisions about their care; and (iii) through our workforce strategy a partnership with staff that fosters an open, inquisitive, responsive and learning culture. This represents an opportunity to deliver care that is not just great, but the best care that can be provided across Cheshire and Merseyside. We believe that we can demonstrate outstanding care and be one of the best providers of healthcare in the country. This Quality Strategy gives us the road map to get there.

Janelle Holmes Chief Executive

Gaynor Westray Chief Nurse

Nicola Stevenson Medical Director

Paul Moore Director of Quality

& Governance

Anthony Middleton Chief Operating

Officer

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4

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Page 21 of 120

5

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Cam

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OUR QUALITY CAMPAIGNS We are dedicated to delivering outstanding care at Wirral University Teaching Hospitals. Our four quality campaigns are:

• Campaign One: Delivering a positive patient experience: by 2022 we aim to: (i) have moved beyond a paternalistic approach to a model of care that is genuinely patient centred and making progress towards models of care developed in partnership with service users; and (ii) to consistently achieve and maintain service user recommendation ratings at or above 98%

• Campaign Two: Care is progressively safer: by 2022 we aim to: (i) have the lowest number of serious incidents of any North West NHS acute care provider; and (ii) achieve 12 consecutive months or more without a Never Event

• Campaign Three: Care is clinically effective and highly reliable: by 2022 we aim to: (i) benchmark in the top quartile for lowest Length of Stay; and (ii) benchmark in the top quartile for lowest rate of readmissions within 28-days of discharge for the same HRG

• Campaign Four: We stand out: by 2022 we aim to: (i) be rated outstanding by the Care Quality Commission; and (ii) at a system level, to keep patients with long term conditions well, as independent as possible and avoid foreseeable crisis points which often result in hospital admission.

The values below define the culture, beliefs and behaviours at Wirral University Teaching Hospitals. These values underpin how we work, how we interact with each other and provide a guiding compass for how we overcome problems and deal with uncertainty. Adopting these values every day in our working lives will support decision making, problem solving and support the delivery of the Quality Strategy.

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Quality Campaign One: A Positive Patient Experience Changing behaviours and the way care is delivered to impact positively on how care is experienced by those who use and depend upon the services we provide

Goals • By 2022 or sooner, ≥95% of staff believe ‘care is the Trust’s top priority’

• By 2022 consistently achieve at least 98% recommendation ratings for inpatient, outpatient and maternity care using friends and family test

Lead(s) Chief Nurse | Director of Quality & Governance | Medical Director | Head of Communications

Supporting Strategies Patient & Public Engagement Strategy | Workforce Strategy | Communications Strategy

Co-ordinating / Oversight Committee

Patient Safety & Quality Board & Quality Committee

Success Criteria Key Outcome BASIC

2019-20 BETTER 2020-21

BEST 2022-22

• Focus on explaining care in an understandable way

At least 90% or more patients satisfied their care was explained in an understandable way

≥95% ≥98%

• Engage and involve people in planning and delivering their care

At least 85% or more patients reporting they were involved in planning their care

≥90% ≥95%

• Educate and train staff to adopt the principle of co-design in care planning

Service improvement leads trained in co-design and the use of co-design principle and piloted in selected areas

The use of co-design evaluated, adapted and rolled out across all divisions

All service improvement projects supported through co-design principle

• Service users will be active participants of PSQB, Quality Committee and Divisional Governance Groups

Patients/service users will attend and participate in proceedings of PSQB and Quality Committee

Patients/service users will attend and participate in proceedings of divisional governance meetings

Patients/service users will attend and participate in proceedings of directorate governance meetings

• Patient stories and pathway diaries used to better understand patient experience and identify touch points and Always Events

Always Events pilot completed and impact on patient experience evaluated Implement pathway diaries in services to better illustrate experience and different points in the journey

At least 1 Always Event a quality priority in each Division and providing a positive impact on patient experience Patient stories are integral to the process of sign off and learning from serious incidents

At least 5 Always Events identified as quality priorities in each Division and demonstrating a positive impact on patient experience

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Quality Campaign Two: Care is Progressively Safer

Focussing on frailty and learning disability we will adapt to meet the healthcare needs of an increasingly elderly patient population and, by delivering basic-better-best care, reduce exposure to harm

Goals • By 2022 have the lowest number of serious incidents of any North West NHS acute care provider

• By 2022, achieve 12 consecutive months or more without a Never Event By 2022 reduce by at least 50% the MET call rate per 1000 bed days

• By 2022 achieved RoSPA Gold for Safety Management

Lead(s) Medical Director | Director of Quality & Governance | Chief Nurse

Supporting Strategies Risk Management Strategy | Patient Safety Culture | Workforce Strategy



Success Criteria

Key Outcome BASIC 2019-20

BETTER 2020-21

BEST 2021-22

• Reducing Hospital Acquired Infections

On trajectory for hospital acquired Clostridium difficile ≥365 consecutive days without MRSA bacteraemia

5% below trajectory

≥700 consecutive days without MRSA bacteraemia

5% below trajectory

≥1000 consecutive days without MRSA

bacteraemia

• Achieve high reliability of risk assessment and effective care planning for patients at risk of falls

92% or more compliance with implementation of falls care plans for at risk patients

≥95% ≥98%

• Achieve high reliability of risk assessment and effective care planning for patients at risk of hospital acquired pressure ulcers

92% or more compliance with implementation of pressure sore prevention plans for at risk patients

≥95% ≥98%

• Achieve high reliability of end-to-end care for patients at risk of venous thromboembolism (VTE)

≥80% ≥90% ≥95%

• Focus on safety culture in operating theatres and other areas where interventional procedures are undertaken

100% compliance with WHO Checks Every ‘query’ raised before or during procedure results in a ‘stop moment’

100% At least 6 consecutive

months without surgical Never Event

100%

At least 12 consecutive months without

surgical Never Event

• Reliable daily completion of charts and calculation of +/- fluid balance

≥90% ≥95% ≥98%

• Delivering harm-free care

≥95% ≥97% ≥98.5%

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Key Outcome BASIC

2019-20 BETTER 2020-21

BEST 2021-22

• Safe staffing:

(i) Reduce the incidence of staffing levels as direct causal factor in harmful incident reports

(ii) Focus on maximising fill rates in rotas;

(iii) Sequentially reduce Band 5 vacancies

Establish 2018/19 baseline of harmful incidents involving staffing levels as cause Reduce by 3% (based on 2018/19) number of harmful incidents involving staffing levels as a cause

Overall fill rate for WUTH ≥95%

≤10%

Reduce by 3%

Every clinical area can demonstrate a fill rate ≥95%

≤8%

Reduce by 3%

Every clinical area can demonstrate a fill rate ≥95%

≤5%

• Apply for RoSPA accreditation of safety management system

Awarded BRONZE

Awarded SILVER

Awarded GOLD

• Minimise and/or respond early and effectively to the signs of clinical deterioration

Establish MET Call Baseline for 2018/19

Reduce by ≥25%

Reduce by ≥25%

• Ensure every patient (not medically optimised) is reviewed by a senior doctor (ST3 or above) at least once daily

≥80% ≥90% ≥95%

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Quality Campaign Three: Care is Clinically Effective and Highly Reliable Patient care and treatment achieves good outcomes, promotes a good quality of life, and is based on the best available evidence.

Goals • By 2021 remain at or below expected levels on all mortality indices

• By 2021 we aim to benchmark in the top quartile for lowest Length of Stay

• By 2021 we aim to benchmark in the top quartile for lowest number of readmissions within 28-days of discharge for the same HRG

Lead(s) Medical Director | Chief Operating Officer | Director of Quality & Governance

Supporting Strategies Risk Management Strategy | Clinical Strategy |Clinical Effectiveness Strategy | Service Improvement Strategy | Workforce Strategy



Success Criteria


BETTER 2020-21

BEST 2021-22

• Reducing harm for those using our services who have a learning disability

Establish 2018/19 baseline of harms involving those who have a learning disability

Reduce by 10% (based on 2018/19) number of harmful incidents involving learning disabled patients

Reduce by 10% (based on 2019/20) number of harmful incidents involving learning disabled patients

• Reducing the percentage of patients with ≥3 emergency admissions in the last 90 days of life

Establish 2018/19 baseline numbers of patients with ≥3 emergency admissions in last 90 days of life

Reduce by 5% Reduce by 5%

• HSMR

• Mortality Reviews

Below 5% of expected range

Avoidable factors associated with mortality ≤3%


≤2%


≤1%

• Improve effectiveness of discharge planning and resilience of discharge venue

Achieve at least 85% or more patients reporting they were involved in planning their discharge Reduce by 5% (based on 2016/17) number of incidents or complaints concerning unsatisfactory/unsafe discharge

≥90%

Reduce by 5%

≥95%

Reduce by 5%

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BETTER 2020-21

BEST 2021-22

• Improving the timeliness of the clinical response to abnormal or unexpected (and clinically significant) radiology or pathology results

10% fewer serious incidents (compared to 2018/19) involving failure to detect and act upon (clinically significant) abnormal pathology or radiology findings

10% fewer serious incidents (compared to

2019/20) involving failure to detect and act upon (clinically

significant) abnormal pathology or radiology

findings

10% fewer serious incidents (compared to

2020/21) involving failure to detect and act upon (clinically

significant) abnormal pathology or radiology

findings

• Compliance with NICE All specialities are reporting their position on uptake of NICE guidelines ≥75% of Clinical Specialties completed baseline assessment against all applicable NICE guidelines

≥90%

≥95%

• Ensuring all patients have a review by a consultant within 14 hours of hospital admission

≥95% ≥98% 100%

• Implementation of CAS Alerts

≥98% closure on or before deadline day ≥99% 100%

• Culture of enquiry and continuous improvement

≥70% of staff report they are able to contribute to improvements at work (staff survey)

≥75% ≥80%

Page 29 of 120

13

Quality Campaign Four: We Stand Out Being a leader and striving for excellence on our journey to outstanding.

Goals • By 2021 we aim to be rated outstanding by the Care Quality Commission

• By 2021 we aim - at a system level – to keep patients with long term conditions well, as independent as possible and avoid foreseeable crisis points which often result in hospital admission

Lead(s) Director of Governance & Quality Improvement | Medical Director | Director of Human Resources and Organisational Development| Chief Operating Officer | Director of Strategy

Supporting Strategies Risk Management Strategy | Clinical Effectiveness Strategy | Service Improvement Strategy | Workforce Strategy



Success Criteria


BETTER 2020-21

BEST 2021-22

• Staff engagement / Satisfaction

KF1: Staff recommendation of the organisation as a place

to work is 3.95 KF2: Staff satisfaction with the quality of their work and care they are

able to deliver is 4.15

4.0

4.20

4.5

4.25

• Getting to the learning faster: response to serious incidents

≥75% of incidents scoped within 72 hours of incident occurring or sooner

≥80% ≥90%

• Learning from high-risk events

5% reduction (based on 2018/19) in number of reported instances of

• Errors involving high-risk medicines (Opiates, Insulin, Sedatives, Anticoagulants)

• Falls involving moderate/severe harm

• Hospital acquired pressure ulcers

5% fewer incidents (compared to 2018/19)

5% fewer incidents (compared to 2019/20)

Item

7.2

- Q

ualit

y S

trat

egy

Page 30 of 120

14


BETTER 2020-21

BEST 2021-22

• Create the perfect system-wide patient pathway for long term conditions such as diabetes, respiratory disease and hypertension

Establish baseline admission rates for Diabetes, Respiratory and Hypertension conditions Pathways for Diabetes, Respiratory diseases and Hypertension are ‘process mapped’ to isolate potential crisis points and act on the analysis Scope and rapidly adopt technological innovations that could promote and support integrated whole-person care (such as home monitoring, smartphone apps etc) Patient experience evaluated: service users positively report less fragmentation and a clear shift in emphasis towards self-care

Reduce by 10% (based on 2018/19 baselines) in admissions to hospital for Diabetes, Respiratory diseases and Hypertension Patient experience: service users report they are actively encouraged and more able to look after their own condition and know where and how to access help if needed

Further reduction by 10% (based on 2019/20 baselines) in admissions to hospital for Diabetes, Respiratory diseases and Hypertension Patient experience: service users positively report self-care as ‘mainstream’

Page 31 of 120

15

W

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Item

7.2

- Q

ualit

y S

trat

egy

Page 32 of 120

BUILDING OUR TEAM OF IMPROVEMENT PIONEERS We recognise that to transform our patient safety culture and consistently deliver excellence in

clinical outcomes and patient experience, it will be necessary to build capacity and capability to learn

and improve. Learning is demonstrated in our ability to reduce the frequency of the same defects

within our system of work. When we learn, we still experience new and novel failures as we adapt to

risk; but we also see a change in the pattern of defects which adversely impact on quality. The

surprising truth about success is that it requires failure1. Failure presents us with an opportunity to

understand how and why our system of work leads to harm, poor outcomes or a bad experience for

service users. We use this intelligence to discover, innovate and adapt. To capitalise on and

transform failure into learning and improvement requires expertise, insight and an unstinting

determination to keep trying no matter how hard the challenges become.

To support the delivery of our Quality Strategy we are making a solid commitment to:

• actively recruit from amongst experts on the front line and build a team of improvement

pioneers;

• join forces with an internationally recognised improvement partner to educate, train and

develop the skills of our improvement pioneers so that they can make a difference;

• move towards an organisational culture where care is the primary concern, ‘safe’ is a

managed outcome and where we exploit the tension between innovation and risk to initiate

adaption and learning; and

• mobilise financial and other resources required to deliver at pace the goals set out in our

Quality Strategy.

HOW WE IMPROVE QUALITY Our approach to quality improvement is based on a well-defined tool for accelerating improvement2 that has been widely adopted across the NHS. We use the following principles to guide how we improve the quality of care at Wirral University Teaching Hospitals. We start every improvement journey by asking a series of important questions:

1. What problem are we attempting to solve - what exactly are we trying to achieve? 2. What change can we make to bring about an improvement? 3. How will we know that making a change delivers an improvement?

Considering these questions will clarify the aims, measures, specific interventions and how changes will be tested in the clinical setting.

Setting Aims Improvement requires setting aims. The aim will be easy to understand, time bound and measurable; it will also define the specific population that will be affected. Agreeing on the aim is crucial; so is clarifying roles and responsibilities and allocating the people and resources necessary to accomplish the aim.

1 Syed, M. (2016) Black Box Thinking: Marginal Gains and the Secrets of High Performance. London. John Murray Publishers. 2 Based on Langley, G.L., Moen, R., Nolan, T.W., Norman, C.L. & Provost, L.P. (2009) The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd Edition). San Fransisco, Josey-Bass

Page 33 of 120

Establishing Measures Measurement is a critical part of testing and implementing sustainable improvement; measures tell a team whether the changes they are making actually lead to improvement or not. Our preference for evaluating improvement is to use quantitative measurement; outcome measures (such as impact on health, well-being, clinical results), process measures (such as system performance, timeliness and compliance) and balancing measures (such as triangulating different measures from different perspectives to evaluate impact). We will, if appropriate, also adopt a combination of quantitative and qualitative measures should it help to determine and demonstrate if a specific change actually leads to sustainable improvement.

Selecting Changes All improvement requires making changes, but not all changes result in improvement. Changes that do not result in improvement are helpful as they can help us to learn and adapt. By implementing changes, succeeding and failing as we go forward, we will identify sustainable change that is most likely to lead to improvement.

Testing Changes The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change in the clinical setting – by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method used for action-orientated learning.

PDSA provides a structured experimental learning approach to testing changes. The purpose of the PDSA method lies in learning as quickly as possible whether or not an intervention works in a particular setting and making adjustments to increase the chances of delivering desired and sustainable improvement. Successful application of PDSA will help Wirral University Teaching Hospitals to achieve our quality improvement goals more efficiently or to address priorities we might otherwise not have achieved under a business as usual approach. But PDSA is also successful if it saves wasted effort by revealing improvement goals that cannot be achieved under realistic constraints or it identifies flaws in the intervention.

Item

7.2

- Q

ualit

y S

trat

egy

Page 34 of 120

THE QUALITY IMPROVEMENT PLAN

Each year, the Trust will review and identify the quality priorities and establish a tactical plan to drive forward the Quality Strategy. This tactical plan shall be known as the Quality Improvement Plan and will be monitored closely, amended as required and updated throughout the year to support the delivery of the Quality Strategy. The progress made towards implementation of the Quality Strategy shall be monitored and reviewed each month by the Patient Safety & Quality Board (PSQB). Any adjustments to the tactical plan shall be determined and agreed by the PSQB and progress reported to the Quality Committee routinely as part of the cycle of business.

Page 35 of 120

Item

7.2

- Q

ualit

y S

trat

egy

Page 36 of 120

1. Executive Summary

This report provides a summary of the Trust’s performance against agreed key quality and performance indicators. The Board of Directors is asked to note performance to the end of March 2019.

2. Background The Quality and Performance Dashboard is designed to provide accessible oversight of the Trust’s performance against key indicators, grouped under the CQC five key question headings.

Board of Directors

Agenda Item 8.1.1

Title of Report Quality and Performance Dashboard


Author(s) WUTH Information Team and Governance Support Unit

Accountable Executive COO, MD, CN, DQG, HRD, DoF

BAF References


• Key Measure

• Principal Risk

Quality and Safety of Care

Patient flow management during periods of high demand

Level of Assurance

• Positive

• Gap(s)

Gaps in Assurance


• Discussion

• Approval

• To Note

Provided for assurance to the Board

Data Quality Rating TBC

FOI status Unrestricted


• Yes

• No

No adverse equality impact identified.

Item

8.1

.1 -

Qua

lity

and

Per

form

ance

Das

hboa

rd a

nd E

xcep

tion

Rep

orts

Page 37 of 120

P a g e | 2

The Quality & Performance Dashboard is work-in-progress and will develop further iterations over time. This will include development of targets and thresholds where these are not currently established and the sourcing of data where new indicators are under development.

3. Key Issues

Of the 51 indicators with established targets that are reported for March 2019:

- 20 are currently off-target or failing to meet performance thresholds - 31 of the indicators are on-target

There are no indicators that were previously GREEN showing 2 consecutive months at RED; therefore there are no IDAs required in this month’s report. 4. Next Steps

WUTH remains committed to attaining standards through 2018-19.

5. Conclusion

Performance against many of the indicators is not where the Trust needs to be. The actions to improve are noted in the exceptions on the qualifying metrics and this report in future will provide monitoring and assurance on progress.

6. Recommendation

The Board of Directors is asked to note the Trust’s current performance against the indicators to the end of March 2019.

Page 38 of 120

Ap

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ital acq

uir

ed

Safe

, hig

h q

ualit

y c

are

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ational

10

00

00

00

10

00

23

Han

d H

yg

ien

e C

om

plian

ce (

*)S

afe

, hig

h q

ualit

y c

are

DoN

≥95%

WU

TH

99%

95.0

%97%

88%

89%

90%

81%

87.0

%85.0

%76.0

%83.0

%86.0

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%

Med

icin

es S

tora

ge T

rust

wid

e a

ud

its -

% o

f

are

as f

ully c

om

plian

t (w

ith

sta

nd

ard

s a

nd

data

su

bm

issio

n)

Safe

, hig

h q

ualit

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are

DoN

≥90%

WU

TH

98%

99%

99%

Pro

tecti

ng

Vu

lnera

ble

Peo

ple

Tra

inin

g -

%

co

mp

lian

t (L

ev

el 1)

(*)

Safe

, hig

h q

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are

DoN

≥90%

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89.5

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%−

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85.6

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Pro

tecti

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lnera

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Peo

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inin

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co

mp

lian

t (L

ev

el 2)

(*)

Safe

, hig

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are

DoN

≥90%

WU

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82.5

%84.8

%−

−82.7

%−

82.2

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Pro

tecti

ng

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lnera

ble

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ple

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inin

g -

%

co

mp

lian

t (L

ev

el 3)

(*)

Safe

, hig

h q

ualit

y c

are

DoN

≥90%

WU

TH

85.2

%85.6

%−

−85.6

%−

86.5

%87.2

%91.7

%91.4

%93.6

%92.6

%93.5

%93.5

%

Nu

rsin

g V

acan

cy R

ate

Safe

, hig

h q

ualit

y c

are

DH

R≤6.5

%W

UT

H6.8

3%

6.5

7%

7.1

1%

7.2

0%

10.2

4%

10.2

0%

9.2

5%

7.9

0%

7.9

0%

7.4

7%

8.9

7%

9.0

7%

9.1

6%

9.1

6%

Co

nsu

ltan

t V

acan

cy R

ate

%S

afe

, hig

h q

ualit

y c

are

DH

R≤6.5

%W

UT

H9.6

8%

6.9

5%

6.9

3%

6.5

8%

7.6

2%

6.8

7%

6.4

5%

6.8

8%

7.9

0%

6.4

8%

6.6

1%

6.4

3%

6.7

3%

6.7

3%

Sic

kn

ess a

bsen

ce %

(12-m

on

th r

ollin

g

av

era

ge)

Safe

, hig

h q

ualit

y c

are

DH

R≤4%

SO

F4.7

7%

4.7

8%

4.8

2%

4.8

4%

4.8

4%

4.8

7%

4.9

1%

4.9

4%

4.9

3%

4.9

4%

4.9

5%

5.0

2%

5.1

0%

5.1

0%

Sh

ort

-term

sic

kn

ess (

in m

on

th r

ate

)S

afe

, hig

h q

ualit

y c

are

DH

RT

BC

WU

TH

2.2

0%

1.7

9%

2.0

4%

2.0

4%

2.0

3%

2.2

4%

2.3

5%

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3%

2.1

9%

2.3

6%

2.9

3%

2.8

0%

2.5

4%

2.3

1%

Lo

ng

-term

sic

kn

ess (

in-m

on

th r

ate

)S

afe

, hig

h q

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y c

are

DH

RT

BC

WU

TH

2.1

9%

2.1

8%

2.3

3%

2.6

5%

2.9

5%

2.7

9%

2.5

5%

2.7

6%

2.8

1%

3.0

9%

2.7

9%

2.8

2%

2.7

2%

2.7

0%

Care

ho

urs

per

pati

en

t d

ay (

CH

PP

D)

Safe

, hig

h q

ualit

y c

are

DoN

TB

CW

UT

H7.1

7.2

7.3

7.4

7.6

7.5

7.1

6.9

7.1

77.3

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−`

Safe

Pag

e 1

of

5

Item

8.1

.1 -

Qua

lity

and

Per

form

ance

Das

hboa

rd a

nd E

xcep

tion

Rep

orts

Page 39 of 120

Ap

pen

dix

1

Wir

ral U

niv

ersi

ty T

each

ing

Ho

spit

al N

HS

Fou

nd

atio

n T

rust

Qu

alit

y P

erf

orm

ance

Das

hb

oar

dA

pri

l 20

19

Ind

icato

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ve

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hre

sh

old

Set

by

Mar-

18

Ap

r-18

May-1

8Ju

n-1

8Ju

l-18

Au

g-1

8S

ep

-18

Oct-

18

No

v-1

8D

ec-1

8Jan

-19

Feb

-19

Mar-

19

2018/1

9T

ren

d

SH

MI

Safe

, hig

h q

ualit

y c

are

MD

≤100

SO

F94.7

−−

97.0

6−

−97.2

2−

−−

−−

−97.2

2

HS

MR

Safe

, hig

h q

ualit

y c

are

MD

≤100

SO

F88.0

88.7

93.0

93.0

95

95

92

92

97

97

−−

−97

Mo

rtality

Rev

iew

s C

om

ple

ted

. M

on

thly

rep

ort

ing

fin

alised

3 m

on

ths late

r

Safe

, hig

h q

ualit

y c

are

MD

≥75%

WU

TH

−−

−−

−−

−−

−−

83%

66%

39%

63%

Nu

trit

ion

an

d H

yd

rati

on

- M

US

T c

om

ple

ted

at

7 d

ays

Safe

, hig

h q

ualit

y c

are

DoN

≥95%

WU

TH

44%

59%

71%

78%

67%

74%

84%

87%

83%

81%

94%

74.7

%

SA

FE

R B

UN

DL

E:

% o

f d

isch

arg

es t

akin

g

pla

ce b

efo

re n

oo

n

Safe

, hig

h q

ualit

y c

are

MD

/ C

OO

≥33%

National

14.6

%14.9

%14.3

%13.9

%12.9

%14.1

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%15.4

%16.4

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%

SA

FE

R B

UN

DL

E:

Av

era

ge n

um

ber

of

str

an

ded

pati

en

ts a

t 10am

(in

ho

sp

ital fo

r 7

or

mo

re d

ays)

- actu

al

Safe

, hig

h q

ualit

y c

are

MD

/ C

OO

≤156 (

WU

TH

Tota

l)W

UT

H436

418

405

409

386

387

411

409

408

397

437

457

438

414

Len

gth

of

sta

y -

ele

cti

ve (

actu

al in

mo

nth

)S

afe

, hig

h q

ualit

y c

are

CO

OT

BC

WU

TH

4.0

3.8

4.3

3.8

5.2

4.1

4.2

4.3

3.8

4.8

3.0

4.4

8.8

4.5

Len

gth

of

sta

y -

no

n e

lecti

ve (

actu

al in

mo

nth

)

Safe

, hig

h q

ualit

y c

are

CO

OT

BC

WU

TH

5.4

5.1

5.2

5.1

5.4

5.0

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5.3

5.1

5.0

5.2

5.6

5.2

5.2

Em

erg

en

cy r

ead

mis

sio

ns w

ith

in 2

8 d

ays

Safe

, hig

h q

ualit

y c

are

CO

OT

BC

WU

TH

814

886

923

873

913

961

888

936

925

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903

788

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902

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yed

Tra

nsfe

rs o

f C

are

Safe

, hig

h q

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are

CO

OT

BC

WU

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913

12

13

13

618

12

17

14

10

16

14

11.4

% T

heatr

e U

tilisati

on

Safe

, hig

h q

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are

CO

O≥85%

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TH

79.8

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%88.6

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%92.3

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%

Effective

Pag

e 2

of

5

Page 40 of 120

Ap

pen

dix

1

Wir

ral U

niv

ersi

ty T

each

ing

Ho

spit

al N

HS

Fou

nd

atio

n T

rust

Qu

alit

y P

erf

orm

ance

Das

hb

oar

dA

pri

l 20

19

Ind

icato

rO

bje

cti

ve

Dir

ecto

rT

hre

sh

old

Set

by

Mar-

18

Ap

r-18

May-1

8Ju

n-1

8Ju

l-18

Au

g-1

8S

ep

-18

Oct-

18

No

v-1

8D

ec-1

8Jan

-19

Feb

-19

Mar-

19

2018/1

9T

ren

d

Sam

e s

ex a

cco

mm

od

ati

on

bre

ach

es

Outs

tandin

g P

atient

Exp

eri

ence

DoN

0S

OF

16

18

22

10

816

14

19

18

15

20

14

13

187

FF

T R

eco

mm

en

d R

ate

: E

DO

uts

tandin

g P

atient

Exp

eri

ence

DoN

≥95%

SO

F82%

85%

90%

91%

89%

89%

86%

87%

84%

92%

85%

87%

87%

88%

FF

T O

vera

ll R

esp

on

se R

ate

: E

DO

uts

tandin

g P

atient

Exp

eri

ence

DoN

≥12%

WU

TH

12.0

%13.0

%9.0

%8.0

%11.0

%12.0

%11.0

%10.0

%11.0

%10.0

%11.0

%11.0

%13.0

%11%

FF

T R

eco

mm

en

d R

ate

: In

pati

en

tsO

uts

tandin

g P

atient

Exp

eri

ence

DoN

≥95%

S

OF

97%

98%

97%

98%

98%

98%

97%

98%

98%

98%

98%

97%

97%

98%

FF

T O

vera

ll r

esp

on

se r

ate

: In

pati

en

tsO

uts

tandin

g P

atient

Exp

eri

ence

DoN

≥25%

WU

TH

18.0

%15.0

%15.0

%20.0

%25.0

%14.0

%22.4

%24.0

%18.0

%18.0

%19.0

%15.0

%13.0

%18%

FF

T R

eco

mm

en

d R

ate

: O

utp

ati

en

tsO

uts

tandin

g P

atient

Exp

eri

ence

DoN

≥95%

S

OF

94%

95%

95%

94%

95%

94%

94%

94%

95%

94%

95%

94%

95%

94.5

%

FF

T R

eco

mm

en

d R

ate

: M

ate

rnit

yO

uts

tandin

g P

atient

Exp

eri

ence

DoN

≥95%

SO

F100%

97%

97%

99%

96%

100%

100%

96%

100%

100%

99%

98%

96%

98%

FF

T O

vera

ll r

esp

on

se r

ate

: M

ate

rnit

y (

po

int

2)

Outs

tandin

g P

atient

Exp

eri

ence

DoN

≥25%

WU

TH

35%

31%

54%

46.0

%37.0

%17.0

%28.2

%11.0

%19.0

%37.0

%27.0

%36.0

%44.0

%32%

Caring

Pag

e 3

of

5

Item

8.1

.1 -

Qua

lity

and

Per

form

ance

Das

hboa

rd a

nd E

xcep

tion

Rep

orts

Page 41 of 120

Ap

pen

dix

1

Wir

ral U

niv

ersi

ty T

each

ing

Ho

spit

al N

HS

Fou

nd

atio

n T

rust

Qu

alit

y P

erf

orm

ance

Das

hb

oar

dA

pri

l 20

19

Ind

icato

rO

bje

cti

ve

Dir

ecto

rT

hre

sh

old

Set

by

Mar-

18

Ap

r-18

May-1

8Ju

n-1

8Ju

l-18

Au

g-1

8S

ep

-18

Oct-

18

No

v-1

8D

ec-1

8Jan

-19

Feb

-19

Mar-

19

2018/1

9T

ren

d

4-h

ou

r A

ccid

en

t an

d E

merg

en

cy T

arg

et

(in

clu

din

g A

rro

we P

ark

All D

ay H

ealt

h

Cen

tre)

Safe

, hig

h q

ualit

y c

are

CO

ON

HS

I T

raje

cto

ry fo

r

2018/1

9S

OF

74.4

%80.3

%83.5

%83.4

%85.6

%83.6

%77.8

%77.8

%75.2

%75.0

%74.0

%74.0

%76.7

%78.9

%

Pati

en

ts w

ait

ing

lo

ng

er

than

12 h

ou

rs in

ED

fro

m a

decis

ion

to

ad

mit

.

Outs

tandin

g P

atient

Exp

eri

ence

CO

O0

National

00

00

00

00

00

20

02

Am

bu

lan

ce H

an

do

vers

>30 m

inu

tes

Safe

, hig

h q

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y c

are

CO

OT

BC

National

623

414

327

291

213

326

474

371

440

393

379

323

273

352

18 w

eek R

efe

rral to

Tre

atm

en

t -

Inco

mp

lete

path

ways <

18 W

eeks

Safe

, hig

h q

ualit

y c

are

CO

O

NH

SI T

raje

cto

ry f

or

2018/1

9 (

80%

by 3

1

Marc

h 2

019)

SO

F77.3

%74.3

%74.6

%75.7

%76.3

%77.2

%78.3

%78.9

8%

79.3

4%

80.0

8%

78.3

2%

79.1

2%

80.0

0%

80.0

0%

Refe

rral to

Tre

atm

en

t -

cases e

xceed

ing

52

weeks

Safe

, hig

h q

ualit

y c

are

CO

O

NH

SI T

raje

cto

ry f

or

2018/1

9 (

zero

by 3

1

Marc

h 2

019)

National

69

66

67

79

57

56

40

43

30

28

28

19

00

Dia

gn

osti

c W

ait

ers

, 6 w

eeks a

nd

ov

er

-DM

01

Safe

, hig

h q

ualit

y c

are

CO

O≥99%

SO

F99.2

%99.0

%98.2

%97.9

%98.5

%97.9

%99.2

%99.4

%98.9

%98.6

%99.1

%99.7

%99.9

%98.9

%

Can

cer

Wait

ing

Tim

es -

2 w

eek r

efe

rrals

Safe

, hig

h q

ualit

y c

are

CO

O≥93%

National

94.9

%94.2

%93.4

%95.2

%95.7

%92.3

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%

Can

cer

Wait

ing

Tim

es -

% r

eceiv

ing

fir

st

defi

nit

ive t

reatm

en

t w

ith

in 1

mo

nth

of

dia

gn

osis

Safe

, hig

h q

ualit

y c

are

CO

O≥96%

National

97.0

%96.5

%96.4

%95.5

%98.2

%96.3

%96.2

%96.8

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%97.1

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%

Can

cer

Wait

ing

Tim

es -

62 d

ays t

o t

reatm

en

tS

afe

, hig

h q

ualit

y c

are

CO

O≥85%

SO

F88.1

%87.0

%86.1

%87.8

%85.4

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%85.7

%85.1

%85.3

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%86.4

%85.6

%86.2

%

Pati

en

t E

xp

eri

en

ce:

Nu

mb

er

of

co

ncern

s

receiv

ed

in

mo

nth

- L

ev

el 1 (

info

rmal)

(**

)

Outs

tandin

g P

atient

Exp

eri

ence

DoN

TB

CW

UT

H144

118

134

110

140

123

155

119

165

118

178

153

157

1670

Pati

en

t E

xp

eri

en

ce:

Nu

mb

er

of

co

mp

lain

ts

receiv

ed

in

mo

nth

- L

ev

els

2 t

o 4

(fo

rmal)

(**

)

Outs

tandin

g P

atient

Exp

eri

ence

DoN

TB

CW

UT

H30

34

23

36

24

25

22

19

13

13

27

28

17

281

Co

mp

lain

t ackn

ow

led

ged

wit

hin

3 w

ork

ing

days (

*)

Outs

tandin

g P

atient

Exp

eri

ence

DoN

≥90%

National

97%

32%

81%

95%

72%

75%

80%

100%

100%

100%

100%

100%

100%

86.2

%

Nu

mb

er

of

re-o

pen

ed

co

mp

lain

tsO

uts

tandin

g P

atient

Exp

eri

ence

DoN

≤5 p

cm

WU

TH

12

27

50

42

32

21

333

Responsive

Pag

e 4

of

5

Page 42 of 120

Ap

pen

dix

1

Wir

ral U

niv

ersi

ty T

each

ing

Ho

spit

al N

HS

Fou

nd

atio

n T

rust

Qu

alit

y P

erf

orm

ance

Das

hb

oar

dA

pri

l 20

19

Ind

icato

rO

bje

cti

ve

Dir

ecto

rT

hre

sh

old

Set

by

Mar-

18

Ap

r-18

May-1

8Ju

n-1

8Ju

l-18

Au

g-1

8S

ep

-18

Oct-

18

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ays

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Use of ResourcesWell-led

Pag

e 5

of

5

Item

8.1

.1 -

Qua

lity

and

Per

form

ance

Das

hboa

rd a

nd E

xcep

tion

Rep

orts

Page 43 of 120

Board of Directors

Agenda Item 8.1.2

Title of Report Month 12 Finance Report


Author Shahida Mohammed – Acting Deputy Director of Finance Julie Clarke – Assistant Director of Finance Deborah Harman – Assistant Director of Finance


Karen Edge Acting Director of Finance

BAF References


• Key Measure

• Principal Risk

8

8c,8d

Level of Assurance

• Positive

• Gap(s)

Gaps: Financial performance below plan


• Discussion

• Approval

• To Note

To discuss and note

Data Quality Rating Silver – quantitative data that has not been externally validated

FOI status

Document may be disclosed in full

Equality Impact

Assessment

Undertaken

• Yes

• No

No Item

8.1

.2 -

Mon

th 1

2 F

inan

ce R

epor

t

Page 44 of 120

Contents

Month 12 Finance Report 2018/19

1. Executive summary

2. Financial performance

2.1. Income and expenditure

2.2. Income

2.3. Expenditure

2.4. CIP

3. Financial Position

3.1. Statement of Financial Position

3.2. Capital expenditure

3.3. Statement of Cash Flows

4. Use of Resources

Page 45 of 120


As the Trust did not accept the Control Total issued by NHSI for 2018/19 of a surplus of £11.0m, it was unable to access the Provider Sustainability Fund (PSF) of £12.5m. The Trust submitted a plan to NHSI which delivered a deficit of (£25.0m); this included a Cost Improvement Programme (CIP) of £11.0m The following summary details the Trust’s outturn position for FY19 against plan, and forecast. Actual performance against the operational forecast deficit of (£31.4m) was slightly better. The Trust concluded the operational position for the year with a deficit of (£31.3m). The net Trust position for 2018/19 is a deficit of (£33.0m), including technical adjustments. This includes a historic VAT charge in relation to Brookson (+Us) of (c£1.5m) for the provision of medical locums. This has been included following external advice and discussions with NHSI. This is pending audit review, and reflects the risk of retrospective VAT being levied by HMRC via Brookson. The second relates to the Frontis building, and reflects the effects of under-occupancy. Including the technical adjustments, the variance against the initial plan of (£25.0m) is (c£8.0m). The patient-related income position is £2.5m better than plan, this predominantly relates to contracted income. This is inclusive of c£6.4m relating to MSK and income CIP added in year, hence the underlying position is (£3.9m) worse than plan. The main areas driving this position are the under performance in elective and daycase activity, which is 2,742 spells (5.4%) behind plan, with a corresponding financial impact of (c£5.2m), and Outpatients attendances, follow up’s and procedures which are showing an adverse variance of (3,131) (1.0%), and a financial consequence of (£0.8m). There is also an under-performance in neonatal cot days of (£0.7m). Non-elective activity underperformed during quarter 4, with a cumulative under performance of (1,542) spells year to date, however from a financial perspective although the complexity of case-mix has been remained strong the impact of the under performance is (£0.6m). Further mitigation of the below income plan position has been the benefit of the MSK block contract (£2.2m) and the release of the accrual related to the Sepsis dispute (£1.4m) which has been concluded with Wirral CCG. The pay reform funding of £4.1m is showing as above plan in other income with the contra entry in pay costs. The overall financial position includes a pressure of (c£0.3m) in relation to actual costs of the AFC changes which were not funded centrally from NHSI. The overall expenditure position is above the NHSI plan by (£15.1m). However, pay costs includes the Agenda for Change (AFC) pay reform as discussed above of (£4.1m) and is offset in other income. Non pay includes (£4.2m) associated with the MSK contracts which were not included within the original NHSI plan as the contract sign off happened in year; this again is offset in clinical income. Excluding these significant planning variances the underlying operational expenditure position is (c£6.8m) worse than plan. The underlying pay position (adj for AFC reform) is overall on plan for the financial year. Although total pay is overall on plan there have been significant pay variances with pressures in medical staffing in acute care to manage winter demand in the Emergency Department and across acute medical beds. The opening of the Grove discharge unit in November last year has supported patient flow as we continue to work with our partners to transfer medically optimised patients to the right community setting. Medical budgets in some specialties are also overspent where there have been key senior medical gaps and have resulted in the use of agency due to constrained market factors. High levels of qualified nurse vacancies have continued throughout the year and have consequently resulted in a high use of bank nurses to maintain safe staffing levels across the wards. Non-clinical vacancies have supported non-recurrent CIP delivery.

Item

8.1

.2 -

Mon

th 1

2 F

inan

ce R

epor

t

Page 46 of 120


The agency spend for the financial year was £7.8m and is £0.4m above the NHSI ceiling/target for the year. Agency spend is largely used to cover key critical medical gaps and is closely managed, however the position since February has seen an increase over the cap largely driven by the VAT pressure on the Brookson contract, this reflects the change in HMRC’s view in relation to VAT. A further (c£1.5m) of historic VAT charge in relation to Brookson (+Us) has been included in the financial position as a technical accounting adjustment as discussed earlier. The underlying non pay (adj for the MSK contracts) is a financial pressure overall of (c£6.8m). The key variance on this significant overspend is undelivered CIP of (c£3.7m) which has been partially mitigated non-recurrently in pay with non-clinical vacancies in-year. Outsourcing costs are in total (c£1.6m) above plan and (c£1.0m) is due to requirements to deliver the patient waiting times in a number of surgical specialties from transfers earlier in the year. A further (c£0.7m) pressure relates to the Grove discharge unit that was opened in late November for medically optimised patients that is a contracted service with an external partner. External management consultants is (c£0.7m) above plan this year and has supported transformation and governance structures in-year. The overall I&E position includes £3.0m of non-recurrent balance sheet support (including Sepsis). The Trust delivered cost improvements of £9.6m, which is in-line with the forecast position. Of the value delivered, c£2.3m is non-recurrent largely relating to non- clinical vacancies. The recurrent CIP for 2019/20 is c£7.2m; this has been reflected in the 19/20 Plan. There is a now a focus on developing and implementing the 19/20 CIP schemes, to ensure the control total can be delivered and the Trust can access the central funding. As part of the Winter Capacity planning the Trust opened the “step down” facility (T2A) beds part way through November 2018. This Ward will manage the previously significantly high numbers of “medically optimised” patients within the acute bed base, reflecting a lack of alternative support within the health and social care system and consequent adverse impact on flow. The facility has cost the Trust (c£1.2m) for 2018/19, Wirral CCG provided funding of c£0.6m. Cash balances at the end of March were £6.5m, exceeding plan by £4.7m. This is primarily due to positive working capital movements, capital outflows below plan and above-plan PDC received, offset by EBITDA below plan.

Page 47 of 120

3.

Fin

an

cia

l p

erf

orm

an

ce

2.1

In

co

me a

nd

exp

en

dit

ure

•

During

Month

12

the p

lan w

as d

eliv

ere

d,

the y

ear

end o

pera

tion

al

positio

n i

s a

deficit o

f (c

£31

.3m

), w

ith t

he i

nclu

sio

n o

f “y

ear

end”

technic

al

adju

stm

ents

, th

e n

et

Tru

st

positio

n f

or

2018/1

9 i

s a

deficit o

f (£

33.0

m).

T

his

inclu

des a

his

toric V

AT

charg

e i

n r

ela

tion t

o

Bro

okson (

+U

s)

of

(c£1.5

m)

for

the p

rovis

ion o

f m

edic

al lo

cum

s. T

his

has b

een inclu

ded f

ollo

win

g e

xte

rnal le

gal advic

e a

nd d

iscussio

ns

with N

HS

I.

This

is p

endin

g a

udit r

evie

w,

and r

eflects

the r

isk o

f re

trospective V

AT

bein

g l

evie

d b

y H

MR

C v

ia B

rookson.

A f

urt

her

(c£0.2

m)

rela

tes to the F

rontis b

uild

ing,

and r

eflects

the e

ffects

of

under-

occupancy.

•

The m

ain

driver

of

this

positio

n is t

he u

nderp

erf

orm

ance o

f th

e e

lective p

rogra

mm

e w

hic

h is (

c£5.2

m)

belo

w p

lan.

E

xclu

din

g M

SK

sub-

contr

act

variations w

hic

h a

re o

ffset

in e

xpenditure

and t

he b

enefit

of

the M

SK

“blo

ck”

arr

ang

em

ent, t

he u

nderlyin

g c

ontr

act

incom

e

positio

n is Y

TD

(c£3.9

m)

wors

e t

han p

lan..

•

The o

vera

ll in

com

e p

ositio

n inclu

des t

he A

FC

pay r

efo

rm fundin

g o

f c£4.1

m Y

TD

whic

h o

ffset in

the p

ay o

vers

pend

.

•

Althoug

h t

ota

l expenditure

is (

c£

15.1

m)

wors

e t

han p

lan,

the u

nderlyin

g e

xpenditure

positio

n (

adj

for

AF

C p

ay r

efo

rm a

nd M

SK

) is

(c

£6.8

m)

overs

pent.

T

he underlyin

g pay is

o

ve

rall

on pla

n and th

e underlyin

g non pay is

(c

£6.8

m)

over

pla

n and re

flects

earlie

r outs

ourc

ing p

ressure

for

ele

ctive c

apacity,

the d

ischarg

e u

nit o

uts

ourc

ing c

osts

, consultancy c

osts

and n

on

-deliv

ery

of

CIP

.

•

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as to b

e n

ote

d the o

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ll year

to d

ate

positio

n a

lso inclu

des c

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m n

on-r

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heet

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Item

8.1

.2 -

Mon

th 1

2 F

inan

ce R

epor

t

Page 48 of 120

3.

Fin

an

cia

l p

erf

orm

an

ce

2.2

In

co

me

•

The m

ain

specia

litie

s d

rivin

g t

he u

nder

perf

orm

ances i

n e

lective a

nd d

aycase a

ctivity w

ere

Colo

recta

l, O

phth

alm

olo

gy,

Uro

log

y a

nd

Tra

um

a a

nd O

rthopaedic

surg

ery

. C

linic

al H

aem

ato

log

y h

as o

ver

perf

orm

ed w

hic

h is p

art

ially

mitig

ating t

he p

ositio

n.

Goin

g f

orw

ard

into

2019/2

0 “

Booked”

activity i

s b

ein

g m

onitore

d o

n a

weekly

basis

by e

ach D

ivis

ion a

nd t

he C

hie

f O

pera

ting O

ffic

er.

This

m

eth

od of

pro

spective m

anag

em

ent

will

enable

th

e D

ivis

ions to

enact

rem

edia

l action pla

ns t

o ensure

th

e positio

n does not

dete

riora

te.

•

In M

arc

h d

em

and f

or

em

erg

ency c

are

was b

elo

w p

lan levels

, th

is is c

onsis

tent

with d

em

and s

een in J

anuary

and F

ebru

ary

, th

e o

vera

ll

positio

n w

as an under

perf

orm

ance to

(1

,542)

spells

; th

is is

acro

ss a num

ber

of

specia

litie

s.

T

he only

are

a over

perf

orm

ing in

em

erg

ency c

are

is U

pper

GI, this

has m

itig

ate

d the o

vera

ll positio

n.

•

Althoug

h O

utp

atient

follo

w up

att

endances im

pro

ved sig

nific

antly during th

e m

onth

, m

ain

ly in

T

raum

a and O

rthopaedic

s th

is w

as

underm

ined b

y a

reduction in O

P f

irst attendances in b

oth

respirato

ry a

nd T

&O

first appoin

tments

.

•

Birth

s w

ere

belo

w p

lan b

y (

c143).

Ac

tiv

ity

Pla

nA

ctu

al

Variance

%P

lan

Actu

al

Variance

%

Inco

me

fro

m p

ati

en

t care

acti

vit

y

Ele

ctive

689

639

(50)

(7.2

2%

)8,3

51

6,8

70

(1,4

81)

(17.7

4%

)

Daycase

3,6

61

3,7

30

69

1.8

8%

42,8

46

41,5

85

(1,2

61)

(2.9

4%

)

Ele

ctive e

xcess b

ed d

ays

321

683

362

112.8

6%

3,9

60

3,0

80

(880)

(22.2

2%

)

Non-e

lective

4,1

50

3,8

62

(289)

(6.9

5%

)46,6

05

45,0

63

(1,5

42)

(3.3

1%

)

Non-e

lective N

on E

merg

ency

538

428

(110)

(20.4

9%

)5,3

09

5,1

62

(147)

(2.7

7%

)

Non-e

lective e

xcess b

ed d

ays

866

914

48

5.5

3%

9,7

50

9,8

28

78

0.8

0%

A&

E7,8

69

7,8

82

13

0.1

6%

92,6

58

90,9

81

(1,6

77)

(1.8

1%

)

Outp

atients

25,0

38

27,5

59

2,5

20

10.0

7%

299,3

63

296,2

32

(3,1

31)

(1.0

5%

)

Dia

gnostic im

agin

g2,4

63

2,7

19

256

10.3

8%

29,2

82

30,8

84

1,6

01

5.4

7%

Mate

rnity

538

501

(37)

(6.8

7%

)6,3

34

5,9

20

(414)

(6.5

4%

)

Tota

l N

HS

patient care

incom

e46,1

35

48,9

17

2,7

82

544,4

60

535,6

06

(8,8

54)

Activity

Curr

ent m

onth

Year

to d

ate

Page 49 of 120

3.

Fin

an

cia

l p

erf

orm

an

ce

•

Within

the o

vera

ll year

to d

ate

positio

n t

he

main

are

a w

hic

h u

nder

perf

orm

ed s

ignific

antly w

as,

ele

ctive a

nd d

aycases,

whic

h is s

how

ing

a

deficit

of

(£5.2

m),

re

flecting

both

activity

and

casem

ix

reductions.

O

utp

atient

attendances

are

(c

£0.8

m)

belo

w

pla

n,

this

is

pre

dom

inantly in f

irst

attendances a

nd p

rocedure

s.

For

2019/2

0,

activity p

lans h

ave b

een s

et

on a

ctu

al dem

and a

nd c

apacity m

odelli

ng

undert

aken b

y t

he D

ivis

ion.

This

ensure

s t

here

is c

loser

alig

nm

ent

of

activity a

nd r

esourc

e,

perf

orm

ance is m

anag

ed p

rospectively

on a

weekly

basis

.

•

The o

vera

ll positio

n is m

itig

ate

d follo

win

g t

he c

om

mencem

ent of

the M

SK

“prim

e p

rovid

er”

contr

act fr

om

July

2018,

whic

h w

as n

ot

inclu

ded in t

he o

rig

inal pla

n s

ubm

itte

d t

o N

HS

I. T

his

is s

upport

ing

the incom

e p

ositio

n b

y c

£6.4

m, (s

om

e o

f th

is w

ill b

e o

ffset

in

expenditure

due to p

aym

ents

to s

ub

-contr

acto

rs e

.g. W

irra

l C

T for

Physio

serv

ices).

A

s this

is a

“blo

ck”

contr

act, the p

ositio

n inclu

de

s a

cum

ula

tive b

enefit of

c£2.2

m.

•

Despite n

on e

lective a

ctivity u

nderp

erf

orm

ing

the c

asem

ix h

as r

em

ain

ed

str

ong

, support

ing the o

vera

ll positio

n.

•

Perf

orm

ance in o

ther

PbR

are

as h

as r

em

ain

ed s

tatic t

hro

ug

hout th

e y

ear

from

a f

inancia

l pers

pective.

The im

pact of

Birth

s b

ein

g u

nder

pla

n w

as (

c0.4

m).

Neonata

l activity c

onclu

ded t

he y

ear

with a

n u

nderp

erf

orm

ance o

f (£

0.7

m).

G

iven t

he u

npre

dic

table

natu

re o

f th

is

activity a

nd t

he r

elia

nce o

n t

he N

eonata

l netw

ork

for

a larg

e p

rop

ort

ion o

f th

is w

ork

, th

e T

rust has s

uccessfu

lly n

eg

otiate

d a

“blo

ck”

arr

ang

em

ent fo

r 19/2

0, based o

n the 1

8/1

9 p

lan.

•

Inclu

ded in the p

ositio

n is t

he s

uccessfu

l conclu

sio

n w

ith W

irra

l C

CG

of th

e d

ispute

d c

odin

g o

f S

epsis

activity,

during

17/1

8. T

his

support

ed t

he p

ositio

n b

y c

£1.4

m,

and o

ther

bala

nce s

heet support

of

£0.9

m, th

is is r

ecord

ed in t

he “

Oth

er”

cate

gory

in t

he a

bove t

able

.

Item

8.1

.2 -

Mon

th 1

2 F

inan

ce R

epor

t

Page 50 of 120

2.

Fin

an

cia

l p

erf

orm

an

ce

2.3

Exp

en

dit

ure

•

The o

vera

ll year

end e

xpenditure

positio

n is (

c£15.1

m)

above p

lan.

How

ever

exclu

din

g s

ignific

ant

pla

n a

dju

stm

ents

for

MS

K o

f c£4.2

m

YT

D a

nd A

FC

refo

rm f

undin

g o

f c£4.1

m Y

TD

there

is a

n u

nder-

lyin

g o

vers

pend o

f (c

£6.8

m).

Pay i

s o

vera

ll on p

lan a

nd

non-p

ay i

s

(c£6.8

m).

Furt

her

deta

ils b

elo

w:-

2.3

.1 P

ay

•

Perf

orm

ance ag

ain

st

the 18/1

9 pla

n f

or

pay costs

(b

efo

re t

echnic

al

adju

stm

ents

) is

(c£4.1

m)

wors

e th

an pla

n.

How

ever,

th

e pla

n

exclu

ded th

e A

FC

pay r

efo

rm f

undin

g of

(c£

4.1

m)

year

to date

w

hic

h is

off

set

in in

com

e.

Hence t

he underlyin

g pay p

ositio

n (i.e

.

adju

ste

d f

or

pay a

ward

fundin

g)

is o

vera

ll on p

lan f

or

the f

inancia

l year.

This

is s

how

n in t

he a

dju

ste

d s

ection o

f th

e t

able

above.

•

Althoug

h o

n p

lan o

vera

ll th

roug

hout

the y

ear

there

have b

een s

ignific

ant

pre

ssure

s o

n t

he m

edic

al budg

ets

with h

igh u

se o

f non

-core

to

cover

key c

ritical g

aps a

nd t

o s

taff

acute

medic

al are

as.

Nurs

ing

budg

ets

have u

nders

pent

part

icula

rly f

or

qualif

ied n

urs

es a

nd t

he T

rust

continues t

o p

rogre

ss s

ubsta

ntive r

ecru

itm

ent

initia

tives.

Non-

clin

ical

va

cancie

s w

ere

hig

h i

n y

ear

and t

hese u

nders

pends h

ave n

on-

recurr

ently s

upport

ed the d

eliv

ery

of

the C

IP targ

et

as w

ell

as o

ffsett

ing o

ther

financia

l pre

ssure

s.

•

The a

gency f

igure

is c

£0.9

m f

or

Marc

h a

nd t

he y

ear

end s

pend o

n a

gency w

as c

£7.8

m,

c£0.4

m a

bove t

he N

HS

I cap.

The c

hang

e o

n

VA

T t

reatm

ent

from

Febru

ary

has im

pacte

d t

his

and t

he t

echnic

al accounting

adju

stm

ent

reflects

the p

ote

ntial re

trospective V

AT

charg

e

on t

he B

rookson c

ontr

act.

Annual

Pay a

naly

sis

Pla

nP

lan

Actu

al

Variance

Pla

nA

ctu

al

Variance

Pla

nA

ctu

al

Variance

£'0

00

£'0

00

£'0

00

£'0

00

£'0

00

£'0

00

£'0

00

£'0

00

£'0

00

£'0

00

Substa

ntive

(225,6

43)

(18,5

52)

(17,7

80)

772

(225,6

43)

(226,1

31)

(488)

(229,7

09)

(226,1

31)

3,5

78

Bank

(6,6

62)

(551)

(1,0

72)

(521)

(6,6

62)

(9,4

88)

(2,8

26)

(6,6

62)

(9,4

88)

(2,8

26)

Medic

al B

ank

(7,0

57)

(589)

(677)

(88)

(7,0

57)

(7,4

33)

(376)

(7,0

57)

(7,4

33)

(376)

Agency

(7,4

69)

(652)

(874)

(222)

(7,4

69)

(7,8

33)

(364)

(7,4

69)

(7,8

33)

(364)

Oth

er

- A

ppre

nticeship

levy

(900)

(75)

(75)

0(9

00)

(907)

(7)

(900)

(907)

(7)

Tota

l P

ay

(247,7

32)

(20,4

19)

(20,4

78)

(58)

(247,7

32)

(251,7

92)

(4,0

60)

(251,7

98)

(251,7

92)

6

Oth

er

Technic

al Y

ear

End A

dj

00

(1,5

23)

(1,5

23)

0(1

,523)

(1,5

23)

0(1

,523)

(1,5

23)

Adju

ste

d N

HS

I T

ota

l P

ay

(247,7

32)

(20,4

19)

(22,0

01)

(1,5

81)

(247,7

32)

(253,3

15)

(5,5

83)

(251,7

98)

(253,3

15)

(1,5

17)

Year

to d

ate

Adju

ste

d for

AF

C F

undin

g

Curr

ent period

Year

to d

ate

Page 51 of 120

2.

Fin

an

cia

l p

erf

orm

an

ce

•

2.3

.3 N

on

pay

•

Perf

orm

ance a

gain

st

the 1

8/1

9 p

lan f

or

non p

ay is (

c£11.0

m)

above p

lan h

ow

ever

the p

lan e

xclu

des t

he M

SK

contr

act

costs

of

c£

4.2

m

YT

D w

hic

h a

re o

ffset

in incom

e.

Hence t

he u

nderlyin

g n

on

-pay p

ositio

n (

adju

ste

d f

or

MS

K)

is (

c£6.8

m)

overs

pent. T

his

is s

how

n in t

he

adju

ste

d s

ection in the table

above.

•

Purc

hase o

f H

ealthcare

– N

on N

HS

(O

uts

ourc

ing)

adju

ste

d f

or

MS

K i

s (

c£1.6

m)

above p

lan.

Earlie

r outs

ourc

ing c

osts

to S

pire i

n

rela

tion t

o g

aps i

n e

lective c

apacity a

t th

e b

eg

innin

g o

f th

e y

ear

for

num

ber

surg

ical

specia

ltie

s (

Ort

hopaedic

s,

Pain

and E

NT

) is

(c£1.0

m),

whils

t a f

urt

her

(c£0.7

m)

is t

he G

rove D

ischarg

e U

nit a

nd r

adio

log

y n

on N

HS

outs

ourc

ing

pre

ssure

s o

f (c

£0.3

m)

to m

anag

e

capacity g

aps. T

he R

TT

outs

ourc

ing r

eserv

e h

as p

art

ially

off

set th

ese p

ressure

s.

•

Clin

ical supplie

s a

re m

arg

inally

belo

w p

lan a

nd d

rug c

osts

have d

eliv

ere

d to p

lan.

•

Consultancy/

exte

rnal m

anag

em

ent

consultant

costs

have c

ontinued in-m

th larg

ely

to s

upport

tra

nsfo

rmation a

nd g

overn

ance

and h

ave

part

ially

been o

ffset by v

acancie

s.

As s

ubsta

ntive s

tructu

res a

re e

mbedded t

hese c

osts

will

decre

ase.

•

In o

ther

the v

ariance la

rgely

reflects

the u

nder-

deliv

ery

of

CIP

of

(c£3.7

m).

The C

IP p

lan w

as h

eavily

weig

hte

d t

o n

on p

ay a

s t

he £

4.0

m

unid

entified g

ap a

t th

e t

ime o

f subm

itting t

he p

lan w

as a

llocate

d t

o n

on p

ay a

nd i

n y

ear

has b

een p

art

ially

deliv

ere

d n

on-r

ecurr

ently i

n

pay d

ue t

o v

acancie

s.

Annual

Non p

ay a

naly

sis

Pla

nP

lan

Actu

al

Variance

Pla

nA

ctu

al

Variance

Pla

nA

ctu

al

Variance

£'0

00

£'0

00

£'0

00

£'0

00

£'0

00

£'0

00

£'0

00

£'0

00

£'0

00

£'0

00

Purc

hase o

f H

ealthcare

- N

on N

HS

(2

,583)

(275)

(635)

(360)

(2,5

83)

(8,4

14)

(5,8

31)

(6,8

05)

(8,4

14)

(1,6

09)

Supplie

s a

nd s

erv

ices -

clin

ical

(35,4

75)

(2,9

18)

(3,1

06)

(189)

(35,4

75)

(35,3

49)

125

(35,4

75)

(35,3

49)

125

Dru

gs

(25,3

95)

(2,1

09)

(2,1

02)

7(2

5,3

95)

(25,4

02)

(6)

(25,3

95)

(25,4

02)

(6)

Consultancy

00

(109)

(109)

0(7

29)

(729)

0(7

29)

(729)

Oth

er

(38,4

22)

(2,6

24)

(4,0

82)

(1,4

58)

(38,4

22)

(43,0

40)

(4,6

18)

(38,4

22)

(43,0

40)

(4,6

18)

Tota

l O

pera

ting N

on P

ay

(101,8

75)

(7,9

25)

(10,0

34)

(2,1

09)

(101,8

75)

(112,9

34)

(11,0

59)

(106,0

97)

(112,9

34)

(6,8

37)

Depre

cia

tion

(8,1

60)

(693)

(689)

3(8

,160)

(8,1

87)

(27)

(8,1

60)

(8,1

87)

(27)

Oth

er

Technic

al Y

ear

End A

dj

00

(10,6

82)

(10,6

82)

0(1

0,6

82)

(10,6

82)

0(1

0,6

82)

(10,6

82)

Adju

ste

d N

HS

I T

ota

l O

pera

ting E

xpenses

(110,0

35)

(8,6

18)

(21,4

05)

(12,7

87)

(110,0

35)

(131,8

03)

(21,7

68)

(114,2

57)

(131,8

03)

(17,5

46)

Year

to d

ate

Adju

ste

d for

MS

K F

undin

g

Curr

ent period

Year

to d

ate

Item

8.1

.2 -

Mon

th 1

2 F

inan

ce R

epor

t

Page 52 of 120

2.

Fin

an

cia

l p

erf

orm

an

ce

2.4

CIP

by p

rog

ram

me

•

Overa

ll c£9.6

m o

f cost im

pro

vem

ents

/eff

icie

ncie

s w

ere

deliv

ere

d in 2

018/1

9, th

is r

epre

sents

c88%

of

the initia

l ta

rget

of £11.0

m

•

Of

the £

9.6

m C

IP a

chie

ved t

o,

£7.2

m is r

ecurr

ent, t

he r

em

ain

ing d

iffe

rence o

f c£2.3

m h

as b

een a

chie

ved

non

-recurr

ently larg

ely

due t

o

in-y

ear

vacancie

s,

whic

h h

ave h

ence

support

ed the e

ffic

iency p

rogra

mm

e f

or

the y

ear.

The v

acancie

s a

re m

ain

ly in n

on-c

linic

al are

as.

•

The r

ecurr

ent

CIP

gap o

f (c

£3.8

m)

has b

een a

ccounte

d for

as p

art

of th

e 1

9/2

0 D

raft p

lan.

NH

SI P

lan

Actu

al

Varia

nce

Dir

ecto

r£k

£k

£k

Tran

sfo

rm

ati

on

Impro

vin

g P

atient F

low

Anth

ony M

iddle

ton

1,0

00

1,3

37

337

Impro

vin

g P

roductivity

Anth

ony M

iddle

ton

478

808

330

Colla

bora

tion

Janelle

Holm

es

952

812

(140)

Dig

ital W

irra

lP

aul C

harn

ley

1,0

00

1,2

60

260

Su

b t

ota

l -

tran

sfo

rm

ati

on

3,4

30

4,2

17

787

Cro

ss c

utt

ing

wo

rkstr

eam

s

Work

forc

eH

ele

n M

ark

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Page 53 of 120

3. Financial position

Capital asset variances £m

Capex underspend 0.5

Donations above plan 0.2

18/19 additional funding balance 2.3

Total variance of capital assets to plan 2.9

Cash variances £m

EBITDA and donation income below plan -8.3

Working capital movements 10.3

Capital expenditure (cash basis) below plan 0.5

PDC received above plan 1.6

Other minor variances above plan 0.6

Total variance of cash to plan 4.7

3.1 Statement of Financial Position (SOFP)

Actual Month- Plan Actual Variance Plan

as at on-month as at as at (to plan)

01.04.18 movement 31.03.19 31.03.19 31.03.19

£'000 £'000 £'000 £'000 £'000

Non-current assets

159,754 Property, plant and equipment 160,148 161,213 1,065 160,148

12,763 Intangibles 12,369 14,225 1,856 12,369

903 Trade and other non-current receivables 903 820 (83) 903

173,420 173,420 176,258 2,838 173,420

Current assets

4,171 Inventories 4,171 3,973 (198) 4,171

18,423 Trade and other receivables 18,424 14,036 (4,388) 18,424

0 Assets held for sale 0 0 0 0

7,950 Cash and cash equivalents 1,773 6,515 4,742 1,773

30,544 24,368 24,524 156 24,368

203,964 Total assets 197,788 200,782 2,994 197,788

(32,538) Trade and other payables (27,752) (34,815) (7,063) (27,752)

(1,074) Borrowings (1,076) (1,077) (1) (1,076)

(37,384) (32,600) (42,173) (9,573) (32,609)

(6,840) Net current assets/(liabilities) (8,232) (17,649) (9,417) (8,240)

166,580 Total assets less current liabilities 165,188 158,609 (6,579) 165,180

Non-current liabilities

(8,812) Other liabilities (8,470) (2,697) 5,773 (8,470)

(49,258) Borrowings (73,221) (73,223) (2) (73,221)

(2,318) Provisions (2,131) (7,787) (5,656) (2,131)

(60,388) (83,822) (83,707) 115 (83,826)

106,192 Total assets employed 81,366 74,902 (6,464) 81,366

Financed by

Taxpayers' equity

77,575 Public dividend capital 78,031 79,587 1,556 78,031

(12,259) Income and expenditure reserve (37,541) (49,803) (12,262) (37,541)

40,876 Revaluation reserve 40,876 45,118 4,242 40,876

106,192 Total taxpayers' equity 81,366 74,902 (6,464) 81,366 Item

8.1

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Page 54 of 120


2018/19 NHSI

capital plan Budget 1 Actual Variance Forecast Actual Variance

£'000 £'000 £'000 £'000 £'000 £'000 £'000

Funding

Depreciation 8,160 8,160 8,187 (27) 8,193 8,187 6

Loan repayment (1,015) (1,015) (1,015) 0 (1,015) (1,015) 0

Finance lease (60) (60) (59) (1) (60) (59) (1)

Additional funding per plan 3,250 3,250 3,250 0 3,250 3,250 0

Additional funding - equipment trade-in 0 108 108 0 0 108 (108)

Additional external (donations / grant) funding 0 185 165 20 176 165 11

Public Dividend Capital (PDC) - GDE 456 456 0 456 0 0 0

Public Dividend Capital (PDC) - Urgent and Emergency Care 0 2,000 2,000 0 2,000 2,000 0

Public Dividend Capital (PDC) - Pharmacy Infrastructure 0 12 12 0 12 12 0

Total funding 10,791 13,096 12,648 448 12,556 12,648 (92)

Expenditure - schemes

Divisional priorities - Medicine and Acute Care 238 130 108 227 130 97

Divisional priorities - Surgery 372 556 (184) 602 556 46

Divisional priorities - Women and Children's 553 538 15 568 538 30

Divisional priorities - Clinical Support and Diagnostics 1,960 1,845 115 1,975 1,845 130

Divisional priorities - Clinical Support and Diagnostics - MRI 1,050 1,518 1,495 23 1,518 1,495 23

Divisional priorities - contingency 3 500 0 0 0 0 0 0

Informatics - Digital Wirral / Global Digital Exemplar 2,811 2,801 2,647 154 3,029 2,647 382

Informatics 500 536 586 (50) 593 586 7

Switchboard 850 787 63 850 787 63

Estates - backlog maintenance 1,500 3,466 3,190 276 3,401 3,190 211

Car park 0 0 0 0 0 0

Cerner (400) (400) 0 (400) (400) 0

Equipment trade-in 0 108 (108) 0 108 (108)

All other expenditures (193) (145) (48) (155) (145) (10)

Urgent and Emergency Care 0 0 0 0 0 0

Contingency 3 1,180 1,210 0 1,210 0 0 0

Reallocated funding 3,250 0 0 0 0 0 0

NHSI plan subtotal 10,791

Donated assets 0 185 165 20 176 165 11

Total expenditure (accruals basis) 10,791 13,096 11,502 1,594 12,384 11,502 882

Capital programme funding less expenditure 0 0 1,146 (1,146) 172 1,146 (974)

1 This is the NHSI plan, adjusted for approved business cases including additional donated, leased and PDC funded spend.

Full year Comparison to M11 Forecast3.2 Capital expenditure

Capex summary

Capital spend for the year is £11.5m against

full-year plan of £10.8m and budget of

£13.1m.

PDC to be received in year (£0.5m), in

respect of the Digital Wirral scheme, has

been deferred to 2019/20.

2019/20 capital expenditure will continue to

be monitored at FPG to ensure that outturn

is in line with budget.

Capital funding

• Capital expenditure is forecast to be within external funding and internally generated limits for the year.

• Internally generated funding includes brought forward cash.

Page 55 of 120


3.3 Statement of Cash Flows

Actual Plan Variance Actual Plan Variance Plan

£'000 £'000 £'000 £'000 £'000 £'000 £'000

Opening cash 7,715 2,446 5,269 7,950 7,950 0 7,950

Operating activities

Surplus / (deficit) (6,869) (712) (6,157) (37,544) (25,281) (12,263) (25,282)

Net interest accrued 167 183 (16) 1,606 1,778 (172) 1,806

PDC dividend expense 91 191 (100) 2,192 2,292 (100) 2,292

Unwinding of discount 1 3 (2) 7 36 (29) 6

(Gain) / loss on disposal (75) 0 (75) (75) 0 (75) 0

Operating surplus / (deficit) (6,684) (335) (6,349) (33,813) (21,175) (12,638) (21,178)

Depreciation and amortisation 689 690 (1) 8,187 8,157 30 8,160

Impairments / (impairment reversals) 4,492 0 4,492 4,492 0 4,492 0

Donated asset income (cash and non-cash) 0 0 0 (165) 0 (165) 0

Changes in working capital 5,620 2,163 3,457 9,336 (982) 10,318 (996)

Investing activities

Interest received 12 3 9 124 36 88 48

Purchase of non-current (capital) assets 1

(3,241) (508) (2,733) (11,898) (12,444) 546 (12,444)

Sales of non-current (capital) assets 218 0 218 218 0 218 0

Receipt of cash donations to purchase capital assets 0 0 0 35 0 35 0

Financing activities

Public dividend capital received 12 0 12 2,012 456 1,556 456

Net loan funding 2

(508) (508) 0 24,027 24,026 1 24,027

Interest paid (658) (1,026) 368 (1,583) (1,844) 261 (1,845)

PDC dividend paid (1,146) (1,146) 0 (2,335) (2,335) 0 (2,335)

Finance lease rental payments (6) (6) 0 (72) (72) 0 (70)

Total net cash inflow / (outflow) (1,200) (673) (527) (1,435) (6,177) 4,742 (6,177)

Closing cash 6,515 1,773 4,742 6,515 1,773 4,742 1,773

1 Outflows due to the purchase of non-current assets are not the same as capital expenditure due to movements in capital creditors.

2 Support funding currently comprises a working capital facility, and 'uncommitted loans', issued by DHSC and administered by NHSI.

Month Year to date Full Year

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4. Use of resources

Metric DescriptorWeight

%

Metric Rating Metric Rating Metric Rating

Liquidity

(days)

Days of operating costs held in cash-

equivalent forms20% -12.9 3 -20.9 4 -12.9 3

Capital service capacity

(times)

Revenue available for capital service:

the degree to which generated

income covers financial obligations

20% -2.5 4 -4.2 4 -2.5 4

I&E margin

(%)

Underlying performance:

I&E deficit / total revenue

20% -7.4% 4 -9.4% 4 -7.4% 4

Distance from financial plan

(%)

Shows quality of planning and

financial control :

YTD deficit against plan

20% 0.0% 1 -2.0% 3 0.0% 1

Agency spend

(%)

Distance of agency spend from

agency cap

20% 0.0% 1 4.8% 2 0.0% 1

3 3 3

Fin

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Fin

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Overall NHSI UoR rating

Year to Date

Plan

Year to Date

ActualFull Year Plan

4.1 Single oversight framework

UoR rating (financial) - summary table

Page 57 of 120

Conclusion

The Trust concluded the year operationally as forecast in month 11 despite continuing

operational pressures.

The Trust has learned from the 2018/19 in-year challenges, and has set a more robust

deliverable activity plan for 2019/20 which is based on demand and capacity modelling,

which is aligned to the staffing resource.

Pay and non pay budgets have been set to support the operational delivery of the plan; this

also includes additional pressures funding of c£4.0m.

The 19/20 plan is also supported by positive contractual agreements reached with both NHS

Wirral and NHS England – Specialised Commissioning. The agreements reflect overall

“system support” to ensure the Trust is able to deliver the control total and access the central

support.

The cost improvement plan for 19/20 is £13.2m, although this is challenging, the Trust has

set up weekly internal monitoring to maintain focus and pace in delivery.

In addition weekly monitoring arrangements have also been introduced, these meetings are

chaired by the Chief Executive, the review includes, vacancy approval, non-core spend, and

discretionary spend authorisation, which are subject to delivery of CIP milestones.

Although the Trust’s closing cash position is above plan, the Trust’s quarter 1 liquidity is

dependent on revenue borrowing. This is due to the outturn position significantly exceeding

the 18/19 plan. As the Trust has matched its borrowings to the initial plan deficit of (£25.0m)

throughout 2018/19, the Trust will now be requesting additional borrowings in Q1 of 2019/20

which will be c£6.5m. Although this will be drawn in the subsequent financial year, this ‘Q1

catch up’ is an allowed feature of the Trust’s borrowings arrangement, this was approved by

the Board during the April meeting.

The Executive Board is asked to note the contents of this report.

Karen Edge Acting Director of Finance April 2019

Ite

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Board of Directors

Agenda Item 9.1

Title of Report

A Review of Freedom to Speak Up Guardian Report

Date of Meeting

1 May 2019

Author

Ann Lucas, Deputy Director of Workforce Intelligence


Helen Marks, Director of Workforce

BAF References


• Key Measure

• Principal Risk

PR2

Level of Assurance

• Positive

• Gap(s)

Gaps


• Discussion

• Approval

• To Note

To note

Data Quality Rating

Bronze

FOI status

Yes


• Yes

• No

No

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1.1 The purpose of this report is to provide the Board with a review of Freedom to Speak Up (FTSU)

matters and associated issues across the Trust.

1.2 The Board is asked to note the contents of this report.

2. Background

2.1 Guidance issued by NHSI in May 2018 (“Guidance for boards on Freedom to Speak Up in NHS

Trusts and NHS Foundation Trusts”) stated that reports should be presented to the Trust Board

on a six monthly basis to enable a good oversight of FTSU matters and issues. Reports should

be presented by the FTSU Guardian or a member of the Trust’s local Guardian network in

person. All data presented has to maintain the confidentiality of individuals who speak up. The

FTSUG also provides information to the national guardian’s office on a regular basis.

3. Key Issues

Year ended March 2019

3.1 In 2018/19 the FTSUGs received 47 cases, which is a reduction on the previous year; during

2017/18 there were 56 cases raised. It is proposed that an external independent review of the

Guardian service be carried out. Included in the review will be to understand if there are any

concerns about using the service that would have led to the reduction.

3.2 Data is submitted to the National Guardians Office on a quarterly basis and 2017/18 quarter 4

has not yet been formally published. Comparable figures for medium sized acute Trusts for the

first three quarters is shown in the table below:

Number of WUTH cases compared both at a regional and national level

As published by National Guardian Office

Q1 2018/19

Q2 2018/19

Q3 2018/19

Q4 2018/19

Total 2018/19

Wirral UTH

25

4

7

10

46

Regional Average

11

13

14

Not yet published

National Average

10

10

12

Page 60 of 120

3.3 The chart below shows the percentage of concerns raised during 2018/19 by division:

Note: Many concerns have more than one theme so the numbers in the chart will not correlate with the number of cases raised

The chart below details the concerns raised in 2018/19 year by staff group:

Note: The categories used reflect those reported to the National Guardian Office in our quarterly returns

The submission of anonymous complaints to the FTSGs continues to make it difficult to extract all of the required data and to personalise the support offered and to give feedback. Feedback from our staff, who have attended the FTSU training, have highlighted the following barriers to speaking up:-

• Fear of disciplinary action

• Limiting career progression

• Fear of negative response from co-workers

• Nothing will change

• Lack of anonymity and confidentiality

32

1113

7

7

15

Percentage of concerns raised per Trust division 2018/19

Medicine

Surgical

Womens & Childrens

Clinical Support & Diagnostics

Corporate

Unknown

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Assessment of issues raised

3.4 Attitude and behaviour continues to be the most reported theme of those concerns raised. However, we have decided to separate out bullying as a category.

From the issues identified above the following themes have been identified in the chart below:

Specific details about the actions that have been taken to resolve issues have not been recorded against each individual case as well as the dates of when a case is closed. However, this is currently being rectified as a matter of urgency. However, all concerns raised to the FTSUGs have been referred to the appropriate level of management for action, although, in some cases the Guardians have been asked by the individual not to take any action and have asked for advice only. In cases where a patient safety issue has been identified the employee has been advised that the Guardians must escalate the concern and have done so accordingly.

In some cases issues have been resolved by explaining or clarifying issues to the individual, such as points of policy for example. Often cases just require signposting the individual for advice or support from a specialist, or expert.

Raising the profile of the FTSUG within the Trust

3.5 The profile of the FTSUG in the Trust forms part of the staff induction process (including junior

doctors) and FTSU training is available across the organisation. Leaflets and posters are available and have recently been refreshed. Work is ongoing to recruit a guardian from the medical body. A Non-Executive director has also been identified with responsibility for overseeing the FTSU agenda.

Update on lessons learned and improvement actions

3.6 Training and development - Given that one of the main themes raised over the last year was

attitudes and behaviours, and in particular bullying, joint training with staff side colleagues is available. However, the compliance figures for the Bullying and Harassment training are disappointingly low and as at 31 March 2019 level 1 (for all staff) was 17.84% and level 2, which is for managers was 24.97%. If managers are undertaking level 2 they do not have to complete level 1. The executive have now taken the decision that this training has to be undertaken by all

35

18

1

12

8

5

16

6

2

3

Number of times theme features in concerns raised - 2018/19

Attitude & Behaviours

Bullying & Harrassment

Equipment & Maintenance

Staffing Levels

Policies, Procedures & Practices

Quality & Safety

Patient Safety

Patient Experience

Performance Capability

Page 62 of 120

staff across the Trust over the next 12 months. Compliance will be monitored by the executive team.

3.7 FTSU training - Whilst the quality of the FTSU training being provided for staff within the Trust has been acknowledged by both NHSI and the National Guardian’s Office current numbers of people who have undertaken the training are again small and as at 31 March 2019 level 1 (for all staff) compliance was 7.2% and level 2 (for managers) 10.69%. The training is currently provided face-to-face as it is an interactive session. This also limits the number of people who can attend each session and the number of sessions available. In order to address this issue a number of actions have been agreed which include:

• E-Learning module training to be available for level 1 training

• To have in place additional trainers to be trained for level 2 face-to-face delivery

• The number of sessions and the availability on those sessions to be increased

. 3.8 FTSU Champions - Expressions of interest have been sent out for FTSU champions and a

number of responses have already been received ahead of the closing date of 26 April 2019. The role will be about promoting speaking up and signposting staff to training. A review of the numbers and the individuals to be enlisted as champions will take place at the end of April.

3.9 A FTSUG from the medical profession – discussions are currently being held with a senior medic who has agreed to take on the role. A date for when they can commence is to be agreed this week with the Lead Guardian. This would give a total of four guardian roles within the Trust.

3.10 Greater granularity of record keeping – the Guardian data base records need to be improved by adding in the dates that issues are resolved, together with actions taken and reason for any delays in resolving issues. This must be done against each individual case. Records must also be undated in real time so that they are always up-to-date.

4 Next Steps 4.2 In addition to the above it is also intended that an external independent review be carried out to

assess the effectiveness of WUTHs FTSUG processes and how the Trust might further improve for the future. Steps are being taken to prepare a scope for this review together with aims and objectives. Progress and outcomes of this review will be monitored through the workforce governance arrangements.

5. Recommendations


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Board of Directors

Agenda Item 9.2

Title of Report Review of Healthcare Flu Vaccination Programme and Lessons Learnt – 2018/19


Author(s) Ann Lucas, Deputy Director of Workforce Intelligence Carol Skillen, Occupational Health & Wellbeing Manager

Accountable Executive Helen Marks, Director of Workforce

BAF References


• Key Measure

• Principal Risk

PR2

Level of Assurance

• Positive

• Gap(s)

Positive


• Discussion

• Approval

• To Note

To note

Data Quality Rating

FOI status Yes


• Yes

• No

No

Item

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P a g e | 2


1.1 The following report provides the Trust Board with details of the final position on the 2018/19

Flu Campaign at WUTH. It outlines the final Trust position compared to other Trusts within the region and compared to WUTH’s own performance last year. The report also highlights the campaign successes and areas where lessons have been learned in order to further improve things for 2019/20.

1.2 The final trust position was 84.5% of frontline healthcare workers vaccinated compared with

81.3% last year and WUTH was fourth highest in the northwest region compared to seventh place last year. Many things went well in the 2018/19 campaign including robust planning and a comprehensive Trust wide communications plan, as well as an early start to the campaign. Newly introduced ‘opt out’ forms proved a challenge for the 2018/19 campaign with only 61 of the 812 people who were not vaccinated completing a form, and the forms were only partially completed. Actions will be built into the 2019/20 plan to improve this. The 2019/20 plan will also give a greater focus to high risk areas such as haematology, oncology, neonatal intensive care and the special care baby unit. Again, the plan will incorporate lessons learnt from this year’s campaign. The relevant actions are included within this report.

2. Background

2.1 In February 2018, the Medical Directors of NHS England and NHS Improvement wrote to all

NHS Trusts to request that the quadrivalent (QIV) flu vaccine was made available to all healthcare workers during winter 2018-19. It was believed that this particular vaccine offered the broadest protection. It was a major initiative, which formed part of a suite of interventions to reduce the impact of flu across the NHS.

2.2 The letter also advised that higher-risk departments such as haematology, oncology and

neonatal intensive care and special care baby units should move to achieve 100% staff vaccination uptake.

2.3 NHS England wrote to NHS CEO’s in September 2018 stating it was the ambition for 100% of healthcare workers with direct patient contact to be vaccinated. Where staff are offered the vaccine and decide, on the balance of evidence and personal circumstance, against having the vaccine, they should be asked to provide their reason for doing so by completing a form. The opt out forms would be collated and used to inform future vaccination programmes.

3. Key Issues

Trust position

3.1 In 2018/19, 4439 out of 5251(which equates to 84.5%) staff with direct patient contact were

vaccinated against influenza. This was WUTH’s highest ever total achieved and an increase on the 2017/18 flu campaign which delivered 81.3%. This meant that the Trust achieved its required CQUIN target of a 75% uptake of the flu vaccination.

3.2 In 2018/19 WUTH achieved the fourth highest rate of vaccination of Trusts in the North West Region compared to seventh highest in 2017/18. However, our ambition is to deliver similar rates of vaccination to the best performing Trusts.

Page 65 of 120

P a g e | 3

NHS Hospital Trusts North West Region

Percentage uptake for

flu vaccination

ST HELENS AND KNOWSLEY HOSPITALS NHS TRUST 95.4%

EAST LANCASHIRE HOSPITALS NHS TRUST 93.6%

WARRINGTON AND HALTON HOSPITALS NHS FOUNDATION TRUST

89.6%

WIRRAL UNIVERSITY TEACHING HOSPITAL NHS FOUNDATION TRUST

84.5%

COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST

81.9%

AINTREE UNIVERSITY HOSPITAL NHS FOUNDATION TRUST 81.8%

THE WALTON CENTRE NHS FOUNDATION TRUST 80.2%

THE CLATTERBRIDGE CANCER CENTRE NHS FOUNDATION TRUST

80.2%

WIRRAL COMMUNITY NHS TRUST 77.5%

LIVERPOOL WOMEN'S NHS FOUNDATION TRUST 77.1%

LIVERPOOL HEART AND CHEST NHS FOUNDATION TRUST 76.8%

MID CHESHIRE HOSPITALS NHS FOUNDATION TRUST 76.3%

EAST CHESHIRE NHS TRUST 76.3%

ROYAL LIVERPOOL AND BROADGREEN UNIVERSITY HOSPITALS NHS TRUST

75.4%

MERSEY CARE NHS TRUST 75.4%

ALDER HEY CHILDREN'S NHS FOUNDATION TRUST 75.3%

WRIGHTINGTON, WIGAN AND LEIGH NHS FOUNDATION TRUST

67.9%

CHESHIRE AND WIRRAL PARTNERSHIP NHS FOUNDATION TRUST

60.0%

Campaign successes

3.3 There were a number of actions that worked well and contributed to the high level of vaccination.

These are described below:

• Having a robust plan in place that was monitored by the Occupation Health team on a daily basis

• Having adequate levels of vaccine stock assessed and ordered early to cover the full duration of the campaign

• Ensuring appropriate storage was agreed and in place with easy, but secure, access and clear communication about this to all relevant vaccinators

• Having robust vaccine stock control methods agreed and communicated to all relevant vaccinators

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P a g e | 4

• Early recruitment and training of 35 peer vaccinators across the Trust to support the campaign.

• A robust and extensive Trust communications campaign

• A variety of interventions such as ‘Dial a Jab’ service, vaccinations available day, evenings and nights to fit with all shift patterns

• Early start to the campaign - 19 September 2018

3.4 Initially the campaign was serviced by the Occupational Health nurses and a bank staff

nurse, as has been the case in previous years. From November 2018 there was a greater reliance on the use of the peer vaccinators to staff the all-day clinics. In December there was also the added benefit of an interim placement nurse provided by one of the divisions. This allowed for fulltime staffing of the all-day clinics.

4. Challenges from the 2018/19 campaign

4.1 The use of the ‘opt out’ form that was introduced in the 2018/19 campaign could have been better and is an area to be improved for 2019/20. Of the 812 people who chose not to be vaccinated only 61 forms were completed. There were several reasons for the low usage of the form which included:

• Staff being reluctant to fill out a form as they were unsure of how the data would be used

• Managers perceiving the form was the individuals’ responsibility to complete and not always encouraging staff to do so

• Vaccinators did not consistently ask staff to complete the form if they chose not to be vaccinated.

4.2 The 61 staff who did complete the ‘opt out’ form did not all complete the form fully with some leaving out details such as role or place of work. Of the staff that did complete forms, the reasons given for opting out are shown in the table below (note more than one reason was frequently ticked).

Reason Number

I don’t like needles 18

I don’t think I’ll get flu 32

I don’t believe the evidence that being vaccinated is beneficial 11

I’m concerned about possible side effects 41

I don’t know how or where to get vaccinated 0

It was too inconvenient to get to a place where I could get the vaccine

0

The times when the vaccination is available are not convenient 0

Other reason 22

Despite the low response rate the messages from the forms that were completed were used to target messages in communications to staff.

Page 67 of 120

P a g e | 5

5. Lessons Learnt from 2018/19 campaign

5.1 The following actions will be taken this year to ensure better completion of the ‘opt out’ forms

which will include:

• Early engagement with managers and staff side representatives to co-brand ‘opt out’ forms

• More to be included within the communication meetings with managers about how the opt out form should be used and why it is important

• Targeting of ‘opt out’ form completion alongside targeting of low uptake areas

• ‘Opt out’ form completion to be included in flu plan and monitored at weekly flu team meetings

• Clearly communicating with staff the reasons for using the form and how their data will be used.

• Having a clearer focus and monitoring on the high risk, areas as described above, to achieve the 100% (Haematology / Oncology 76% and Neonatal Intensive Care / SCBU 83%)

• Increasing the number of peer vaccinators to enable maximum flexibility in delivering vaccinations.

• In addition to learning from our own experience we will be approaching the highest performing Trusts to learn from their experiences

• Having a greater granuality around the flu data.

6. Next Steps 6.1 The Trust is currently planning for next flu season 2019/20 which will include:

• Peer vaccinator in every clinical area e.g ward, department

• Even earlier communication plan actions and launch prior to campaign starting

• Use of all day clinic on both sites

• Communication and meeting with managers to support improved buy-in to ensuring their staff are fully informed and encouraged to have the vaccine or complete the opt out form

• Identification of and focused action on the high risk clinical areas

• Consideration of a prize draw to incentivise staff to get vaccinated early in the campaign

• Learning from other successful acute Trusts.

7. Recommendations


Item

9.2

- R

evie

w o

f Hea

lthca

re F

lu V

acci

natio

n P

rogr

amm

e an

d Le

sson

s Le

arnt

Page 68 of 120

Board of Directors Agenda Item 10.3

Title of Report Report of Programme Board


Author

Part 1. Steve Sewell, Delivery Director Part 2. Joe Gibson, External Programme Assurance



BAF References


• Key Measure

• Principal Risk

Level of Assurance

• Positive

• Gap(s)


• Discussion

• Approval

• To Note

For Noting

Choose an item N/A



• Yes

• No

No

Item

10.

3 -

Rep

ort o

f Pro

gram

me

Boa

rd

Page 69 of 120

PART ONE – PROGRAMME DELIVERY 1. Update

Priority areas in the Trust Programme are receiving increasing focus and have all recently reviewed and reset objectives, plans and defined benefits to reflect this increased priority, however delivery against benefits remains challenging. Programme Board has initiated work to bring together a pool of people with change management capabilities across the organisation and develop a consistent change approach for the whole organisation. This approach would reduce the current fragmented approaches and provide a more cohesive method of supporting the resource and capability requirements of the priority projects. Programme Board agreed a definition of change management and supported the next steps. Programme Board reviewed the plans and ambitions of the Patient Flow work. The work of the ‘Paperless Steering Group’ was also reviewed, with agreement that the priority of the work needed to be higher and that governance needed to be linked to service change programmes. The work currently supports the establishment of a single safe digital record on the Cerner system through eliminating paper elements of this record in: In Patient areas, Outpatient clinics and ED.

2. Programme Delivery – Priority Areas

2.1. Patient Flow A rapid improvement event over the past month has begun to impact on some aspects of hospital flow with: – 30% reduction in ambulance waits over – 33% reduction in medical outliers – 40% more patients being admitted from ED into AMU & OPAU – 52% reduction in Length of Stay on AMU – 8% increase in daily medical discharges. This good progress, however there are many areas where further progress needs to be made including sustaining the progress made to date. The current plan for the patient flow work is focused on; strengthening Stranded Patient Reviews, redesigning element of the Integrated Discharge Team and the development of a Capacity and Demand model.

2.2 Perioperative Plans have been revisited and a fall in cancelled theatre sessions within 28 days has been seen, but needs to be continued and sustained. Progress against milestones is good, however progress on key benefit metrics remains challenging.

2.3 Outpatients

Page 70 of 120

Outpatient activity has been higher in the past two months although this was lower than hoped. Monitoring of activity has now transferred to the weekly performance meetings and the programme is now completely focused on improvement work that aims to improve efficiency and release capacity through; reducing Trust initiated appointment cancellations, increasing telephone clinics and reducing unnecessary follow ups. The programme plan is being reviewed following final agreement of the outpatient element of the 19/20 contract. A workshop is being held in late April to further develop an innovative clinically led approach to outpatients. Board will receive a more detailed update in the near future.

3. Next Steps

Ensure that priority projects have the right level of resource and that digital projects are aligned and supportive of the objectives of these priority projects.

4. Recommendations

The Board of Directors are asked to note this update.

Item

10.

3 -

Rep

ort o

f Pro

gram

me

Boa

rd

Page 71 of 120

PART TWO – PROGRAMME ASSURANCE

1. Summary

The assurance indicators have remained largely static since the last report. The trend of improvement in the governance domain has stalled and there has been a slight deterioration in the assurance ratings for delivery. Overall pace is not yet responding to deliver the ambition. The realisation of benefits is still falling short of the desired trends as highlighted by the ratings. The actions needed to improve the confidence levels are described in the assurance statements for each project and independent monitoring will continue to assess the assurance evidence.

2. Background

The attached assurance report has been undertaken by Joe Gibson, External Programme Assurance, and provides a detailed oversight of assurance ratings per project. The report provides a summary of the Assurance Report to the Trust’s Programme Board; the independent assurance ratings have been undertaken to gauge the confidence of delivery. The supporting assurance evidence has been discussed at the Programme Board meeting (the membership of which includes two non-executive directors) held on Wednesday 17th April 2019.

3. Programme Assurance - Key Points

3.1. Governance Ratings The trend graph shows a consistent improvement in project governance since August 2018; however, this has recently plateaued and a renewed focus and determination is required to ensure that the changes are being enacted in a safe and governed fashion.

3.2. Delivery Ratings The trend graph shows a stubborn level of amber and red rated projects. The reasons for this are diverse across the projects within the change programme scope; however, definition of benefits and tracking of milestone plans will lead to improvements. In sum, the realisation of ‘service benefits’ at the levels aspired to remains elusive.

4. Assurance Focus

As requested at the Programme Board, and in line with current change strategy, the Trust Board report has now been reframed to provide an executive summary on the top 3 priority projects, namely: Flow, Theatres and Outpatients. It follows, in aggregate, that the assurance ratings for these projects should carry much greater weight than the other 12 projects. This weighting is true not only in terms of their significance to the Trust mission in the near term but also the size and degree of difficulty of the work involved.

The first page of the Change Programme Assurance Report provides a summary of each of the 3 Priority Projects and highlights key issues and progress. The second and third pages show the trends of assurance ratings for governance and delivery respectively.

5. Recommendations

The Board of Directors are asked to note the Trust’s Change Programme Assurance Report and consider the following recommendation:

a. That the Board of Directors requests Senior Responsible Owners to direct their projects to improve confidence in delivery.

Page 72 of 120

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Item

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3 -

Rep

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Boa

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Page 73 of 120

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Page 74 of 120

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Rep

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Page 75 of 120

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Page 76 of 120

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OVERALL

GOVERNANCE

1. Scope and

Approach Defined

2. An Effective Project

Team is in Place

3. Proj. Governance is

in Place

4. All Stakeholders are

engaged

5. EA/Quality Impact

Assessment

OVERALL

DELIVERY

6. Milestone plan is

defined/on track

7. KPIs defined / on

track

8. Risks are identified

and being managed

9. Issues identified

and being managed

1W

ork

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oard

Page 77 of 120

War

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velo

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en

tO

vera

ll G

ove

rnan

ceO

vera

llD

eliv

ery

Nik

ki S

teve

nso

nSh

aun

Bro

wn

Jan

eH

ayes

-Gre

en

Imp

lem

enta

tio

nG

ree

nA

mb

er

Ind

ep

en

de

nt

Ass

ura

nce

Stat

em

en

t

1.

PID

Ver

sio

n 1

.3 d

ated

20

Mar

ch 2

01

9 d

escr

ibes

th

e p

roje

ct; s

ecti

on

4.0

'Ben

efit

s &

Mea

sure

s' s

till

sho

ws

4 o

f 8

met

rics

to

ha

ve t

he

pro

po

sed

im

pro

vem

ent

def

ined

. 2.

& 3

. N

ames

of

the

pro

ject

tea

m o

n t

his

das

hb

oar

d a

re n

ow

co

mp

lete

d.

An

age

nd

a an

d m

inu

tes

for

the

War

d B

ased

Car

e fo

r Ea

rlie

r D

isch

arge

s m

eeti

ngs

up

to

27

Mar

19

are

in e

vid

ence

. Tre

llo B

oar

d is

in u

se f

or

this

pro

ject

. 4

. Th

ere

is n

ow

ext

ensi

ve e

vid

ence

of

stak

eho

lder

en

gage

me

nt.

5. E

A/Q

IA a

re n

ow

co

mp

lete

d.

6.

A 'W

ard

Bas

ed C

are

Mile

sto

ne

Pla

n' d

ated

29

Mar

19

is n

ow

ava

ilab

le a

nd

sh

ow

s ac

tio

ns

bro

adly

on

tra

ck (

a w

eekl

y gr

anu

lari

ty w

ou

ld a

dd

fu

rth

er p

reci

sio

n);

SH

OP

mo

del

no

w b

ein

g em

bed

ded

in M

edic

ine

& A

cute

wit

h a

vie

w t

o

con

sist

ent

use

by

Oct

19

. 7. '

Ben

efit

s an

d M

easu

res:

Rev

ised

20

th M

arch

fo

llow

ing

PFI

G' s

ho

ws

the

ben

efit

s as

def

ined

in t

he

PID

; ho

wev

er, 4

of

8

nee

d t

arge

ts s

et a

nd

tra

ckin

g sh

ou

ld b

e av

aila

ble

. 8

& 9

. T

her

e is

no

w e

vid

ence

of

risk

an

d is

sue

man

agem

en

t in

th

e fo

rm o

f a

RA

ID L

og

wit

h r

isks

re

view

ed u

p t

o 2

0 M

ar 1

9.

Mo

st r

ece

nt

assu

ran

ce e

vid

ence

su

bm

itte

d 8

Ap

r 1

9.

PM

O

Re

fP

rog

ram

me

Tit

leP

rog

ram

me

De

scri

pti

on

SR

O/

Sp

on

so

r

Assu

res

OVERALL

GOVERNANCE

1. Scope and

Approach Defined


Team is in Place


in Place


engaged


Assessment

OVERALL

DELIVERY


defined/on track


track


and being managed


and being managed

2.1

War

d B

ased

Ca

re f

or

Earl

ier

Dis

char

ges

Pati

ents

are

ab

le t

o a

cces

s th

e ri

ght

care

at

the

righ

t ti

me

in t

he

righ

t p

lace

Nik

ki S

teve

nso

ng

a

2. P

rog

ram

me T

wo

- Im

pro

vin

g P

ati

en

t F

low

Page 78 of 120

Co

mm

and

Ce

ntr

e -

Pro

gram

me

Ass

ura

nce

Up

dat

e –

17

thA

pri

l20

19

Exec

Sp

on

sor

Pro

gram

me

Lead

Tran

sfo

rmat

ion

Lea

dSt

age

of

De

velo

pm

en

tO

vera

ll G

ove

rnan

ceO

vera

llD

eliv

ery

Nik

ki S

teve

nso

nSh

aun

Bro

wn

Kati

e B

rom

ley

Imp

lem

enta

tio

nA

mb

er

Red

Ind

ep

en

de

nt

Ass

ura

nce

Stat

em

en

t

1. T

he

PID

, dra

ft v

0.4

dat

ed 8

Ap

r 1

9, l

acks

met

rics

by

wh

ich

ben

efit

s w

ill b

e m

easu

red

. 2

. &

3.

Evid

ence

of

do

cum

ente

d p

roje

ct m

eeti

ngs

is n

ow

o

ut

of

dat

e vi

s-a-

vis

the

gove

rnan

ce d

escr

ibed

in t

he

PID

. U

pd

ates

to

PFI

G a

re o

nly

in e

vid

ence

up

to

Dec

18

. Th

ere

is a

DR

AFT

go

vern

ance

st

ruct

ure

up

load

ed o

n 7

Mar

19

. 4.T

he

PID

ou

tlin

es a

co

mp

reh

ensi

ve c

om

mu

nic

atio

ns

pla

n b

ut

this

nee

ds

to b

e tr

acke

d. T

her

e is

evi

den

ce o

f re

cen

t d

ialo

gue

wit

h s

taff

sid

e co

nce

rnin

g th

e p

roje

ct.

5. E

A h

as b

een

dra

fted

an

d Q

IA s

ign

ed-o

ff. 6

.Th

e n

ew C

om

man

d C

entr

e P

roje

ct P

lan

dat

ed

9 A

pr

19

sh

ow

s go

od

pro

gres

s an

d n

eed

s a

revi

sed

'in

form

atic

s/d

igit

al' s

ecti

on

co

mp

leti

ng.

7.

As

des

crib

ed a

bo

ve, t

her

e ar

e n

o m

etri

cs f

or

the

ben

efit

s to

be

mea

sure

d b

y. 8

& 9

Th

ere

is n

ow

a R

AID

Lo

g u

pd

ated

to

11

Ap

r 1

9. M

ost

rec

en

t as

sura

nce

evi

den

ce s

ub

mit

ted

11

Ap

r 1

9.

PM

O

Re

fP

rog

ram

me

Tit

leP

rog

ram

me

De

scri

pti

on

SR

O/

Sp

on

so

r

Assu

res

OVERALL

GOVERNANCE

1. Scope and

Approach Defined


Team is in Place


in Place


engaged


Assessment

OVERALL

DELIVERY


defined/on track


track


and being managed


and being managed

2.2

Co

mm

and

Ce

ntr

eTo

imp

lem

ent

a n

ew r

eal t

ime

bed

man

agem

ent

syst

em,

incl

ud

ing

a re

-des

ign

of a

ll re

leva

nt

pro

cess

es a

nd

pra

ctic

es t

o

enab

le a

ccu

rate

ref

lect

ion

of t

he

bed

sta

te

Nik

ki S

teve

nso

na

r

2. P

rog

ram

me T

wo

- Im

pro

vin

g P

ati

en

t F

low

Item

10.

3 -

Rep

ort o

f Pro

gram

me

Boa

rd

Page 79 of 120

Tran

sfo

rmat

ion

of

Dis

char

geSe

rvic

es

-P

rogr

amm

eA

ssu

ran

ce U

pd

ate

–1

7th

Ap

ril 2

01

9

Exec

Sp

on

sor

Pro

gram

me

Lead

Tran

sfo

rmat

ion

Lea

dSt

age

of

De

velo

pm

en

tO

vera

ll G

ove

rnan

ceO

vera

llD

eliv

ery

Nik

ki S

teve

nso

nSh

aun

Bro

wn

Kati

e B

rom

ley

Imp

lem

enta

tio

nG

ree

nA

mb

er

Ind

ep

en

de

nt

Ass

ura

nce

Stat

em

en

t

1. T

he

sco

pe

do

cum

ent

com

pri

ses

a 'f

inal

dra

ft' P

ID, T

DSS

v0

.4 u

plo

aded

8 A

pr

19

, fo

r th

e 'T

ran

sfo

rmat

ion

of

Dis

char

ge S

ervi

ces

Sust

ain

abili

ty

Pro

gram

me'

wh

ich

is in

DR

AFT

un

til s

ign

ed o

ff b

y th

e P

roje

ct T

eam

. Ben

efit

#4

sti

ll re

qu

ires

a t

arge

t an

d s

tart

dat

e. 2

.Pro

ject

Tea

m n

ames

are

no

w

com

ple

te o

n t

his

das

hb

oar

d.

3.T

he

'Tra

nsf

orm

atio

n o

f D

isch

arge

Se

rvic

es S

ust

ain

abili

ty P

rogr

amm

e B

oar

d' h

as T

erm

s o

f R

efer

ence

(v7

dat

ed A

pri

l 2

01

9)

and

th

ere

is a

lso

an

act

ion

log

up

dat

ed t

o 1

1 M

ar 1

9.

4.

Ther

e is

no

w a

co

mp

reh

ensi

ve c

om

mu

nic

atio

ns

pla

n T

OD

v3

, 5 M

ar 1

9, a

nd

th

is w

ill

nee

d t

rack

ing

to a

ssu

re d

eliv

ery.

Th

ere

is a

lso

no

tice

fo

r th

e d

emo

nst

rati

on

of

the

new

'So

cial

Car

e p

roce

ss...

' on

9 A

pr

19

.5

. EA

/QIA

hav

e b

een

co

mp

lete

d f

or

an 'I

nd

epen

den

t P

rovi

der

Led

Dis

char

ge U

nit

'. 6

. Th

ere

is a

'TD

S In

tern

al P

lan

' dat

ed A

pri

l 20

17

wit

h d

etai

led

mile

sto

nes

ou

t to

Q3

2

01

9 a

nd

is c

urr

entl

y o

n t

rack

. 7. T

he

key

KP

Is -

Lon

g St

ay P

atie

nt

Imp

rove

me

nt

Traj

ect

ory

(Ta

rget

) o

f 2

82

by

Oct

19

sh

ow

s in

form

atio

n t

o M

arch

2

01

9; f

urt

her

, su

pp

ort

ing,

met

ric

mea

sure

me

nt

will

be

use

ful .

8 a

nd

9.

Ris

ks a

nd

issu

es a

re f

eatu

red

in a

RA

ID L

og

and

wer

e re

view

ed o

n 4

Ap

r 1

9.

Mo

st r

ece

nt

assu

ran

ce e

vid

ence

su

bm

itte

d 8

Ap

r 1

9.

PM

O

Re

fP

rog

ram

me

Tit

leP

rog

ram

me

De

scri

pti

on

SR

O/

Sp

on

so

r

Assu

res

OVERALL

GOVERNANCE

1. Scope and

Approach Defined


Team is in Place


in Place


engaged


Assessment

OVERALL

DELIVERY


defined/on track


track


and being managed


and being managed

2.3

Tran

sfo

rmat

ion

of

Dis

char

ge S

ervi

ces

To r

edu

ce p

atie

nts

len

gth

of s

tay

in a

cute

ho

spit

al b

eds

by

earl

y

iden

tifi

cati

on

of p

atie

nts

ab

le t

o b

e d

isch

arge

d t

hro

ugh

tra

nsf

er

to a

sses

s h

om

e an

d b

ed b

ased

pat

hw

ays.

Nik

ki S

teve

nso

ng

a

2. P

rog

ram

me T

wo

- Im

pro

vin

g P

ati

en

t F

low

Page 80 of 120

Pe

rio

pe

rati

ve M

ed

icin

eIm

pro

vem

en

t –

Pro

gram

me

Ass

ura

nce

Up

dat

e –

17

thA

pri

l 20

19

Exec

Sp

on

sor

Pro

gram

me

Lead

Tran

sfo

rmat

ion

Lea

dSt

age

of

De

velo

pm

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ove

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eliv

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An

tho

ny

Mid

dle

ton

Jo K

eogh

Vic

ky C

lark

eIm

ple

men

tati

on

Gre

en

Red

Ind

ep

en

de

nt

Ass

ura

nce

Stat

em

en

t

1. T

he

PID

v4

dat

ed 2

8 M

ar 1

9 h

as a

co

mp

reh

ensi

ve s

et o

f o

bje

ctiv

es (

wit

h s

om

e p

reci

sio

n s

till

req

uir

ed) a

nd

mea

sura

ble

ben

efit

s d

efin

ed w

ith

m

etri

cs. 2

. A

Pro

ject

Tea

m is

in p

lace

wit

h a

wid

e ra

nge

of

acti

vity

in e

vid

ence

. 3

. Th

e Pe

rio

per

ativ

e M

edic

ine

Stee

rin

g G

rou

p is

go

vern

ing

wit

h

evid

ence

of

mee

tin

gs t

o 2

Ap

r 1

9; b

rief

min

ute

s o

f th

ese

mee

tin

gs w

ou

ld a

ssis

t go

vern

ance

. 4

.Th

ere

is e

vid

ence

of

wid

er s

take

ho

lder

en

gage

me

nt

and

a c

om

mu

nic

atio

ns

pla

n is

no

w a

vaila

ble

, th

is w

ill n

eed

to

be

trac

ked

. 5

. Th

e Q

IA h

as n

ow

bee

n r

eval

idat

ed. 6

. Th

e re

vise

d

mile

sto

ne

pla

n, d

ated

2 A

pr

19

, is

a d

etai

led

an

d w

ell t

rack

ed d

ocu

men

t; h

ow

ever

, it

sho

ws

sign

ific

ant

del

ays

in s

om

e ke

y ar

eas

of

the

pro

ject

in

exce

ss o

f 6

mo

nth

s. 7

. KP

Is a

re d

evel

op

ed in

th

e P

ID.

The

fou

r m

etri

cs b

ein

g tr

acke

d, m

on

thly

, sh

ow

an

ave

rage

of

'am

ber

' per

form

ance

(e.

g. 'C

ore

se

ssio

n u

tilis

atio

n –

aim

is t

o u

tilis

e 8

0%

of

52

wee

k ca

pac

ity

by

Ap

ril 1

st 2

01

9';

this

is r

epo

rted

as

81

% in

Mar

ch 2

01

9 a

nd

ha

s av

erag

ed 7

6.7

%

ove

r th

e p

ast

12

mo

nth

s).

8 a

nd

9.

Evid

ence

in p

lace

co

nce

rnin

g ri

sk a

nd

issu

e m

anag

emen

t b

ut

'dat

e o

f la

st r

evie

w' i

nfo

rmat

ion

is n

ow

ess

enti

al

on

th

e R

isk

Log.

Mo

st r

ece

nt

assu

ran

ce e

vid

ence

su

bm

itte

d 1

0 A

pr

19

.

PM

O

Ref

Pro

gra

mm

e T

itle

Pro

gra

mm

e D

escri

pti

on

SR

O/

Sp

on

so

r

Assu

res

OVERALL

GOVERNANCE

1. Scope and

Approach Defined


Team is in Place


in Place


engaged


Assessment

OVERALL

DELIVERY


defined/on track


track


and being managed


and being managed

3.1

Per

iop

erat

ive

The

spec

ific

focu

s/b

rief

of t

he

Thea

tre

Pro

du

ctiv

ity

Gro

up

, to

ach

ieve

ou

r o

bje

ctiv

es, w

as t

o: R

eco

nfi

gure

th

e Th

eatr

e

Sch

edu

le; E

nab

le t

he

pla

nn

ing

of t

hea

tre

staf

f an

d

anae

sth

etic

s; im

ple

men

t a

syst

em t

o t

rack

an

d m

on

ito

r 45

wee

k

usa

ge; r

edu

ce s

pec

ialt

y le

vel v

aria

tio

n s

o t

hat

all

lists

are

ach

ievi

ng

85%

uti

lisat

ion

tar

get;

imp

lem

ent

a w

eekl

y p

roce

ss t

o

enab

le p

rosp

ecti

ve a

nd

ret

rosp

ecti

ve a

sses

smen

t o

f ses

sio

n

uti

lisat

ion

.

An

tho

ny

Mid

dle

ton

gr

3. P

rog

ram

me T

hre

e -

Op

era

tio

nal T

ran

sfo

rmati

on

Item

10.

3 -

Rep

ort o

f Pro

gram

me

Boa

rd

Page 81 of 120

Ou

tpat

ien

ts Im

pro

vem

en

t-

Pro

gram

me

Ass

ura

nce

Up

dat

e -

17

thA

pri

l 20

19

Exec

Sp

on

sor

Pro

gram

me

Lead

Tran

sfo

rmat

ion

Lea

dSt

age

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ton

Stev

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rah

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ed

Ind

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en

de

nt

Ass

ura

nce

Stat

em

en

t

1.P

ID v

0.5

dat

ed 2

2 M

arch

20

19

def

ines

th

e p

roje

ct.

It w

as a

pp

rove

d b

y th

e O

P T

ran

sfo

rmat

ion

Gro

up

on

1 A

pr

19

an

d w

ill n

eed

re

view

po

st t

he

'Ince

nti

vise

d C

on

trac

t' d

ecis

ion

of

8 A

pr

19

. 2

.A

pro

ject

tea

m is

in p

lace

. 3.

The

'Ou

tpat

ien

ts T

ran

sfo

rmat

ion

Gro

up

' is

in p

lace

wit

h T

oR

agr

eed

at

the

mee

tin

g o

f 1

No

v 1

8 a

nd

do

cum

ents

to

evi

den

ce t

he

mee

tin

gs u

p t

o 1

Ap

r 1

9; t

his

is s

up

ple

men

ted

by

evid

ence

of

ho

w t

his

rep

ort

s in

to t

he

'Op

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ion

al T

ran

sfo

rmat

ion

Ste

eri

ng

Gro

up

' (ag

end

a an

d a

ctio

ns

in e

vid

ence

) th

rou

gh t

o A

pr

19

. 4

. Th

ere

is n

ow

a c

om

pre

hen

sive

'Ou

tpat

ien

ts

Co

mm

un

icat

ion

s an

d E

nga

gem

en

t P

lan

' dra

ft v

1.1

Jan

19

(th

is w

ill n

eed

tra

ckin

g) a

s w

ell a

s ac

tio

n p

lan

nin

g fr

om

sta

keh

old

er w

ork

sho

ps.

5.

The

sign

ed Q

IA h

as b

een

su

bm

itte

d.

6. T

he

Trel

lo' B

oar

d' i

s b

ein

g u

sed

to

cre

ate

and

tra

ck m

ilest

on

es; m

ore

ove

r, a

hig

h le

vel s

um

mar

y p

lan

has

no

w

bee

n p

rod

uce

d t

o c

ove

r 2

01

9 b

ut

nee

ds

to b

e 't

rack

able

'. 7

.K

PIs

are

no

w in

pla

ce w

ith

tra

ject

ori

es f

eatu

red

in t

he

OP

D H

igh

ligh

t R

epo

rt fo

r A

pri

l 2

01

9; t

his

sh

ow

s th

e b

enef

its

sub

stan

tial

ly o

ff t

rack

at

M1

2. 8

an

d 9

. Th

ere

is a

RA

ID L

og

in e

vid

ence

wit

h r

isks

an

d is

sues

last

rev

iew

ed o

n 8

Ap

r 1

9. M

ost

rec

en

t as

sura

nce

evi

den

ce s

ub

mit

ted

8 A

pr

19

.

PM

O

Re

fP

rog

ram

me

Tit

leP

rog

ram

me

De

scri

pti

on

SR

O/

Sp

on

so

r

Assu

res

OVERALL

GOVERNANCE

1. Scope and

Approach Defined


Team is in Place


in Place


engaged


Assessment

OVERALL

DELIVERY


defined/on track


track


and being managed


and being managed

3.2

Ou

tpat

ien

ts

Imp

rove

men

t

To d

esig

n a

nd

imp

lem

ent

21st

cen

tury

ou

tpat

ien

t se

rvic

es t

o

mee

t th

e n

eed

s o

f th

e W

irra

l po

pu

lati

on

. Go

als/

Exp

ecte

d

Ben

efit

s: t

o a

chie

ve t

he

pla

nn

ed o

utp

atie

nt

acti

vity

fo

r 18

/19

by

Mar

ch 2

019;

to

des

ign

a T

rust

Wid

e O

per

atio

nal

Str

uct

ure

for

ou

tpat

ien

ts t

hat

is a

ble

to

cre

ate

an

d m

anag

e a

con

sist

ent

op

erat

ion

al fr

amew

ork

fo

r o

utp

atie

nts

rig

ht

acro

ss t

he

Tru

st; t

o

des

ign

an

d im

ple

men

t 21

st C

entu

ry O

utp

atie

nts

an

d e

limin

ate

pap

er fr

om

ou

tpat

ien

t p

roce

sses

; im

pro

ve p

atie

nt

exp

erie

nce

.

An

tho

ny

Mid

dle

ton

gr

3. P

rog

ram

me T

hre

e -

Op

era

tio

nal T

ran

sfo

rmati

on

Page 82 of 120

Dia

gno

stic

s D

em

and

Man

age

me

nt

-P

rogr

amm

e A

ssu

ran

ce U

pd

ate

-1

7th

Ap

ril 2

01

9

Exec

Sp

on

sor

Pro

gram

me

Lead

Tran

sfo

rmat

ion

Lea

dSt

age

of

De

velo

pm

en

tO

vera

ll G

ove

rnan

ceO

vera

llD

eliv

ery

An

tho

ny

Mid

dle

ton

Alis

tair

Lein

ster

Will

Ivat

tD

esig

nG

ree

nA

mb

er

Ind

ep

en

de

nt

Ass

ura

nce

Stat

em

en

t

1.T

he

pro

ject

PID

, v0

.6 a

s u

plo

aded

28

Mar

19

, ap

pea

rs t

o h

ave

the

ben

efit

s w

ork

no

w c

om

ple

ted

. It

is s

up

ple

men

ted

by

a B

OSC

AR

D,'

Init

iati

on

Pa

ck'

and

th

e p

aper

'Un

war

ran

ted

Var

iati

on

& D

eman

d M

anag

eme

nt:

Pat

ho

logy

Tes

ts',

A B

amb

er.

2.

A p

roje

ct t

eam

is d

efin

ed.

3. T

her

e is

a

com

pre

hen

sive

mee

tin

gs lo

g w

ith

age

nd

as a

nd

act

ion

no

tes

to 2

8 M

ar 1

9.

4.

Ther

e is

a s

take

ho

lder

map

pin

g as

sess

men

t an

d d

raft

Co

mm

s P

lan

(a

lth

ou

gh t

he

latt

er s

till

req

uir

es a

n a

ctio

n p

lan

) b

ut

lack

s ev

iden

ce o

f w

ider

sta

keh

old

er e

nga

gem

en

t (b

eyo

nd

pro

ject

mee

tin

gs).

5.

A Q

IA/E

A h

ave

bee

n d

raft

ed a

nd

QIA

has

bee

n s

ign

ed o

ff o

n 1

8 M

ar 1

9.

6.

A c

om

pre

hen

sive

mile

sto

ne

Gan

tt c

har

t p

lan

has

bee

n d

evel

op

ed, v

1.5

dat

ed 1

5 M

ar

19

, bu

t th

e tr

acki

ng

is n

ow

ou

t o

f d

ate.

7.T

her

e is

no

w a

co

mp

reh

ensi

ve d

ocu

men

t d

escr

ibin

g b

asel

ines

, tar

gets

an

d t

raje

cto

ries

to

geth

er w

ith

a

full

fin

anci

al p

rofi

le; a

lth

ou

gh t

he

firs

t b

enef

it s

tart

dat

e is

Ju

ne

20

19

, a d

ash

bo

ard

has

bee

n p

rep

ared

in a

dva

nce

. 8

an

d 9

. R

isks

an

d is

sues

are

re

cord

ed; r

isk

regi

ster

sh

ow

s th

e 'd

ate

risk

last

rev

iew

ed' a

s 2

8 M

ar 1

9.

Mo

st r

ece

nt

assu

ran

ce e

vid

ence

su

bm

itte

d 2

8 M

ar 1

9.

PM

O

Re

fP

rog

ram

me

Tit

leP

rog

ram

me

De

scri

pti

on

SR

O/

Sp

on

so

r

Assu

res

OVERALL

GOVERNANCE

1. Scope and

Approach Defined


Team is in Place


in Place


engaged


Assessment

OVERALL

DELIVERY


defined/on track


track


and being managed


and being managed

3.3

Dia

gno

stic

s D

eman

d

Man

agem

ent

This

pro

gram

me

aim

s: t

o r

edu

ce s

pen

d o

n d

iagn

ost

ic t

esti

ng

to

acce

pta

ble

leve

ls a

s in

dic

ated

by

NH

SI M

od

el H

osp

ital

Dat

a; t

o

red

uce

dem

and

for

pat

ho

logy

tes

ts (c

ost

s, p

atie

nt

exp

erie

nce

);

to r

edu

ce t

he

nu

mb

er o

f un

its

of b

loo

d t

ran

sfu

sed

into

pat

ien

ts

(ris

k, c

ost

); t

o c

rea

te a

tem

pla

te t

o r

edu

ce d

eman

d fo

r

dia

gno

stic

imag

ing

(& o

ther

pro

ject

s); a

nd

An

tho

ny

Mid

dle

ton

ga

3. P

rog

ram

me T

hre

e -

Op

era

tio

nal T

ran

sfo

rmati

on

Item

10.

3 -

Rep

ort o

f Pro

gram

me

Boa

rd

Page 83 of 120

Dig

ital

: G

DE

Me

dic

ine

s M

anag

em

en

t –

Pro

gram

me

Ass

ura

nce

Up

dat

e –

17

thA

pri

l 20

19

Exec

Sp

on

sor

Pro

gram

me

Lead

Tran

sfo

rmat

ion

Lea

dSt

age

of

De

velo

pm

en

tO

vera

ll G

ove

rnan

ceO

vera

llD

eliv

ery

Nik

kiSt

even

son

PR

ob

erts

LTa

rpey

Imp

lem

enta

tio

nA

mb

er

Red

Ind

ep

en

de

nt

Ass

ura

nce

Stat

em

en

t

1.O

PD

PID

v2

dat

ed 1

6 J

an 1

9 (

no

met

rics

). A

MS

PID

v3

, 25

Oct

18

, 1 b

enef

it o

f £

18

7k

CQ

UIN

(n

o m

etri

cs).

MA

T N

NU

PID

v2

, 23

Oct

18

, 1 b

enef

it

fro

m E

PM

A f

or

mat

ern

ity

/ n

eon

ates

; bas

elin

e b

ut

no

tar

get.

MED

Eye

PID

v4

, 25

Oct

18

, 1 b

enef

it 'c

lose

d lo

op

med

s ad

min

' (n

om

etri

cs).

Pap

er

Ch

arts

PID

v1

, 23

Oct

18

, 1 b

enef

it t

o im

pro

ve s

afet

y (n

o m

etri

cs).

Th

e eP

MA

in O

PD

PID

ad

ded

4 J

an 1

9; m

etri

cs r

equ

ired

for

ben

efit

s.2

. Th

e 'P

rogr

amm

e C

ore

Tea

m' n

ow

co

mp

lete

. 3. T

oR

(u

nd

ated

) fo

r M

edic

ine

GD

E m

eeti

ng

avai

lab

le. N

ote

s o

f m

eeti

ngs

ava

ilab

le t

o 2

7 M

ar 1

9.

PID

s ye

t to

be

app

rove

d b

y th

e 'P

roje

ct B

oar

d'.

4. C

om

ms

Pla

ns

ou

tlin

ed in

th

e P

IDs

bu

t o

nly

AM

S h

as e

vid

ence

of

a 'li

ve' (

v3 1

2 O

ct 1

8)

list

of

acti

on

s;

furt

her

evi

den

ce o

f m

eeti

ngs

wit

h s

take

ho

lder

s to

Mar

19

. 5

.N

o E

A/Q

IA in

evi

den

ce. 6

.M

ilest

on

e P

lan

s: A

MS

PP

v2

20

18

01

19

(d

ate?

) co

mp

lete

b

ut

2 o

verd

ue

com

ms

acti

on

s; M

at a

nd

NN

U P

P v

4 d

ated

9 S

ep 1

8, s

ho

ws

del

ays

and

has

act

ivit

ies

un

dat

ed;

MED

Eye

PP

v1

, 1 N

ov

18

, sh

ow

s d

elay

s an

d h

as m

any

acti

viti

es u

nd

ated

. Pap

er C

har

ts P

P v

25

Jan

19

, lar

gely

up

to

dat

e.7

. Of

the

20

ben

efit

s d

efin

ed o

n t

he

'Med

s B

enef

its

Mat

rix'

u

plo

aded

Mar

ch 2

01

9, n

on

e h

as a

n im

ple

men

tati

on

dat

e an

d t

her

e ar

e o

nly

3 w

ith

tar

gets

. 8

& 9

. R

isks

& Is

sues

: R

AID

Lo

g v1

6, 6

Mar

19

, co

lou

r co

din

g o

f ri

sk s

core

s as

per

th

e ke

y w

ou

ld a

id c

om

pre

hen

sio

n. M

ost

rec

en

t as

sura

nce

evi

den

ce r

ece

ived

4 A

pr

19

.

PM

O

Re

fP

rog

ram

me

Tit

leP

rog

ram

me

De

scri

pti

on

SR

O/

Sp

on

so

r

Assu

res

OVERALL

GOVERNANCE

1. Scope and

Approach Defined


Team is in Place


in Place


engaged


Assessment

OVERALL

DELIVERY


defined/on track


track


and being managed


and being managed

5.1

Me

ds

Man

agem

ent

This

mee

tin

g ex

ists

to

mo

nit

or

pro

gres

s o

f th

e ag

reed

an

d

rati

fied

GD

E M

edic

ine

pro

gram

me.

To

en

sure

th

at a

pp

rop

riat

e

reso

urc

es a

re a

vaila

ble

to

mee

t th

e re

qu

irem

ents

of t

he

pro

gram

me

and

ob

ject

ives

an

d b

enef

its

are

iden

tifi

ed a

nd

rea

lised

. Th

ere

is a

lso

an

ack

no

wle

dge

men

t th

at it

is e

ssen

tial

that

BA

U w

ork

fo

r th

e Ph

arm

acy

serv

ice

is c

arri

ed o

ut

in

par

alle

l. It

is u

nd

erst

oo

d t

hat

BA

U a

nd

GD

E p

roje

cts

will

imp

act

on

ea

ch o

ther

as

esse

nti

ally

th

e sa

me

reso

urc

es a

re r

equ

ired

for

bo

th. T

his

mee

tin

g w

ill s

up

po

rt p

rio

riti

sati

on

of w

ork

fo

r b

oth

BA

U a

nd

GD

E p

roje

cts.

Nik

ki S

teve

nso

na

r

5. P

rog

ram

me F

ive -

Dig

ital

Page 84 of 120

Dig

ital

: GD

E D

evic

e In

tegr

atio

n –

Pro

gram

me

Ass

ura

nce

Up

dat

e –

17

thA

pri

l 20

19

Exec

Sp

on

sor

Pro

gram

me

Lead

Tran

sfo

rmat

ion

Lea

dSt

age

of

De

velo

pm

en

tO

vera

ll G

ove

rnan

ceO

vera

llD

eliv

ery

Nik

kiSt

even

son

Gay

no

rW

estr

ayM

ich

elle

Mu

rray

Imp

lem

enta

tio

nA

mb

er

Red

Ind

ep

en

de

nt

Ass

ura

nce

Stat

em

en

t

1.I

nfu

sio

n P

um

ps

GD

E P

ID v

0.4

, 23

Feb

19

; ben

efit

s to

sav

e n

urs

es t

ime,

pre

ven

t in

accu

rate

dat

a in

to E

PR

(n

o m

etri

cs).

PC

ECG

GD

E P

ID v

0.3

, 0

11

02

01

8; b

enef

its

'tb

c'. V

ital

slin

k G

DE

PID

v0

.8, 2

3 F

eb 1

9; b

enef

its:

a. s

ave

nu

rses

tim

e @

30

,66

5 h

ou

rs b

y A

pr

20

20

b. e

nsu

real

l bas

ic

ob

serv

atio

ns

are

reco

rded

acc

ura

tely

-d

etai

ls p

rovi

ded

for

Mar

-M

ay 1

8 h

as s

ho

wn

a d

ecre

ase

"in

err

or"

rat

e to

0.1

11

9%

(b

asel

ine

0.2

16

1%

).

SEC

A P

ID v

0.6

dat

ed 2

3 F

eb 1

9 h

as o

bje

ctiv

es a

nd

1 o

f 3

ben

efit

s d

efin

ed.

2.'

Pro

gram

me

Co

re T

eam

' nam

es

on

das

hb

oar

d c

om

ple

ted

.3.D

evic

e In

tegr

atio

n P

roje

ct t

eam

min

ute

s in

evi

den

ce t

o 1

2 F

eb 1

9.

PID

s h

ave

no

w b

een

ap

pro

ved

(Fe

b 1

9)

in a

'Pro

ject

Bo

ard

'.4

.'V

ital

slin

k C

om

mu

nic

atio

n P

lan

', 3

01

02

01

8, i

s a

sch

edu

le f

or

Pro

j. B

oar

d a

nd

no

t ev

iden

ce o

f en

gage

me

nt.

5.N

o E

A/Q

IA in

evi

den

ce.6

.SEC

A P

roje

ct P

lan

, 6

Mar

19

, sh

ow

s so

me

del

ays.

In

fusi

on

Pu

mp

s p

roje

ct p

lan

, 25

Jan

19

, nee

ds

to s

ho

w c

om

ple

tio

n/p

rogr

ess

of

task

s. D

evic

e In

tegr

atio

n P

roje

ct P

lan

v0

.10

4 D

ec 2

01

8 s

ho

ws

man

y el

em

ents

co

mp

lete

d b

ut

ove

rdu

e 'G

o L

ive'

in P

aed

iatr

ics

sin

ce J

un

e 2

01

8; p

lan

no

w c

om

ple

tes

Feb

19

. PC

ECG

P

roje

ct P

lan

v0

.7 d

ated

22

Mar

19

ap

pea

rs t

o b

e o

n t

rack

. 7

.No

evi

den

ce o

f tr

acki

ng

of

ben

efit

s.8

& 9

.Evi

den

ce o

f ri

sk m

anag

eme

nt

on

Sh

areP

oin

t to

12

Feb

19

. M

ost

rec

en

t as

sura

nce

evi

de

nce

rec

eiv

ed 4

Ap

r 1

9.

PM

O

Re

fP

rog

ram

me

Tit

leP

rog

ram

me

De

scri

pti

on

SR

O/

Sp

on

so

r

Assu

res

OVERALL

GOVERNANCE

1. Scope and

Approach Defined


Team is in Place


in Place


engaged


Assessment

OVERALL

DELIVERY


defined/on track


track


and being managed


and being managed

5.2

Dev

ice

Inte

grat

ion

To c

on

nec

t an

d in

tegr

ate

Med

ical

Dev

ices

wit

h W

irra

l

Mill

enn

ium

en

ablin

g th

e au

tom

atio

n o

f res

ult

s re

cord

ing

in t

he

follo

win

g ar

eas:

Ob

serv

atio

ns,

EC

G’s

an

d In

fusi

on

Pu

mp

s

Nik

ki S

teve

nso

na

r

5. P

rog

ram

me F

ive -

Dig

ital

Item

10.

3 -

Rep

ort o

f Pro

gram

me

Boa

rd

Page 85 of 120

Dig

ital

: G

DE

Imag

e M

anag

em

en

t -

Pro

gram

me

Ass

ura

nce

Up

dat

e -

17

thA

pri

l 20

19

Exec

Sp

on

sor

Pro

gram

me

Lead

Tran

sfo

rmat

ion

Lea

dSt

age

of

De

velo

pm

en

tO

vera

ll G

ove

rnan

ceO

vera

llD

eliv

ery

Nik

kiSt

even

son

Nik

ki S

teve

nso

nM

ich

elle

Mu

rray

Imp

lem

enta

tio

nA

mb

er

Red

1.S

cop

e co

mp

rise

s: P

ID B

ron

cho

sco

py

PID

v0

.2 0

21

12

01

8, P

ID C

olp

osc

op

y v0

.1 0

21

12

01

8, T

hea

tres

Imag

e M

gt P

ID 0

21

12

01

8, P

ID M

edic

alP

ho

togr

aphy

; 09

11

20

18

; 1 b

enef

it c

ited

-fo

r al

l 4 p

roje

cts

-is

th

at a

ll cl

inic

al im

ages

will

be

sto

red

ele

ctro

nic

ally

in o

ne

cen

tral

loca

tio

n (

PAC

's),

th

eref

ore

clin

icia

ns

can

acc

ess

the

imag

es m

ore

eff

icie

ntl

y. 2

. Th

e 'P

rogr

amm

e C

ore

Tea

m' n

ame

s o

n d

ash

bo

ard

hav

e b

een

co

mp

lete

d. 3

. Ev

iden

ce

of

pro

ject

mee

tin

gs: '

re-s

tart

mee

tin

g' o

f 1

Feb

19

an

d M

edic

al P

ho

togr

aph

y to

18

Ap

r 1

9; a

ll P

IDs

yet

to b

e ap

pro

ved

at

a P

roje

ct B

oar

d.

4. T

her

e is

a 'C

olp

osc

op

y C

om

ms

Pla

n' v

0.1

02

11

20

18

wh

ich

is a

sch

edu

le o

f su

bm

issi

on

dat

es t

o P

roje

ct B

oar

d a

nd

no

t ev

iden

ce o

f st

ake

ho

lder

en

gage

me

nt.

5.N

o E

A/Q

IA in

evi

den

ce. 6

.Rev

ised

Pro

ject

Pla

ns,

dat

ed 6

Mar

19

, rec

eive

d f

or

Bro

nch

osc

op

y, M

ed P

ho

to a

nd

Th

eatr

e. C

olp

osc

op

y P

P 0

71

12

01

7 s

tart

ed a

nd

fin

ish

ed in

No

v 1

7 h

as b

een

su

bm

itte

d (

bu

t n

ot

clea

r w

hy)

. 7

.N

o e

vid

ence

of

trac

kin

g o

f b

enef

its

yet

sub

mit

ted

. 8 &

9.

A

con

solid

ated

'Ris

k an

d Is

sue

Log'

is n

ow

in u

se, u

pd

ated

on

6 M

ar 1

9, a

nd

nee

ds

a 'd

ate

of

last

rev

iew

' co

lum

n f

or

risk

s.

Mo

st r

ece

nt

assu

ran

ce

evid

ence

rec

eiv

ed 4

Ap

r 1

9.

PM

O

Re

fP

rog

ram

me

Tit

leP

rog

ram

me

De

scri

pti

on

SR

O/

Sp

on

so

r

Assu

res

OVERALL

GOVERNANCE

1. Scope and

Approach Defined


Team is in Place


in Place


engaged


Assessment

OVERALL

DELIVERY


defined/on track


track


and being managed


and being managed

5.3

Imag

e M

anag

emen

t

This

pro

ject

aim

s to

del

iver

: Dig

ital

imag

es a

nd

rep

ort

s fr

om

Bro

nch

osc

op

y ex

amin

atio

ns

sto

red

wit

hin

th

e EM

R v

ia t

he

PAC

S N

etw

ork

; Pro

vid

e Ex

celle

nt

serv

ices

to

: ou

r co

llea

gues

,

qu

alit

y se

rvic

es, c

linic

ian

led

ch

ange

s to

imp

rove

ser

vice

s,

elim

inat

ing

un

wan

ted

clin

ical

var

iati

on

; To

max

imis

e va

lue:

in

the

solu

tio

ns

and

Wir

ral M

illen

niu

m; C

linic

ian

s w

ill h

ave

all

imag

es t

hey

nee

d a

vaila

ble

to

th

em e

lect

ron

ical

ly; I

mp

rove

d

clin

ical

saf

ety;

Op

po

rtu

nit

y to

rev

iew

clin

ical

pro

cess

es.

Nik

ki S

teve

nso

na

r

5. P

rog

ram

me F

ive -

Dig

ital

Page 86 of 120

Dig

ital

: G

DE

Pat

ien

t P

ort

al -

Pro

gram

me

Ass

ura

nce

Up

dat

e -

17

thA

pri

l 20

19

Exec

Sp

on

sor

Pro

gram

me

Lead

Tran

sfo

rmat

ion

Lea

dSt

age

of

De

velo

pm

en

tO

vera

ll G

ove

rnan

ceO

vera

llD

eliv

ery

Nik

kiSt

even

son

Mr

Dav

id R

ow

lan

ds

Kath

erin

e H

anlo

nIm

ple

men

tati

on

Am

be

rA

mb

er

Ind

ep

en

de

nt

Ass

ura

nce

Stat

em

en

t

1.P

ID v

1.5

, 25

Oct

18

, ap

pro

ved

by

pro

ject

bo

ard

on

28

Ju

n 1

7. 3

ben

efit

s re

du

cin

g fo

llow

-up

O/P

ap

pts

for

Uro

logy

, Co

lore

ctal

an

d B

reas

t b

ut

no

b

asel

ine

or

targ

et m

etri

cs (

exce

pt

£2

8k

ben

efit

bas

elin

e ci

ted

fo

r U

rolo

gy w

ith

£3

6.5

k ta

rget

). P

atie

nt

Sto

ry d

efin

es p

atie

nt

ben

efit

.2.T

he

'Pro

gram

me

Co

re T

eam

' nam

es

on

th

is d

ash

bo

ard

to

be

com

ple

ted

.3.M

inu

tes

of

the

Pro

ject

Bo

ard

ava

ilab

le t

o 2

6 S

ep

18

; ho

wev

er, t

he

mee

tin

g o

f 2

1 N

ov

18

was

can

celle

d d

ue

lack

of

qu

ora

cy a

nd

th

e d

ecis

ion

was

tak

en, d

ue

to 'd

win

dlin

g at

ten

dan

ce' t

o c

ance

l th

e m

eeti

ng

of

12

Dec

18

-th

e n

ext

mee

tin

g w

ill b

e 2

3 J

an 1

9 a

lth

ou

gh n

o e

vid

ence

of

this

mee

tin

g re

ceiv

ed t

o d

ate.

Ther

e is

an

'Act

ion

Lo

g' n

ow

ava

ilab

le d

ated

20

Feb

19

. 4

.Th

ere

is a

Co

mm

s P

lan

, v4

24

Oct

18

, wh

ich

has

so

me

acti

viti

es r

eco

rded

bu

t la

cks

forw

ard

loo

kin

g sc

hed

ule

; th

ere

is a

lso

a p

rese

nta

tio

n t

o

Pro

ject

Bo

ard

of

20

Mar

19

.5.N

o E

A/Q

IA in

evi

den

ce.6

.Mile

sto

ne

Pla

n, v

1.6

of

5 M

ar 1

9, i

s tr

acke

d b

ut

beh

ind

sch

edu

le in

so

me

area

s.7

.2

grap

hs

sho

w, p

rosp

ecti

vely

, th

e le

vel o

f b

enef

its

exp

ecte

d f

rom

20

20

.8

& 9

,Ris

ks a

nd

Issu

es:

RA

ID L

og,

5 M

ar 1

9, c

aptu

res

risk

s an

d is

sues

an

d

thes

e w

ere

-fo

r th

e m

ost

par

t -

last

rev

iew

ed a

t th

e P

roje

ct B

oar

d o

f 2

Feb

19

. O

ne

risk

ap

pea

rs t

o h

ave

bee

n r

evie

wed

on

7 F

eb 1

9.M

ost

re

cen

t as

sura

nce

evi

den

ce r

ece

ived

4 A

pr

19

.

PM

O

Re

fP

rog

ram

me

Tit

leP

rog

ram

me

De

scri

pti

on

SR

O/

Sp

on

so

r

Assu

res

OVERALL

GOVERNANCE

1. Scope and

Approach Defined


Team is in Place


in Place


engaged


Assessment

OVERALL

DELIVERY


defined/on track


track


and being managed


and being managed

5.4

Pat

ien

t P

ort

al

On

e o

f th

e p

iece

s o

f fu

nct

ion

alit

y C

ern

er M

illen

niu

m o

ffer

s is

a

“pat

ien

t p

ort

al”.

Th

rou

gh p

atie

nt

po

rtal

ind

ivid

ual

s ca

n h

ave

rea

l-ti

me

acce

ss t

o s

pec

ific

req

ues

ts s

uch

ap

po

intm

ent

chan

ges

and

clin

ical

info

rmat

ion

th

at c

an b

e vi

ewed

in t

he

Cer

ner

Mill

enn

ium

ele

ctro

nic

med

ical

rec

ord

(EM

R).

Th

e p

atie

nt

po

rtal

is e

ssen

tial

for

rem

ote

su

rvei

llan

ce a

nd

sel

f -

man

agem

ent

of p

atie

nts

livi

ng

bey

on

d c

ance

r. T

he

po

rtal

,

alo

ng

wit

h a

ro

bu

st t

rack

ing

syst

em w

ill a

llow

for

pat

ien

ts t

o b

e

man

aged

rem

ote

ly a

nd

th

eref

ore

red

uce

th

e am

ou

nt

of f

ollo

w

up

s re

qu

ired

wit

hin

a h

osp

ital

set

tin

g.

Nik

ki S

teve

nso

na

a

5. P

rog

ram

me F

ive -

Dig

ital

Item

10.

3 -

Rep

ort o

f Pro

gram

me

Boa

rd

Page 87 of 120

Par

tne

rsh

ips:

Wo

me

n &

Ch

ildre

n’s

-P

rogr

amm

e A

ssu

ran

ce U

pd

ate

-1

7th

Ap

ril 2

01

9

Exec

Sp

on

sor

Pro

gram

me

Lead

Tran

sfo

rmat

ion

Lea

dSt

age

of

De

velo

pm

en

tO

vera

ll G

ove

rnan

ceO

vera

llD

eliv

ery

TBD

Gar

y P

rice

/Jo

e D

ow

nie

Am

yB

arto

nIm

ple

men

tati

on

Am

be

rR

ed

Ind

ep

en

de

nt

Ass

ura

nce

Stat

em

en

t

1. S

cop

e is

in: '

Ap

pen

dix

1, W

irra

l an

d W

este

rn C

hes

hir

e W

om

en a

nd

Ch

ildre

n’s

Alli

ance

ob

ject

ives

an

d K

PIs

: Su

mm

ary.

Rev

ised

No

v1

8O

verv

iew

'; a

PID

has

bee

n u

plo

aded

bu

t ap

pea

rs t

o b

e at

leas

t 1

2 m

on

ths

ou

t o

f d

ate.

A W

om

en's

& C

hild

ren

's A

llian

ce s

lide

pac

k, M

ar 1

9,

also

ava

ilab

le. 2

.'P

rogr

amm

e C

ore

Tea

m' i

n p

lace

. Min

ute

s o

f a

W&

C A

llian

ce L

ead

ersh

ip G

rou

p o

f W

edn

esd

ay 2

0th

Mar

ch 2

01

9 a

re a

vaila

ble

. 3

.To

R f

or

the

'Wo

men

’s &

Ch

ildre

n’s

Alli

ance

–So

uth

of

the

Mer

sey

Lead

ersh

ip D

eliv

ery

Gro

up

' are

in e

vid

ence

. Th

e W

&C

Alli

ance

rec

ord

of

atte

nd

ance

/ a

ctio

n

log

/ m

inu

tes

are

avai

lab

le t

o 1

5 N

ov

18

. 4.T

her

e is

so

me

evid

ence

of

stra

tegi

c en

gage

me

nt

and

a r

ecen

t st

art

on

an

inco

mp

lete

pro

cess

map

fo

r th

e Pa

edia

tric

Hu

b. 5

.QIA

an

d E

A d

raft

ed a

nd

du

e to

be

sign

ed o

ff w

/c 1

0 D

ec 1

8.

6.T

her

e is

no

cu

rren

t m

ilest

on

e p

lan

in e

vid

ence

. 7.

Ther

e ar

e 7

K

PIs

ass

oci

ated

wit

h t

he

pro

gram

me

rep

ort

ed o

n S

har

ePo

int

thes

e ar

e b

ein

g ra

ted

: 3 G

ree

n, 3

Am

ber

, 4 R

ed.

8 a

nd

9.

Ris

ks a

nd

Issu

es u

pd

ated

in

RA

ID lo

g o

f N

ov

18

sh

ow

ing

no

live

ris

ks o

r is

sues

(n

eed

to

ver

ify

that

th

e p

rogr

amm

e o

f 6

wo

rk s

trea

ms

has

no

cu

rren

t ri

sks

or

issu

es).

Mo

st

rece

nt

assu

ran

ce e

vid

ence

rec

eiv

ed 4

Ap

r 1

8.

PM

O

Re

fP

rog

ram

me

Tit

leP

rog

ram

me

De

scri

pti

on

SR

O/

Sp

on

so

r

Assu

res

OVERALL

GOVERNANCE

1. Scope and

Approach Defined


Team is in Place


in Place


engaged


Assessment

OVERALL

DELIVERY


defined/on track


track


and being managed


and being managed

Co

llab

ora

tio

n -

Wo

me

n a

nd

Ch

ildre

n

6.2

Wo

men

an

d C

hild

ren

s T

he

Ch

esh

ire

and

Mer

sey

STP

calls

for

loca

l so

luti

on

s fo

r

wo

men

an

d c

hild

ren

’s s

ervi

ces

to a

dd

ress

wo

rkfo

rce

and

qu

alit

y ch

alle

nge

s

Nat

alia

Arm

esa

r

6. P

rog

ram

me S

ix -

Part

ners

hip

s (

GD

E E

nab

led

)

Page 88 of 120

He

alth

y W

irra

l: M

ed

icin

es

Man

age

me

nt

-P

rogr

amm

e A

ssu

ran

ce U

pd

ate

-1

7th

Ap

ril 2

01

9

Exec

Sp

on

sor

Pro

gram

me

Lead

Tran

sfo

rmat

ion

Lea

dSt

age

of

De

velo

pm

en

tO

vera

ll G

ove

rnan

ceO

vera

llD

eliv

ery

Mik

e Tr

ehar

ne,

DO

F C

CG

TBD

Pip

pa

Ro

ber

tsIm

ple

men

tati

on

Am

be

rA

mb

er

Ind

ep

en

de

nt

Ass

ura

nce

Stat

em

en

t

1.'

Sco

pe'

: 'M

edic

ines

Op

tim

isat

ion

Pro

gram

me

Bo

ard

is a

n e

nab

ling

pro

gram

me

of

wo

rk s

up

po

rtin

g H

ealt

hy

Wir

ral'

of

12

Dec

18

an

dth

ere

is a

PID

in

dra

ft, u

plo

aded

on

13

Dec

18

. Th

ere

is a

lso

a 'W

irra

l Fo

rmu

lary

Tra

nsi

tio

n In

corp

ora

tin

g Pa

n M

erse

y D

ecis

ion

-Mak

ing'

up

load

ed

12

Mar

19

. 2.

No

tes

of

Hea

lth

y W

irra

l OPA

T M

eeti

ng,

6 M

arch

20

19

, are

ava

ilab

le; n

o m

inu

tes

seen

of

the

'Med

icin

es O

pti

mis

atio

n P

rogr

amm

e B

oar

d'.

3.

Go

vern

ance

str

uct

ure

sh

ow

s h

ow

th

e 'M

edic

ines

Op

tim

isat

ion

Pro

gram

me

Bo

ard

' rel

ates

to

th

e 'H

ealt

hy

Wir

ral E

xecu

tive

Del

iver

yG

rou

p' a

nd

th

e 'H

ealt

hy

Wir

ral P

rogr

amm

e B

oar

d';

vers

ion

5 o

f th

e P

rogr

amm

e B

oar

d T

oR

nee

ds

a d

ate

to s

ho

w w

he

n t

he

do

cum

ent

was

au

tho

rise

d.A

Gen

eral

P

ract

ice

Clin

ical

Ph

arm

acis

t (G

PC

P)

Imp

lem

enta

tio

n G

rou

p m

eets

, To

R Is

sue

3 s

ign

ed o

ff J

un

e 2

01

8.

Bio

sim

ilars

has

To

Rs

dat

edA

pr

18

, met

in S

ep

1

8. 4

. Th

ere

is e

vid

ence

of

GP

CP

sta

keh

old

er e

nga

gem

en

t an

d c

om

ms.

5.

EA/Q

IA s

ign

ed o

ff 1

8 M

ar 1

9. 6

. Th

ere

is n

o m

ilest

on

e p

lan

. 7.

Som

e K

PIs

ar

e b

ein

g tr

acke

d in

ter

ms

of

acti

vity

fo

r G

PC

P b

ut

no

sen

se o

f ta

rget

th

resh

old

s fo

r o

utp

ut

/ o

utc

om

e. B

iosi

mila

r fi

nan

cial

sav

ings

are

sh

ow

n in

'A

dal

imu

mab

Bio

sim

ilar

Imp

lem

enta

tio

n: J

anu

ary

20

19

Up

dat

e'. 8

an

d 9

.A

Ris

k R

egis

ter

is in

th

e p

roce

ss (

at 6

Mar

19

) o

f b

ein

g d

raft

ed. M

ost

re

cen

t as

sura

nce

evi

den

ce s

ub

mit

ted

18

Mar

19

.

PM

O

Re

fP

rog

ram

me

Tit

leP

rog

ram

me

De

scri

pti

on

SR

O/

Sp

on

so

r

Assu

res

OVERALL

GOVERNANCE

1. Scope and

Approach Defined


Team is in Place


in Place


engaged


Assessment

OVERALL

DELIVERY


defined/on track


track


and being managed


and being managed

Co

llab

ora

tio

n -

He

alth

y W

irra

l

6.3

Me

dic

ines

Op

tim

isat

ion

The

Med

icin

es V

alu

e Pr

ogr

amm

e fo

r W

irra

l has

bee

n

esta

blis

hed

to

imp

rove

hea

lth

ou

tco

mes

fro

m m

edic

ines

thro

ugh

imp

rovi

ng

pat

ien

t in

form

atio

n, m

akin

g b

est

use

of t

he

clin

ical

ski

lls o

f ph

arm

acis

ts a

nd

ph

arm

acy

tech

nic

ian

s, a

nd

imp

lem

enti

ng

clin

ical

ly e

ffec

tive

pre

scri

bin

g an

d m

edic

ines

revi

ews

to e

nsu

re w

e ar

e ge

ttin

g th

e b

est

valu

e fr

om

ou

r

med

icin

es e

xpen

dit

ure

.

Mik

e T

reh

arn

e,

DO

F C

CG

aa

6. P

rog

ram

me S

ix -

Part

ners

hip

s (

GD

E E

nab

led

)

Item

10.

3 -

Rep

ort o

f Pro

gram

me

Boa

rd

Page 89 of 120

WW

C A

llian

ce: P

ath

olo

gy -

Pro

gram

me

Ass

ura

nce

Up

dat

e -

17

thA

pri

l 20

19

Exec

Sp

on

sor

Pro

gram

me

Lead

Tran

sfo

rmat

ion

Lea

dSt

age

of

De

velo

pm

en

tO

vera

ll G

ove

rnan

ceO

vera

llD

eliv

ery

Kare

nEd

geA

lista

irLe

inst

erTB

DD

esig

nA

mb

er

Red

Ind

ep

en

de

nt

Ass

ura

nce

Stat

em

en

t

1. T

he

sco

pe

do

cum

ent

com

pri

ses

the

'Str

ateg

ic P

ath

olo

gy C

olla

bo

rati

on

Wir

ral a

nd

Wes

t C

hes

hir

e: C

urr

ent

Posi

ton

an

d N

ext

Step

s'd

ated

Oct

ob

er

20

18

an

d s

ub

mit

ted

to

th

e Tr

ust

Bo

ard

on

1 N

ove

mb

er 2

01

8.

This

has

no

w b

een

su

pp

lem

ente

d b

y a

sum

mar

y d

ocu

men

t. 2

.P

roje

ct T

eam

nam

es

nee

d t

o b

e p

op

ula

ted

on

th

is d

ash

bo

ard

. 3

.Th

e 'W

irra

l & W

est

Ch

esh

ire

Path

olo

gy S

ervi

ce T

ran

siti

on

al M

anag

emen

t Te

am' h

as T

erm

s o

f R

efer

ence

(u

nd

ated

) an

d m

inu

tes

of

the

mee

tin

gs a

re a

vaila

ble

to

28

Feb

19

.4

.Th

ere

is e

vid

ence

of

stak

eho

lder

en

gage

me

nt

by

mea

ns

of

the

no

tes

of

a 'W

ho

le L

ab M

eeti

ng'

of

19

Ju

ly 2

01

8 b

ut

no

evi

den

ce o

f a

com

mu

nic

atio

ns

pla

n o

r w

ider

/su

bse

qu

ent

staf

f en

gage

me

nt.

5.

Ther

e is

no

EA

/QIA

. 6. T

her

e is

a 'W

WC

Pat

ho

logy

Tim

elin

e' P

lan

in e

vid

ence

bu

t ap

pea

rs t

o b

e su

bje

ct t

o s

ign

ific

ant

del

ays

(5 M

on

ths)

an

d t

he

trac

kin

go

f th

e p

lan

is n

ot

clea

r. 7

. K

PIs

(...

Nex

t St

eps

pap

er -

Oct

18

) ar

e p

ote

nti

al s

avin

gs f

rom

a jo

int

CO

CH

/ W

UTH

Pat

ho

logy

ser

vice

are

est

imat

ed t

o b

e b

etw

een

£1

.6m

an

d £

2.6

m; t

hes

e fr

om

pro

cure

me

nt

and

sta

ffin

g sa

vin

gs.

8 a

nd

9.

The

'...N

ext

Step

s p

aper

ref

ers

to is

sues

an

d r

isks

as

top

ics

and

th

ere

is a

ris

k re

gist

er in

evi

den

ce; h

ow

ever

, th

e ri

sk r

egis

ter

wo

uld

ben

efit

fro

m h

avin

g a

'dat

e o

f la

st r

evie

w' c

olu

mn

. M

ost

rec

en

t as

sura

nce

ev

iden

ce s

ub

mit

ted

13

Mar

19

.

PM

O

Re

fP

rog

ram

me

Tit

leP

rog

ram

me

De

scri

pti

on

SR

O/

Sp

on

so

r

Assu

res

OVERALL

GOVERNANCE

1. Scope and

Approach Defined


Team is in Place


in Place


engaged


Assessment

OVERALL

DELIVERY


defined/on track


track


and being managed


and being managed

Co

llab

ora

tio

n -

Wir

ral W

est

Ch

esh

ire

Alli

ance

6.4

Pat

ho

logy

For

WU

TH a

nd

CO

CH

to

form

a jo

int

pat

ho

logy

ser

vice

acr

oss

the

two

Tru

sts

wh

ich

will

del

iver

aga

inst

ind

icat

ive

NH

SI s

avin

gs

targ

ets,

pro

vid

e o

per

atio

nal

ben

efit

s, r

edu

ce a

nu

mb

er o

f

curr

ent

op

erat

ion

al r

isks

an

d p

osi

tio

n b

oth

Tru

sts

for

futu

re

bro

ader

reg

ion

al c

olla

bo

rati

on

.

Kare

n E

dge

ar

6. P

rog

ram

me S

ix -

Part

ners

hip

s (

GD

E E

nab

led

)

Ass

ura

nce

rat

ings

will

be

susp

end

ed f

rom

17

Ap

r 1

9, a

s ag

ree

d a

t P

rogr

amm

e B

oar

d, p

end

ing

a Tr

ust

dec

isio

n

on

th

e cr

eati

on

of

a jo

int

serv

ice

wit

h C

oC

H

Page 90 of 120

Board of Directors

Agenda Item 10.4

Title of Report CQC Action Plan Progress Update


Author(s) Paul Moore, Director of Quality & Governance

Accountable Executive Janelle Holmes, Chief Executive

BAF References


• Key Measure

• Principal Risk

Quality and Safety of Care Patient flow management during periods of high demand

Level of Assurance

• Positive

• Gap(s)

To be confirmed


• Discussion

• Approval

• To Note

Provided for assurance to the Board

The Board is invited to receive and consider this report

Data Quality Rating To be confirmed

FOI status Unrestricted

Equality Impact

Assessment Undertaken

• Yes

• No

No adverse equality impact identified

Item

10.

4 -

CQ

C A

ctio

n P

lan

Pro

gres

s U

pdat

e

Page 91 of 120

CQC ACTION PLAN UPDATE REPORT POSITION AS AT 23RD APRIL, 2019

1. PURPOSE

1.1.1 The purpose of this report is to ensure the Board of Directors are up to date on the progress of

the CQC Action Plan, and to highlight to the Board, by exception, any elements of the plan that are not on track or at risk of not meeting target dates for implementation. This report also provides assurance to the Board on those actions that have been embedded (completed and sustained for a period of 3 months or more).

2. BACKGROUND OR CONTEXT 2.1 The CQC Action Plan brings together the actions required to address the CQC compliance

concerns identified following inspection in March 2018. The plan takes account of: (i) all the ‘must do’ and should do’ recommendations contained within the inspection reports; and (ii) some improvement interventions identified locally as immediate quality priorities by the Trust. After sufficient progress has been made the plan will evolve to incorporate matters highlighted as high risk within the Quality & Risk Profile for WUTH, and develop into the tactical plan to drive and deliver the Trust’s Quality Strategy.

2.2 The CQC Action Plan has implications for NHS Improvement’s enforcement undertakings and, in this regard, the Board is committed demonstrating, no later than August 2019, that: (i) it has addressed all the ‘must do’ and ‘should do’ recommendations to the CQC, NHSI and CCG satisfaction; (ii) is no longer considered by CQC to be inadequate in the well-led domain; and (iii) has improved against all CQC domains rated as inadequate or requires improvement when compared to the CQC’s inspection findings.

3. ANALYSIS 3.1 The CQC inspected the Trust in March and May 2018. The outcome of the inspection was as

follows:

Safe Requires improvement Effective Requires improvement Caring Good Responsive Requires improvement Well Led Inadequate

OVERALL REQUIRES IMPROVEMENT

The Trust has developed a quality improvement action plan to address all concerns identified by the CQC. The quality improvement action plan has 221 specific actions/work-plans for implementation by (31st March 2019). The delivery of the quality improvement action plan is reviewed monthly and performance is reported through to the Board at each formal meeting.

Page 92 of 120

4. CQC Action Plan Progress – 23R APRIL 2019

5. EXCEPTIONS

Following the Confirm and Challenge meetings held week commencing 08th April 2019, there are 2 actions which have been 'red-rated’ and one ‘amber rated’ action and are to be reported as exceptions for this reporting period Overdue actions concern patient flow management, ED Assessment protocols, and medicines storage. For reference the detail of overdue actions is set out in Annex A.

B R A G B R A G B R A G B R A G B R A G

48 1 0 14 11 0 0 0 27 0 0 4 31 1 1 8 52 0 0 23

Blue Red Amber Total

48 1 0 15

11 0 0 0

27 0 0 4

31 1 1 10

52 0 0 23

Total 169 2 1

Green

49

Overall

Effective

Well-Led

14

0

4

Safe Caring Responsive Effective Well-Led

8

23

Safe

Caring

Responsive

3 10

4660

112

144157

169151

159

162 143

108

7460

50

7557

19 225 7 3 2

67.25% 74.45%

91.63%90.22% 97.78% 97.32%

98.19% 99.10%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

0

50

100

150

200

250

Tota

l Nu

mb

er

of

Act

ion

s b

y M

on

th

CQC Action Plan Progress

Overdue

On Target

Embedded

Percentage ontarget

Item

10.

4 -

CQ

C A

ctio

n P

lan

Pro

gres

s U

pdat

e

Page 93 of 120

In Annex B we draw the Board’s attention to ‘embedded’ actions (i.e. those actions completed and sustained for 3 months or more). In line with expectations set out in the plan, the number of embedded actions has increased in this reporting period with 12 actions moving into the embedded category. This can be interpreted by the Board as positive evidence of implementation, and the progressive work that is happening across the Trust to address each element of the action plan.

6. POTENTIAL IMPLICATIONS (of failing to deliver the plan)

Risks (associated with failing to deliver the CQC action plan) include:

I. Service users are exposed to unacceptable levels of harm arising from

inadequate compliance with CQC fundamental standards of care; II. The Trust fails to comply with CQC Registration Regulations and has it’s

Certification of Registration revoked; and/or III. A failure to resolve basic compliance concerns in respect of CQC regulations

leads to further NHSI enforcement undertakings and compromise the Trust’s Provider Licence.

The CQC Action Plan provides the means of improving control over these risks alongside the Trust pre-existing organisational control framework.

7. RECOMMENDATION

The Board of Directors are invited to:

• consider and where necessary discuss corrective actions to bring the CQC Action Plan back on track; and

• advise on any further action or assurance required by the Board.

Page 94 of 120

AN

NE

X A

No

M

us

t/

Sh

ou

ld

do

De

pt

C

QC

re

co

mm

en

da

tio

n/a

cti

on

A

PH

ac

tio

n

Dir

ec

tor

W

ork

str

ea

m

Pro

gre

ss

D

ue

Da

te

RA

G

17

3

Sho

uld

D

o

Co

rpo

rate

/

Tru

st-W

ide

Issu

es

PA

TIEN

T FL

OW

Th

e tr

ust

mu

st e

nsu

re t

hat

all

info

rmat

ion

is

mo

nit

ore

d t

o im

pro

ve t

he

flo

w o

f p

atie

nts

th

rou

gh t

he

ho

spit

al a

nd

all

area

s b

ein

g u

sed

fo

r ad

dit

ion

al b

eds

are

fit

for

pu

rpo

se.

Del

iver

all

com

po

nen

ts o

f w

ork

str

eam

s go

vern

ed

by

the

Pat

ien

t Fl

ow

Im

pro

vem

ent

Gro

up

: W

ard

Bas

ed C

are

and

Tr

ansf

orm

atio

n o

f D

isch

arge

s B

ed

Man

agem

en

t M

edic

al A

sse

ssm

en

t U

nit

R

evie

w -

ou

tlin

e ke

y el

emen

ts o

f p

lan

Exec

uti

ve D

irec

tor

of

Qu

alit

y &

G

ove

rnan

ce

Wel

l Led

Up

dat

ed

: 0

2/0

4/2

01

9

A r

evie

w o

f th

e go

vern

ance

ar

ran

gem

en

ts a

nd

ro

le o

f P

FIG

is

un

der

way

. Th

e G

ove

rnan

ce is

in

pla

ce a

nd

bei

ng

led

th

rou

gh P

atie

nt

Flo

w Im

pro

vem

ent

Gro

up

an

d

Pro

gram

me

Bo

ard

. Th

e im

pro

vem

ent

con

tro

ls h

ave

no

t h

ad t

he

de

sire

d im

pac

t o

n t

he

del

ive

ry o

f th

e P

atie

nt

Flo

w

Imp

rove

men

t G

rou

p d

o d

ate.

Fu

ture

p

rop

osa

ls a

re b

ein

g co

nsi

der

ed

.

31

/11

/20

18

20

8

Sho

uld

D

o

Urg

ent

An

d

Emer

gen

cy

Car

e (A

cute

&

Med

ical

D

ivis

ion

)

INIT

IAL

ASS

ESSM

ENT

The

serv

ice

mu

st e

nsu

re t

hat

pat

ien

ts

rece

ive

an in

itia

l ass

ess

me

nt

wit

hin

15

m

inu

tes

of

arri

val,

in li

ne

wit

h t

rust

p

olic

y an

d R

oya

l Co

llege

of

Emer

gen

cy

Med

icin

e st

and

ard

s.

Ensu

re p

ract

ice

wit

hin

ED

ad

her

es t

o T

rust

po

licy

– al

l p

atie

nts

to

be

asse

ssed

w

ith

in 1

5 m

inu

tes

of

bo

oki

ng

in –

by

rein

forc

ing

exis

tin

g SO

Ps

(1/8

/18

)

Ch

ief

Op

erat

ing

Off

icer

Effe

ctiv

e

Up

dat

ed

02

.04

.20

19

Tr

ansp

ose

d r

epo

rtin

g ar

ran

gem

en

ts

wit

hin

ou

r d

ata

cap

ture

sys

tem

s h

ave

bee

n id

en

tifi

ed. T

rial

of

tria

ge o

nly

p

roce

ss is

has

bee

n u

nd

erta

ken

wit

h

con

sult

ant

colle

agu

es a

nd

a c

han

ge

in p

ract

ice

will

be

imp

lem

en

ted

.

01

/09

/20

18

10

4

Sho

uld

D

o

12

– S

afe

Car

e an

d

Trea

tmen

t,

15

-

Pre

mis

es

and

Eq

uip

me

nt

MED

ICIN

ES T

EMP

ERA

TUR

ES

The

serv

ice

sho

uld

en

sure

th

at s

taff

m

on

ito

r th

e d

rugs

ro

om

tem

pe

ratu

re a

nd

ta

ke a

ctio

n t

o a

dd

ress

th

e te

mp

era

ture

if it

is

ou

tsid

e o

f an

ap

pro

pri

ate

ran

ge.

SLU

ICES

AN

D M

EDIC

INES

RO

OM

S Th

e se

rvic

e sh

ou

ld e

nsu

re a

ll sl

uic

e ar

eas

and

med

icat

ion

ro

om

s in

th

e u

nit

are

se

cure

an

d t

hat

ref

rige

rato

rs in

th

e m

edic

al

roo

m a

nd

pac

ked

ap

pro

pri

atel

y.

Mat

ern

ity:

Th

e se

rvic

e sh

ou

ld e

nsu

re t

hat

all

dru

gs

frid

ges

are

secu

re, u

sed

fo

r th

eir

inte

nd

ed

p

urp

ose

an

d c

hec

ked

as

per

re

com

men

dat

ion

s.

Co

ncl

ud

e d

iscu

ssio

ns

on

ca

se f

or

chan

ge t

o

intr

od

uce

air

co

nd

itio

nin

g in

sel

ecte

d/a

ll m

edic

ines

st

ora

ge a

reas

du

e to

te

mp

erat

ure

exc

urs

ion

s >2

5 d

egre

es

Exec

uti

ve D

irec

tor

of

Nu

rsin

g an

d

Mid

wif

ery

U

pd

ate

d 0

2.0

4.2

01

9 C

lari

ty is

re

qu

ired

on

wh

at d

ecis

ion

has

be

en

reac

hed

in r

ega

rd t

o t

he

fun

din

g an

d

imp

lem

en

tati

on

pla

ns

pre

vio

usl

y id

enti

fie

d.

“ri

sk a

sses

smen

t h

as

bee

n

un

der

take

n r

esid

ua

l nu

mb

er o

f ro

om

s th

at

do

no

t cu

rren

tly

ha

ve a

ir

con

dit

ion

ing

ha

ve b

een

iden

tifi

ed.

Ass

essm

ent

ha

s b

een

un

der

take

n a

nd

a

wo

rk p

lan

ha

s b

een

dev

elo

ped

. We

ha

ve p

rio

riti

sed

a n

um

ber

of

roo

ms,

1

0 p

rio

riti

es o

ut

of

a n

um

ber

of

circ

a

30

ro

om

s. Im

ple

men

tati

on

/del

iver

y p

lan

to

be

dev

elo

ped

, lo

ng

ter

m”

01

/10

/20

19

Item

10.

4 -

CQ

C A

ctio

n P

lan

Pro

gres

s U

pdat

e

Page 95 of 120

AN

NE

X B

(E

mb

ed

ded

acti

on

s i

n M

arc

h 2

01

9)

No

M

us

t/

Sh

ou

ld

do

De

pt

C

QC

re

co

mm

en

da

tio

n/a

cti

on

A

PH

ac

tio

n

Dir

ec

tor

W

ork

str

ea

m,

Pro

gre

ss

D

ue

Da

te

RA

G

12

M

ust

Do

Co

rpo

rate

/

Tru

st-W

ide

Issu

es

MA

INTE

NA

NC

E &

C

LEA

NLI

NES

S

Em

erg

en

cy D

ep

artm

en

t: T

he

se

rvic

e m

ust

en

sure

th

at t

he

envi

ron

me

nt

and

eq

uip

me

nt

are

mai

nta

ined

an

d c

lean

ed

in li

ne

wit

h t

rust

po

licy

and

be

st p

ract

ice

guid

ance

. M

ed

icin

e:

Th

e se

rvic

e sh

ou

ld e

nsu

re

that

eq

uip

men

t an

d p

rem

ise

s ar

e ke

pt

clea

n a

nd

dai

ly

chec

ks t

ake

pla

ce.

Mat

ern

ity:

Th

e se

rvic

e sh

ou

ld e

nsu

re u

p

to d

ate

clea

nin

g sc

hed

ule

s ar

e in

pla

ce in

all

area

s an

d

that

all

area

s ar

e cl

ean

. Su

rge

ry:

The

serv

ice

sho

uld

en

sure

th

at a

ll e

qu

ipm

ent

is

reco

rded

, se

rvic

ed a

nd

ca

libra

ted

in li

ne

wit

h t

he

man

ufa

ctu

rer’

s in

stru

ctio

ns.

Esta

blis

h s

yste

ms

for

mo

nit

ori

ng

and

re

po

rtin

g th

e st

and

ard

of

war

d a

nd

se

rvic

e ar

ea c

lean

lines

s

Exec

uti

ve

Dir

ecto

r o

f N

urs

ing

and

M

idw

ifer

y an

d

Med

ical

D

irec

tor

Safe

02

.04

.20

19

- IP

C a

ud

its

are

man

aged

via

p

erfe

ct w

ard

. Ro

uti

ne

wal

kab

ou

ts t

ake

pla

ce in

par

tne

rsh

ip w

ith

est

ate

s co

lleag

ues

. Sta

ffin

g is

sues

hav

e b

een

id

enti

fie

d f

or

clea

nin

g te

ams.

C

hie

f N

urs

e is

co

nfi

de

nt

that

th

e sy

stem

s h

ave

be

en e

stab

lish

ed a

nd

th

ey a

re

flag

gin

g w

her

e th

ere

are

issu

es in

ter

ms

of

cap

acit

y th

at n

eed

to

be

add

ress

ed.

01

/11

/20

18

45

M

ust

Do

Med

ical

Car

e (A

cute

&

Med

ical

D

ivis

ion

)

PR

EMIS

ES

The

serv

ice

mu

st e

nsu

re

pre

mis

es a

re s

uit

able

fo

r th

e p

urp

ose

fo

r w

hic

h t

hey

are

u

sed

, esp

ecia

lly in

th

e d

isch

arge

h

osp

ital

ity

cen

tre

and

day

ca

se u

nit

.

Invi

te s

erv

ice

use

rs/H

ealt

h W

atch

to

vis

it t

he

dis

char

ge h

osp

ital

ity

cen

tre

and

day

cas

e u

nit

to

giv

e th

eir

feed

bac

k o

n t

he

qu

alit

y o

f th

e e

nvi

ron

men

t

Ch

ief

Op

erat

ing

Off

icer

(e

xecu

tive

lead

fo

r Es

tate

s)

Wel

l Led

02

/04

/20

19

- H

ealt

h W

atch

Wir

ral

atte

nd

ed t

he

dis

char

ge u

nit

on

W

edn

esd

ay 1

3th

Mar

ch, a

fee

db

ack

rep

ort

has

bee

n r

ecei

ved

an

d a

n a

ctio

n

pla

n w

ill b

e d

evis

ed

.

01

/04

/20

19

90

M

ust

Do

Co

rpo

rate

/

Tru

st-W

ide

SAFE

GU

AR

DIN

G

Tru

st w

ide

:

Rev

iew

th

e ef

fect

iven

ess

an

d

up

take

of

curr

en

t tr

ain

ing

on

Ex

ecu

tive

D

irec

tor

of

Safe

02

/04

/20

19

– C

hie

f N

urs

e re

po

rted

a

sign

ific

ant

imp

rove

me

nt

PV

P t

rain

ing.

A

01

/10

/20

19

Page 96 of 120

No

M

us

t/

Sh

ou

ld

do

De

pt

C

QC

re

co

mm

en

da

tio

n/a

cti

on

A

PH

ac

tio

n

Dir

ec

tor

W

ork

str

ea

m,

Pro

gre

ss

D

ue

Da

te

RA

G

Issu

es

Th

e tr

ust

mu

st e

nsu

re t

hat

all

app

licat

ion

fo

r d

ep

riva

tio

n o

f lib

erty

saf

egu

ard

s ar

e m

ade

in li

ne

wit

h le

gisl

atio

n; a

nd

Th

e tr

ust

mu

st e

nsu

re t

hat

sa

fegu

ard

ing

child

ren

tra

inin

g is

in li

ne

wit

h n

atio

nal

gu

idan

ce.

Me

dic

ine

:

The

serv

ice

mu

st e

nsu

re t

hat

sa

fegu

ard

ing

syst

ems

and

p

roce

sses

are

op

erat

ed

effe

ctiv

ely

and

cap

acit

y as

sess

men

ts c

om

ple

ted

in a

ti

mel

y m

ann

er t

o e

nsu

re t

hat

p

atie

nts

are

no

t d

epri

ved

of

thei

r lib

erty

wit

ho

ut

law

ful

auth

ori

ty.

Eme

rge

ncy

De

par

tme

nt

: Th

e se

rvic

e sh

ou

ld e

nsu

re

that

be

st in

tere

st d

ecis

ion

s an

d m

enta

l cap

acit

y as

sess

men

ts a

re r

eco

rded

in

line

wit

h

tru

st p

olic

y an

d le

gisl

atio

n

safe

guar

din

g

Nu

rsin

g an

d

Mid

wif

ery

revi

ew o

f o

ur

curr

ent

trai

nin

g p

rovi

sio

n

has

be

en u

nd

erta

ken

aga

inst

nat

ion

al

Inte

rco

llegi

ate

do

cum

ent

- w

e aw

ait

nat

ion

al o

pin

ion

fo

llow

ing

revi

ew o

f th

at

do

cum

ent

of

any

man

dat

ed

ch

ange

s n

eces

sary

to

ou

r tr

ain

ing

pro

visi

on

.

Item

10.

4 -

CQ

C A

ctio

n P

lan

Pro

gres

s U

pdat

e

Page 97 of 120

No

M

us

t/

Sh

ou

ld

do

De

pt

C

QC

re

co

mm

en

da

tio

n/a

cti

on

A

PH

ac

tio

n

Dir

ec

tor

W

ork

str

ea

m,

Pro

gre

ss

D

ue

Da

te

RA

G

98

M

ust

Do

Co

rpo

rate

/

Tru

st-W

ide

Issu

es

TRA

NSF

ER O

F P

ATI

ENTS

Em

erg

en

cy D

ep

artm

en

t :

Th

e se

rvic

e sh

ou

ld e

nsu

re

that

th

e tr

ansf

er o

f ca

re f

or

all p

atie

nts

is c

om

ple

ted

ap

pro

pri

atel

y, in

lin

e w

ith

tr

ust

po

licy.

M

ed

icin

e :

Th

e se

rvic

e m

ust

dec

reas

e th

e n

um

ber

of

pat

ien

ts

tran

sfer

red

bet

wee

n w

ard

s at

n

igh

t. T

he

tran

sfer

of

dem

enti

a p

atie

nts

at

nig

ht

mu

st o

nly

ta

ke p

lace

in e

xce

pti

on

al

circ

um

stan

ces

to e

nsu

re t

hat

ca

re a

nd

tre

atm

ent

is

app

rop

riat

e, m

eets

ind

ivid

ual

n

eed

s an

d r

efle

cts

pre

fere

nce

s.

Au

dit

co

mp

lian

ce w

ith

th

e Tr

ansf

er P

roce

du

re

Exec

uti

ve

Dir

ecto

r o

f N

urs

ing

and

M

idw

ifer

y

Safe

02

/04

/20

19

- S

OP

's h

ave

be

en

dev

elo

pe

d. T

he

inte

nti

on

is t

o s

imp

lify

and

rat

ion

alis

e tr

ansf

er p

olic

y in

lin

e w

ith

re

view

tim

efra

me

s

30

/04

/20

19

10

1

Sho

uld

D

o

Co

rpo

rate

/

Tru

st-W

ide

Issu

es

In

tro

du

ce p

har

mac

y in

du

ctio

n f

or

new

mat

ron

s an

d w

ard

man

ager

s to

en

sure

aw

are

of

med

icin

es

man

agem

ent

role

s an

d

resp

on

sib

iliti

es

fro

m o

uts

et

Exec

uti

ve

Dir

ecto

r o

f N

urs

ing

and

M

idw

ifer

y

Effe

ctiv

e

0

2/0

4/2

01

9 C

hie

f N

urs

e ch

eckl

ist

dev

elo

pe

d a

nd

pre

sen

ted

as

evid

ence

0

1/1

1/2

01

8

11

3

Sho

uld

D

o

Urg

ent

An

d

Emer

gen

cy C

are

(Acu

te &

M

edic

al

Div

isio

n)

A

ud

it c

om

plia

nce

th

rou

gh u

se o

f p

erfe

ct w

ard

an

d r

ou

nd

ing

Exec

uti

ve

Dir

ecto

r o

f N

urs

ing

and

M

idw

ifer

y

Effe

ctiv

e

0

2/0

4/2

01

9 –

Co

mp

lian

ce is

ro

uti

nel

y au

dit

ed

via

pe

rfec

t w

ard

re

po

rtin

g to

ol

01

/02

/20

19

Page 98 of 120

No

M

us

t/

Sh

ou

ld

do

De

pt

C

QC

re

co

mm

en

da

tio

n/a

cti

on

A

PH

ac

tio

n

Dir

ec

tor

W

ork

str

ea

m,

Pro

gre

ss

D

ue

Da

te

RA

G

11

4

Sho

uld

D

o

Med

ical

Car

e (A

cute

&

Med

ical

D

ivis

ion

)

RES

USC

ITA

TIO

N T

RO

LLEY

S Th

e se

rvic

e sh

ou

ld e

nsu

re

that

all

resu

scit

atio

n t

rolle

ys

acro

ss t

he

serv

ice

are

regu

larl

y ch

ecke

d a

nd

em

erge

ncy

eq

uip

me

nt

has

th

e ap

pro

pri

ate

po

rtab

le

app

lian

ce t

ests

car

rie

d o

ut.

Su

rge

ry:

The

serv

ice

sho

uld

en

sure

an

y em

erge

ncy

eq

uip

men

t in

ar

eas

acce

ssib

le t

o t

he

pu

blic

w

ith

ou

t a

con

stan

t st

aff

pre

sen

ce s

ho

uld

be

secu

re.

For

tho

se m

anag

ers

un

able

to

p

rovi

de

that

ass

ura

nce

, agr

ee

per

form

ance

ob

ject

ive

s w

ith

th

at

ind

ivid

ual

Exec

uti

ve

Dir

ecto

r o

f N

urs

ing

and

M

idw

ifer

y

Res

po

nsi

ve

0

2/0

4/2

01

9 C

om

plia

nce

an

d a

ud

it

mee

tin

gs a

re in

pla

ce. A

ctio

n p

lan

an

d

mo

nit

ori

ng

too

ls a

re in

pla

ce a

nd

m

anag

ed v

ia p

erfe

ct w

ard

ap

p

07

/12

/20

18

12

4

Sho

uld

D

o

Cri

tica

l Car

e (D

iagn

ost

ics

and

Clin

ical

Su

pp

ort

D

ivis

ion

)

AN

TT

The

serv

ice

sho

uld

mo

nit

or

and

au

dit

nu

rsin

g st

aff

carr

yin

g o

ut

ase

pti

c n

on

to

uch

tec

hn

iqu

e w

hen

ad

min

iste

rin

g m

ed

icat

ion

.

Un

der

take

re

gula

r au

dit

of

AN

TT

pra

ctic

e

Exec

uti

ve

Dir

ecto

r o

f N

urs

ing

and

M

idw

ifer

y

Safe

02

/04

/20

19

- E

mb

edd

ed p

roce

ss -

au

dit

to

ols

are

in p

lace

an

d e

vid

ence

th

at

regu

lar

aud

its

are

un

der

take

n

30

/04

/20

19

17

6

Mu

st D

o

C

orp

ora

te /

Tr

ust

-Wid

e Is

sue

s

STA

FFIN

G IS

SUES

The

tru

st s

ho

uld

co

nsi

der

h

ow

th

ere

is a

tru

st o

vers

igh

t o

f al

l sta

ffin

g is

sue

s.

Imp

rove

rec

ruit

me

nt

to v

acan

t p

ost

s

Exec

uti

ve

Dir

ecto

r o

f W

ork

forc

e

Wel

l Led

0

9/0

4/2

01

9 a

s re

po

rted

to

Tru

st B

oar

d

we

hav

e se

en

an

incr

ease

in r

ecru

itm

ent

figu

res,

par

ticu

larl

y in

Med

icin

e an

d

Acu

te

31

/03

/20

19

19

1

Mu

st D

o

C

orp

ora

te /

Tr

ust

-Wid

e Is

sue

s

MED

ICIN

ES S

TOR

AG

E

The

serv

ice

sho

uld

en

sure

th

e sa

fe a

nd

pro

per

sto

rage

of

med

icin

es o

n t

he

war

ds.

Pro

vid

e as

sura

nce

re

po

rt o

f co

mp

lian

ce t

o P

SQB

Ch

ief

Nu

rse

Effe

ctiv

e

0

2/0

4/2

01

9 -

em

be

dd

ed a

ctio

n

com

plia

nce

rep

ort

s p

rovi

de

d t

o P

SQB

3

1/1

2/2

01

9

20

3

Mu

st D

o

C

orp

ora

te /

Tr

ust

-Wid

e Is

sue

s

SAFE

ST

AFF

ING

Em

erg

en

cy D

ep

artm

en

t :

Th

e se

rvic

e m

ust

en

sure

th

at

app

rop

riat

e n

um

ber

s o

f n

urs

ing

and

me

dic

al s

taff

are

av

aila

ble

at

all t

imes

.

M

ed

icin

e :

Ensu

re t

hat

th

e sh

ift

rota

s ar

e p

re-p

lan

ned

(6

wee

ks in

ad

van

ce)

Ch

ief

Nu

rse

Safe

02

/04

/20

19

- e

vid

ence

pro

vid

ed

con

firm

ing

that

sh

ift

rota

s ar

e n

ow

p

lan

ned

6 w

eeks

in a

dva

nce

. Th

is is

m

anag

ed v

ia E

Ro

ster

pro

ject

an

d P

erfe

ct

War

d

01

/12

/20

19

Item

10.

4 -

CQ

C A

ctio

n P

lan

Pro

gres

s U

pdat

e

Page 99 of 120

No

M

us

t/

Sh

ou

ld

do

De

pt

C

QC

re

co

mm

en

da

tio

n/a

cti

on

A

PH

ac

tio

n

Dir

ec

tor

W

ork

str

ea

m,

Pro

gre

ss

D

ue

Da

te

RA

G

The

serv

ice

mu

st d

eplo

y su

ffic

ien

t st

aff

wit

h t

he

app

rop

riat

e sk

ills

on

war

ds

and

on

th

e ac

ute

me

dic

al

un

it, m

edic

al s

ho

rt s

tay

war

d

and

am

bu

lato

ry c

are

un

it

Surg

ery

:

The

tru

st m

ust

en

sure

th

ere

are

eno

ugh

sta

ff w

ith

th

e ri

ght

qu

alif

icat

ion

s, s

kills

, tr

ain

ing

and

exp

erie

nce

to

ke

ep p

eop

le s

afe

fro

m

avo

idab

le h

arm

an

d a

bu

se

and

to

pro

vid

e th

e ri

ght

care

an

d t

reat

men

t.

Page 100 of 120

No

M

us

t/

Sh

ou

ld

do

De

pt

C

QC

re

co

mm

en

da

tio

n/a

cti

on

A

PH

ac

tio

n

Dir

ec

tor

W

ork

str

ea

m,

Pro

gre

ss

D

ue

Da

te

RA

G

20

4

Mu

st D

o

C

orp

ora

te /

Tr

ust

-Wid

e Is

sue

s

SAFE

ST

AFF

ING

Em

erg

en

cy D

ep

artm

en

t:

The

serv

ice

mu

st e

nsu

re t

hat

ap

pro

pri

ate

nu

mb

ers

of

nu

rsin

g an

d m

ed

ical

sta

ff a

re

avai

lab

le a

t al

l tim

es.

Me

dic

ine

: Th

e se

rvic

e m

ust

dep

loy

suff

icie

nt

staf

f w

ith

th

e ap

pro

pri

ate

skill

s o

n w

ard

s an

d o

n t

he

acu

te m

ed

ical

u

nit

, med

ical

sh

ort

sta

y w

ard

an

d a

mb

ula

tory

car

e u

nit

Su

rge

ry:

The

tru

st m

ust

en

sure

th

ere

are

eno

ugh

sta

ff w

ith

th

e ri

ght

qu

alif

icat

ion

s, s

kills

, tr

ain

ing

and

exp

erie

nce

to

ke

ep p

eop

le s

afe

fro

m

avo

idab

le h

arm

an

d a

bu

se

and

to

pro

vid

e th

e ri

ght

care

an

d t

reat

men

t.

Ensu

re e

ffec

tive

use

of

NH

S P

rofe

ssio

nal

s ac

ross

6 w

eek

rota

Ch

ief

Nu

rse

Safe

02

/04

/20

19

- e

vid

ence

pro

vid

ed

con

firm

ing

that

sh

ift

rota

s ar

e n

ow

p

lan

ned

6 w

eeks

in a

dva

nce

, th

us

sup

po

rtin

g th

e Tr

ust

to

eff

ecti

vely

m

anag

e it

s N

HS

pro

fess

ion

al u

sage

. Th

is

is m

anag

ed

via

E R

ost

er p

roje

ct

01

/12

/20

19

Item

10.

4 -

CQ

C A

ctio

n P

lan

Pro

gres

s U

pdat

e

Page 101 of 120

Board of Directors Agenda Item 10.5

Title of Report Board Assurance Framework 2019/20


Author Andrea Leather, Board Secretary



BAF References


• Key Measure

• Principal Risk

All

Level of Assurance

• Positive

• Gap(s)

Gaps with mitigating action


• Discussion

• Approval

• To Note

For Noting

Data Quality Rating Bronze - qualitative data



• Yes

• No

No

Item

10.

5 -

Rev

iew

of B

oard

Ass

uran

ce F

ram

ewor

k

Page 102 of 120


The Board Assurance Framework (BAF) is a method of setting out the most important risks facing the organisation and providing assurance on the effectiveness of controls to mitigate them. It should outline the control framework used to manage the most important risks, any gaps in control and how the Board satisfies itself that the controls are working as intended.

The Board Assurance Framework contributes to the effectiveness of the system of internal control in the Annual Governance Statement. The BAF contains the six primary risk scenario’s. Each primary risk has an identified lead Executive Director and is aligned to a Board Committee to monitor progress on behalf of the Board.

The BAF identifies sources of assurance incorporate the three lines of defence:

• Level 1 Management (those responsible for the area reported on);

• Level 2 Corporate functions (internal but independent of the area reported on);

• Level 3 Independent assurance (Internal audit and other external assurance providers)

2. Background

In November 2018 the Board of Directors identified and approved the primary risk scenarios which informed the development of the 2019/20 Board Assurance Framework.

3. Key Issues/Gaps in Assurance

As identified in the attached BAF. 4. Next Steps

The 2019/20 BAF will be monitored by the relevant Board Assurance Committee and subsequently provide progress reports to the Board on a regular basis.

5. Recommendations

The Board of Directors formally notes the 2019/20 Board Assurance Framework approved at the Board Development session held on 3rd April 2019.

Page 103 of 120

Boar

d As

sura

nce

Fram

ewor

k (B

AF):

2019

/20

(Dra

ft –

val

id a

s of 0

1 Ap

ril 2

019)

Pa

ge 1

of 1

7

This

BAF

incl

udes

the

follo

win

g pr

imar

y ris

k sc

enar

io’s

that

cou

ld, i

f not

suffi

cien

tly m

itiga

ted,

impa

ct a

dver

sely

on

deliv

ery

of th

e Bo

ard’

s Str

ateg

ic g

oals:

Prim

ary

Risk

Sce

nario

’s

Seve

rity

Like

lihoo

d Cu

rren

t Ri

sk E

xpos

ure

Chan

ge

Tole

rabl

e Ri

sk

Gap

s in

cont

rol

Gap

s in

assu

ranc

e Le

ad A

ssur

ance

Co

mm

ittee

Pa

ge N

o.

PR1

Dem

and

that

ove

rwhe

lms c

apac

ity to

del

iver

car

e ef

fect

ivel

y

5. V

.Hig

h 5.

V.L

ikel

y 25

Sig

nific

ant

12

Hig

h Ye

s Ye

s FB

PAC

2

PR2

Criti

cal s

hort

age

of w

orkf

orce

cap

acity

& c

apab

ility

5. V

.Hig

h 4.

Lik

ely

20 S

igni

fican

t

12 H

igh

Yes

Non

e id

entif

ied

WAC

4

PR3

Failu

re to

ach

ieve

and

mai

ntai

n fin

anci

al su

stai

nabi

lity

5.

V.H

igh

5. V

.Lik

ely

25 S

igni

fican

t

8 M

ediu

m

Yes

Yes

FBPA

C 6

PR4

Cata

stro

phic

failu

re in

stan

dard

s of s

afet

y an

d ca

re

4.

Hig

h 4.

Lik

ely

16 S

igni

fican

t

9 M

ediu

m

Yes

Non

e id

entif

ied

Qua

lity

8

PR5

A m

ajor

disr

uptiv

e ev

ent l

eadi

ng to

rapi

d op

erat

iona

l ins

tabi

lity

3.

Med

ium

5.

V.L

ikel

y 15

Sig

nific

ant

5

Med

ium

Ye

s N

one

iden

tifie

d FB

PAC

10

PR6

Fund

amen

tal l

oss o

f sta

keho

lder

con

fiden

ce

3.

Med

ium

5.

V.L

ikel

y 15

Sig

nific

ant

5

Med

ium

Ye

s N

one

iden

tifie

d Bo

ard

12

Item

10.

5 -

Rev

iew

of B

oard

Ass

uran

ce F

ram

ewor

k

Page 104 of 120

Boar

d As

sura

nce

Fram

ewor

k (B

AF):

2019

/20

(Dra

ft –

val

id a

s of 0

1 Ap

ril 2

019)

Pa

ge 2

of 1

7

How

to u

se th

e BA

F Th

e ke

y el

emen

ts o

f the

BAF

to b

e co

nsid

ered

are

:

• A

simpl

ified

des

crip

tion

of e

ach

Prin

cipa

l (st

rate

gic)

Risk

, tha

t for

ms t

he b

asis

of th

e Tr

ust’s

risk

fram

ewor

k (w

ith c

orre

spon

ding

cor

pora

te a

nd o

pera

tiona

l risk

s def

ined

at a

syst

em, t

rust

wid

e

• an

d se

rvic

e le

vel)

• A

simpl

ified

way

of d

ispla

ying

the

risk

ratin

g (c

urre

nt re

sidua

l risk

and

tole

rabl

e le

vel o

f risk

)

• Cl

ear i

dent

ifica

tion

of p

rimar

y st

rate

gic

thre

ats a

nd o

ppor

tuni

ties w

ithin

a 5

yea

r hor

izon,

alo

ng w

ith th

e an

ticip

ated

pro

xim

ity w

ithin

whi

ch ri

sks

are

expe

cted

to m

ater

ialis

e an

d th

e de

gree

of c

erta

inty

that

the

leve

l of r

isk w

ill

chan

ge (I

nten

sify

ing

= ris

k le

vel i

s exp

ecte

d to

incr

ease

; Unc

erta

in =

una

ble

to p

redi

ct c

hang

e; M

oder

atin

g =

risk

leve

l if l

ikel

y to

redu

ce)

•

A st

atem

ent o

f risk

app

etite

for e

ach

risk,

to b

e de

term

ined

by

the

lead

com

mitt

ee o

n be

half

of th

e Bo

ard

(Ave

rse

= ai

m to

avo

id th

e ris

k en

tirel

y; M

inim

al =

insis

tenc

e on

low

risk

opt

ions

; Cau

tious

= p

refe

renc

e fo

r low

risk

op

tions

; Ope

n =

prep

ared

to a

ccep

t a h

ighe

r lev

el o

f res

idua

l risk

than

usu

al, i

n pu

rsui

t of p

oten

tial b

enef

its)

• Th

e ov

er-a

rchi

ng ri

sk tr

eatm

ent s

trat

egy

for e

ach

prin

cipl

e ris

k is

iden

tifie

d (S

eek;

Mod

ify; A

void

; Acc

ept;

Tran

sfer

)

•

Key

elem

ents

of t

he ri

sk tr

eatm

ent s

trat

egy

iden

tifie

d fo

r eac

h ris

k, e

ach

assig

ned

to a

n ex

ecut

ive

lead

and

indi

vidu

ally

rate

d by

the

Lead

Com

mitt

ee fo

r the

leve

l of a

ssur

ance

they

can

take

that

the

stra

tegy

will

be

effe

ctiv

e in

tr

eatin

g th

e ris

k (s

ee b

elow

for k

ey)

•

Sour

ces

of a

ssur

ance

inco

rpor

ate

the

thre

e lin

es o

f def

ence

: Le

vel 1

Man

agem

ent (

thos

e re

spon

sible

for t

he a

rea

repo

rted

on)

; Lev

el 2

Cor

pora

te fu

nctio

ns (i

nter

nal b

ut in

depe

nden

t of t

he a

rea

repo

rted

on)

; and

Lev

el 3

In

depe

nden

t ass

uran

ce (I

nter

nal a

udit

and

othe

r ext

erna

l ass

uran

ce p

rovi

ders

)

• Cl

early

iden

tifie

d ga

ps in

the

prim

ary

cont

rol f

ram

ewor

k, w

ith d

etai

ls of

pla

nned

resp

onse

s eac

h as

signe

d to

a m

embe

r of t

he S

enio

r Lea

ders

hip

Team

(SLT

) with

agr

eed

times

cale

s

• Re

leva

nt K

ey R

isk In

dica

tors

(KRI

s) fo

r eac

h st

rate

gic

risk,

take

n fr

om th

e Tr

ust p

erfo

rman

ce m

anag

emen

t fra

mew

ork

to p

rovi

de e

vide

ntia

l dat

a th

at in

form

s the

regu

lar e

valu

atio

n of

exp

osur

e.

Key

to le

ad c

omm

ittee

ass

uran

ce ra

tings

:

Gree

n =

Posit

ive

assu

ranc

e: th

e Co

mm

ittee

is sa

tisfie

d th

at th

ere

is re

liabl

e ev

iden

ce o

f the

app

ropr

iate

ness

of t

he c

urre

nt ri

sk tr

eatm

ent s

trat

egy

in a

ddre

ssin

g th

e ris

k

Ambe

r = In

conc

lusiv

e as

sura

nce:

the

Com

mitt

ee is

unc

erta

in th

at th

ere

is su

ffici

ent e

vide

nce

to b

e ab

le to

mak

e a

judg

emen

t as t

o th

e ap

prop

riate

ness

of t

he c

urre

nt ri

sk tr

eatm

ent s

trat

egy

Re

d =

Neg

ativ

e as

sura

nce:

the

Com

mitt

ee is

satis

fied

that

ther

e is

suffi

cien

t rel

iabl

e ev

iden

ce th

at th

e cu

rren

t risk

is n

ot b

eing

kep

t und

er p

rude

nt c

ontr

ol

This

appr

oach

info

rms t

he a

gend

a an

d re

gula

r man

agem

ent i

nfor

mat

ion

rece

ived

by

the

rele

vant

lead

com

mitt

ees,

to e

nabl

e th

em to

mak

e in

form

ed ju

dgem

ents

as t

o th

e le

vel o

f ass

uran

ce th

at th

ey c

an ta

ke a

nd w

hich

can

then

be

prov

ided

to th

e Bo

ard

in re

latio

n to

eac

h Pr

inci

pal R

isk a

nd a

lso to

iden

tify

any

furt

her a

ctio

n re

quire

d to

impr

ove

the

man

agem

ent o

f tho

se ri

sks.

Page 105 of 120

Boar

d As

sura

nce

Fram

ewor

k (B

AF):

2019

/20

(Dra

ft –

val

id a

s of 0

1 Ap

ril 2

019)

Pa

ge 3

of 1

7

Stra

tegi

c pr

iorit

y PE

RFO

RMAN

CE: C

onsis

tent

ly d

eliv

er fi

nanc

ial s

usta

inab

ility

and

per

form

ance

st

anda

rds

Lead

Com

mitt

ee

FBPA

C Cu

rren

t ris

k ex

posu

re

Tole

rabl

e ris

k Ri

sk T

reat

men

t St

rate

gy:

Mod

ify

Prin

cipa

l ris

k (w

hat c

ould

pre

vent

us

achi

evin

g th

is st

rate

gic

prio

rity)

PR 1

: Dem

and

that

ove

rwhe

lms c

apac

ity to

del

iver

care

effe

ctiv

ely

A su

stai

ned,

exc

eptio

nal l

evel

of d

eman

d fo

r ser

vice

s tha

t ove

rwhe

lms c

apac

ity

resu

lting

in a

pro

long

ed, w

ides

prea

d re

duct

ion

in th

e qu

ality

of p

atie

nt c

are

and

repe

ated

failu

re to

ach

ieve

con

stitu

tiona

l sta

ndar

ds

Exec

utiv

e le

ad

COO

Li

kelih

ood:

5.

V. L

ikel

y

3.Po

ssib

le

Initi

al d

ate

of a

sses

smen

t 01

/04/

2019

Co

nseq

uenc

e 5.

V. H

igh

4. H

igh

Risk

app

etite

O

pen

Last

revi

ewed

01

/04/

2019

Ri

sk ra

ting

25. S

igni

fican

t 12

. Hig

h

Last

cha

nged

01

/04/

2019

An

ticip

ated

cha

nge

Inte

nsify

ing

Deta

ils o

f cha

nge

Revi

sed

BAF

for B

oard

con

sider

atio

n

Risk

Vec

tor

(wha

t mig

ht c

ause

this

to h

appe

n)

Prim

ary

Risk

Tre

atm

ent

(wha

t con

trol

s/ sy

stem

s & p

roce

sses

do

we

alre

ady

have

in p

lace

to a

ssist

us i

n m

anag

ing

the

risk

and

redu

cing

the

likel

ihoo

d/ im

pact

of t

he th

reat

)

Gap

s in

cont

rol

(Spe

cific

are

as /

issue

s whe

re fu

rthe

r w

ork

is re

quire

d to

man

age

the

risk

to a

ccep

ted

appe

tite/

tole

ranc

e le

vel)

Plan

s to

impr

ove

cont

rol

(are

furt

her c

ontr

ols p

ossib

le i

n or

der

to re

duce

risk

exp

osur

e w

ithin

tole

rabl

e ra

nge?

)

Leve

l & S

ourc

e of

ass

uran

ce (&

dat

e)

(Evi

denc

e th

at th

e co

ntro

ls/ sy

stem

s whi

ch w

e ar

e pl

acin

g re

lianc

e on

are

effe

ctiv

e)

Gap

in A

ssur

ance

/ Ac

tion

to

addr

ess g

ap

(Insu

ffici

ent e

vide

nce

as to

effe

ctiv

enes

s of

the

cont

rols

or n

egat

ive

assu

ranc

e)

Assu

ranc

e ra

ting

Thre

at: E

xpon

entia

l gro

wth

in

dem

and

for c

are

caus

ed b

y an

ag

eing

pop

ulat

ion

(fore

cast

an

nual

incr

ease

in e

mer

genc

y de

man

d of

4-5

% p

er a

nnum

); -

2% re

duce

d so

cial

car

e fu

ndin

g an

d in

crea

sed

acui

ty le

adin

g to

m

ore

adm

issio

ns &

long

er le

ngth

of

stay

Em

erge

ncy

dem

and

& p

atie

nt fl

ow m

anag

emen

t arr

ange

men

ts

W

inte

r cap

acity

pla

n

Acce

ss P

olic

y in

pla

ce

De

taile

d op

erat

iona

l pla

ns a

gree

d an

nual

ly

Ac

tivity

bas

ed c

ontr

act a

nd c

omm

issio

ners

Wor

kfor

ce m

odel

adj

uste

d fo

r pla

nned

act

ivity

ED S

trea

min

g

Defin

ed e

scal

atio

n ar

eas (

act a

s flo

od p

lane

) dur

ing

perio

ds o

f ex

cept

iona

l pre

ssur

e

Disc

harg

e pr

oced

ures

Use

of a

dmiss

ion

avoi

danc

e sc

hem

es

U

se o

f SHO

P m

odel

med

ical

revi

ew

Am

bula

tory

& D

ay c

ase

care

Co

ntin

genc

y co

ntro

ls

Em

erge

ncy

prep

ared

ness

(Sur

ge p

lan)

Expa

nsio

n in

to c

orrid

or /

desig

nate

d es

cala

tion

area

Staf

fing

plan

for e

scal

atio

n

Hi

gher

than

exp

ecte

d le

ngth

of s

tay

(LO

S)

N

orm

alise

d re

lianc

e up

on

esca

latio

n ar

eas d

urin

g pr

essu

re

In

suffi

cien

t dai

ly d

ischa

rges

to

del

iver

net

pat

ient

flow

Stan

dard

s of c

are

in

corr

idor

s or e

scal

atio

n ar

eas d

urin

g pe

riods

of v

ery

high

dem

and

and

very

hig

h be

d oc

cupa

ncy

Ca

paci

ty a

nd d

eman

d m

odel

ling

inc.

thea

tre

utili

satio

n

Relia

bilit

y of

SHO

P im

plem

enta

tion

Patie

nt fl

ow tr

ansf

orm

atio

n pr

ogra

mm

e SL

T Le

ad: M

D/Tr

ansf

orm

atio

n Le

ad

Tim

esca

les:

As p

er p

rogr

amm

e

Leve

l 1

Di

visio

nal p

erfo

rman

ce re

view

s (m

onth

ly);

Stra

nded

pat

ient

revi

ews (

2 pe

r wee

k)

O

vera

ll be

d oc

cupa

ncy

rate

(dai

ly)

52

wee

k w

ait &

size

of w

aitin

g lis

t Le

vel 2

Q&

P Da

shbo

ard

(mon

thly

);

PFI

G Re

port

to B

oard

(mon

thly

);

Tr

ansf

orm

atio

n Bo

ard;

Wirr

al A

&E

Deliv

ery

Boar

d;

Leve

l 3

CQ

C im

prov

emen

t ove

rsig

ht;

Sy

stem

Impr

ovem

ent B

oard

Lim

ited

scop

e ex

tern

al a

udit

– Q

ualit

y Ac

coun

t 20

17/1

8

CQC

unan

noun

ced

insp

ectio

n (M

arch

’18)

Cont

ract

mee

tings

Non

e id

entif

ied

Revi

ew o

f out

patie

nt p

roce

sses

SL

T Le

ad: C

OO

/ Tra

nsfo

rmat

ion

Lead

Ti

mes

cale

s: A

s per

pro

gram

me

Proc

ess w

here

by Q

ualit

y m

atro

ns c

ondu

ct p

atie

nt sa

fety

ch

ecks

for a

ll pa

tient

s in

corr

idor

/ esc

alat

ion

area

s is

fully

impl

emen

ted

and

embe

dded

SL

T Le

ad: C

hief

nur

se

Tim

esca

les:

June

201

9

Prox

imity

of t

hrea

t 19

/20

20/2

1 21

/22

22/2

3 23

/24

Thre

at &

Opp

ortu

nity

: O

pera

tiona

l fai

lure

of G

ener

al

Prac

tice

to c

ope

with

dem

and

resu

lting

in e

ven

high

er d

eman

d fo

r sec

onda

ry c

are

as th

e ‘p

rovi

der o

f las

t res

ort’

Em

erge

ncy

prep

ared

ness

con

tinge

ncy

in th

e ev

ent o

f sur

ge in

ac

tivity

–Tr

ust m

itiga

tion

actio

n pl

an –

OPE

L; E

scal

atio

n Ac

tion

Plan

s - O

PEL

Enga

gem

ent w

ith st

akeh

olde

rs a

cros

s loc

al h

ealth

syst

em to

es

tabl

ish fo

resig

ht a

nd a

dapt

ive

capa

city

in th

e ev

ent o

f pra

ctic

e co

llaps

e

Re

lianc

e on

Wal

k-in

-Cen

tres

/ U

rgen

t Car

e Ce

ntre

A&E

deliv

ery

Boar

d(U

COG

& U

CEXG

)

Syst

em p

artn

ers e

scal

atio

n pr

oces

s

Not

with

in th

e Tr

usts

sphe

re

of c

ontr

ol.

In th

e ev

ent o

f GP

prac

tice

colla

pse

on W

irral

th

ere

wou

ld li

kely

be

surg

es in

de

man

d fo

r sec

onda

ry c

are

Enga

ge w

ith C

omm

issio

ners

SL

T Le

ad: C

OO

Ti

mes

cale

s: O

ngoi

ng

Leve

l 2

Re

port

s to

TMB

Leve

l 3

Co

nfirm

and

Cha

lleng

e by

NHS

Eng

land

Re

gion

al te

am a

nd C

CGs (

Ong

oing

);

LH

RP

Assura

nce P

rocess

Unc

erta

inty

re: f

ragi

lity

of g

ener

al

prac

tice

in th

e W

irral

Ac

tion:

A

requ

est t

o be

mad

e to

revi

ew

CCG

BAF

to b

ette

r und

erst

and

frag

ility

of G

ener

al p

ract

ice

in

Wirr

al

SLT

Lead

: CO

O

Tim

esca

les:

May

201

9

Prox

imity

of t

hrea

t 19

/20

20/2

1 21

/22

22/2

3 23

/24

Th

reat

& O

ppor

tuni

ty:

Ope

ratio

nal f

ailu

re o

f ne

ighb

ourin

g pr

ovid

ers t

hat

crea

tes a

larg

e-sc

ale

shift

in th

e flo

w o

f pat

ient

s and

refe

rral

s to

WU

TH

Pr

epar

edne

ss c

ontin

genc

y in

the

even

t of s

urge

in a

ctiv

ity –

Trus

t m

itiga

tion

actio

n pl

an –

OPE

L; E

scal

atio

n Ac

tion

Plan

s - O

PEL

Enga

gem

ent w

ith st

akeh

olde

rs a

cros

s loc

al h

ealth

syst

em to

es

tabl

ish fo

resig

ht a

nd a

dapt

ive

capa

city

in th

e ev

ent o

f pra

ctic

e co

llaps

e

Re

lianc

e on

Wal

k-in

-Cen

tres

/ U

rgen

t Car

e Ce

ntre

A&E

deliv

ery

Boar

d (U

COG

& U

CEXG

)

Syst

em p

artn

ers e

scal

atio

n pr

oces

s

Not

with

in th

e Tr

usts

sphe

re

of c

ontr

ol.

In th

e ev

ent o

f co

llaps

e, e

mer

genc

y pr

oced

ures

will

gov

ern

the

resp

onse

Enga

ge w

ith C

omm

issio

ners

SL

T Le

ad: C

OO

Ti

mes

cale

s: O

ngoi

ng

Leve

l 2

Re

port

s to

TMB

Leve

l 3

Co

nfirm

and

Cha

lleng

e by

NHS

Eng

land

Re

gion

al te

am a

nd C

CGs (

Ong

oing

);

LH

RP

Assura

nce P

rocess

Unc

erta

inty

re: f

ragi

lity

of

neig

hbou

ring

prov

ider

s in

the

Wirr

al

Actio

n:

A re

ques

t to

be m

ade

to re

view

CC

G BA

F to

bet

ter u

nder

stan

d fr

agili

ty o

f nei

ghbo

urin

g pr

ovid

ers

in th

e W

irral

SL

T Le

ad: C

OO

Ti

mes

cale

s: M

ay 2

019

Prox

imity

of t

hrea

t 19

/20

20/2

1 21

/22

22/2

3 23

/24

Revi

ew C

ontin

genc

y pl

ans

SLT

Lead

: CO

O

Tim

esca

les:

Ong

oing

Item

10.

5 -

Rev

iew

of B

oard

Ass

uran

ce F

ram

ewor

k

Page 106 of 120

Boar

d As

sura

nce

Fram

ewor

k (B

AF):

2019

/20

(Dra

ft –

val

id a

s of 0

1 Ap

ril 2

019)

Pa

ge 4

of 1

7

Key

risk

indi

cato

rs (K

RIs)

–Da

ta u

pdat

ed 2

1/03

/19

Tota

l no.

on w

aitin

g lis

t

WU

TH a

ctiv

ity (A

dmitt

ed, D

isch

arge

s & N

et fl

ow)

To b

e de

velo

ped

B

ed o

ccup

ancy

on

a w

eek

by w

eek

basi

s To

be

deve

lope

d

60%

65%

70%

75%

80%

85%

90%

95%

100%

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

A&E

Four

Hou

r Tar

get (

Arro

we

Park

site

incl

udin

g Al

l Day

Hea

lth C

entr

e)

Actu

als

UCL

LCL

020406080100

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Refe

rral

to T

reat

men

t - c

ases

exc

eedi

ng 5

2 w

eeks

Actu

als

Targ

etU

CLLC

L

96%

97%

98%

99%

100%

Jan-18Feb-18Mar-18Apr-18

May-18Jun-18Jul-18

Aug-18Sep-18Oct-18Nov-18Dec-18Jan-19Feb-19

Diag

nost

ic W

aite

rs, 6

wee

ks a

nd o

ver -

DM

01

Actu

als

Targ

etU

CLLC

L

70%

75%

80%

85%

90%

95%

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Canc

er W

aitin

g Ti

mes

- 62

day

s to

trea

tmen

t

Actu

als

Targ

etU

CLLC

L

Page 107 of 120

Boar

d As

sura

nce

Fram

ewor

k (B

AF):

2019

/20

(Dra

ft –

val

id a

s of 0

1 Ap

ril 2

019)

Pa

ge 5

of 1

7

Stra

tegi

c pr

iorit

y I.

PEO

PLE:

Sup

port

ed e

mpo

wer

ed w

orkf

orce

II.

PER

FORM

ANCE

: Con

siste

ntly

del

iver

fina

ncia

l sus

tain

abili

ty a

nd p

erfo

rman

ce st

anda

rds

Lead

Com

mitt

ee

WAC

Cu

rren

t ris

k ex

posu

re

Tole

rabl

e ris

k Ri

sk T

reat

men

t St

rate

gy:

Mod

ify

Prin

cipa

l ris

k (w

hat c

ould

pre

vent

us

achi

evin

g th

is st

rate

gic

prio

rity)

PR 2

: Crit

ical

shor

tage

of w

orkf

orce

cap

acity

& c

apab

ility

A

criti

cal s

hort

age

of w

orkf

orce

cap

acity

with

the

requ

ired

skill

s to

man

age

dem

and

resu

lting

in a

pro

long

ed, w

ides

prea

d re

duct

ion

in th

e qu

ality

of s

ervi

ces a

nd re

peat

ed fa

ilure

to

ach

ieve

con

stitu

tiona

l sta

ndar

ds

Exec

utiv

e le

ad

Dir.

HR/W

orkf

orce

Li

kelih

ood:

5.

V. l

ikel

y 3.

Poss

ible

Ri

sk a

ppet

ite

Ope

n In

itial

dat

e of

as

sess

men

t 01

/04/

2019

Co

nseq

uenc

e 4.

Hig

h 4.

Hig

h

Last

revi

ewed

01

/04/

2019

Ri

sk ra

ting

20. S

igni

fican

t 12

.Hig

h

Last

cha

nged

01

/04/

2019

An

ticip

ated

cha

nge

Inte

nsify

ing

Deta

ils o

f cha

nge

Revi

sed

BAF

for B

oard

con

sider

atio

n

Risk

Vec

tor

(wha

t mig

ht c

ause

this

to h

appe

n)

Prim

ary

risk

trea

tmen

t (w

hat c

ontr

ols/

syst

ems &

pro

cess

es d

o w

e al

read

y ha

ve in

pla

ce to

ass

ist u

s in

man

agin

g th

e ris

k an

d re

duci

ng th

e lik

elih

ood/

impa

ct o

f the

thre

at)

Gap

s in

cont

rol

(Spe

cific

are

as /

issue

s whe

re fu

rthe

r w

ork

is re

quire

d to

man

age

the

risk

to a

ccep

ted

appe

tite/

tole

ranc

e le

vel)

Plan

s to

impr

ove

cont

rol

(are

furt

her c

ontr

ols p

ossib

le i

n or

der t

o re

duce

risk

exp

osur

e w

ithin

to

lera

ble

rang

e?)

Leve

l & S

ourc

e of

ass

uran

ce (&

dat

e)

(Evi

denc

e th

at th

e co

ntro

ls/ sy

stem

s whi

ch w

e ar

e pl

acin

g re

lianc

e on

are

effe

ctiv

e)

Gap

in

Assu

ranc

e/

Actio

n to

ad

dres

s gap

Assu

ranc

e ra

ting

Thre

at: D

emog

raph

ic c

hang

es

(incl

udin

g th

e im

pact

of B

rexi

t and

an

agei

ng w

orkf

orce

) and

shift

ing

cultu

ral

attit

udes

to c

aree

rs, c

ombi

ned

with

em

ploy

men

t mar

ket f

acto

rs (s

uch

as

redu

ced

avai

labi

lity

and

incr

ease

d co

mpe

titio

n) re

sulti

ng in

crit

ical

w

orkf

orce

gap

s in

som

e cl

inic

al se

rvic

es

E-

rost

erin

g an

d jo

b pl

anni

ng t

o su

ppor

t sta

ff de

ploy

men

t

Vaca

ncy

man

agem

ent a

nd re

crui

tmen

t sys

tem

s & p

roce

sses

TRAC

syst

em fo

r rec

ruitm

ent;

e-Ro

ster

ing

syst

ems a

nd

proc

edur

es u

sed

to p

lan

staf

f util

isatio

n

Defin

ed sa

fe m

edic

al &

nur

se st

affin

g le

vels

for a

ll w

ards

&

depa

rtm

ents

/ Saf

e St

affin

g St

anda

rd O

pera

ting

Proc

edur

e

Tem

pora

ry st

affin

g ap

prov

al a

nd re

crui

tmen

t pro

cess

es w

ith

defin

ed a

utho

risat

ion

leve

ls

‘N

o de

al’ E

U E

xit P

lann

ing

Team

– in

cl w

orkf

orce

pla

nnin

g –

actio

n ca

rds/

glo

bal c

omm

s/ E

U e

xit p

age

on in

tran

et

M

edic

al st

affin

g &

HR

Team

s in

plac

e

Nur

sing

& M

idw

ifery

recr

uitm

ent &

rete

ntio

n st

rate

gy

Vo

lunt

eer s

trat

egy

Re

crui

tmen

t cam

paig

n (B

and

5; C

SW; V

olun

teer

s)

W

ard

esta

blish

men

t rev

iew

Divi

siona

l ow

ners

hip

and

unde

rsta

ndin

g of

thei

r w

orkf

orce

issu

es

Deve

lop

unde

rsta

ndin

g &

bo

ost o

wne

rshi

p th

roug

h W

F St

eerin

g gr

oup/

Div

ision

al

Perf

orm

ance

revi

ews

SLT

Lead

: Dir

HR

Tim

esca

les:

Com

men

ce A

pril

‘19

Leve

l 1

Di

visio

nal p

erfo

rman

ce re

view

s – w

orkf

orce

met

rics (

mon

thly

)

Wor

kfor

ce st

eerin

g gr

oup

– al

l KPI

’s (m

onth

ly)

Leve

l 2

W

orkf

orce

stra

tegy

& p

lan

Q

ualit

y an

d Pe

rfor

man

ce d

ashb

oard

- W/f

orce

met

rics (

mon

thly

);

Re

port

of W

orkf

orce

Ass

uran

ce C

omm

ittee

to B

oard

(Mon

thly

);

FBP

AC re

port

s (M

onth

ly)

EU

exi

t pap

er p

rese

nted

to T

MB

and

Chai

rman

s rep

ort t

o Bo

ard

(Feb

/ Mar

’19)

Non

e id

entif

ied

Lack

of u

nder

stan

ding

re: t

he

impa

ct o

f age

dem

ogra

phic

s on

sta

ff re

tent

ion

risk

Vaca

ncy

rate

s / h

igh

locu

m

use

and

hard

to re

crui

t m

edic

al p

osts

Bed

mod

ellin

g &

spec

ialty

ca

paci

ty/ d

eman

d re

view

SL

T Le

ad: C

OO

Ti

mes

cale

s: B

y en

d Ap

ril ‘1

9 Va

canc

y ra

tes f

or n

ursin

g

post

s T&

F gr

oup

– re

crui

tmen

t B 5

’s

SLT

Lead

: Ch.

Nur

se

Tim

esca

les:

July

‘20

Prox

imity

of t

hrea

t 19

/20

20/2

1 21

/22

22/2

3 23

/24

No

wor

kfor

ce p

lan

alig

ned

to

serv

ice

stra

tegy

De

velo

p an

d ap

prov

e w

orkf

orce

stra

tegy

and

im

plem

enta

tion

plan

by

end

of A

pril

‘19

Thre

at: A

failu

re to

acq

uire

or l

oss o

f of

wor

kfor

ce p

rodu

ctiv

ity a

risin

g fr

om a

re

duct

ion

in d

iscre

tiona

ry e

ffort

am

ongs

t sub

stan

tial p

ropo

rtio

n of

the

wor

kfor

ce a

nd/o

r los

s of e

xper

ienc

ed

colle

ague

s fro

m th

e se

rvic

e, o

r cau

sed

by o

ther

fact

ors s

uch

as p

oor j

ob

satis

fact

ion,

lack

of o

ppor

tuni

ties f

or

pers

onal

dev

elop

men

t, on

-goi

ng p

ay

rest

rain

t or w

orkf

orce

fatig

ue

St

aff C

omm

unic

atio

n bu

lletin

; Sch

war

tz ro

unds

Divi

siona

l act

ion

plan

s fro

m st

aff s

urve

y

Polic

ies (

Inc.

staf

f dev

elop

men

t; ap

prai

sal p

roce

ss; s

ickn

ess

and

rela

tions

hips

at w

ork

polic

y)

Le

ader

ship

dev

elop

men

t pro

gram

me

/ Dut

ies o

f a d

octo

r pr

ogra

mm

e

Exec

utiv

e &

SLT

visi

bilit

y; B

ig d

ebat

es; A

sk th

e Ex

ec T

eam

Divi

siona

l sta

ff su

ppor

t net

wor

ks; F

reed

om to

Spe

ak u

p Gu

ardi

ans;

Occ

upat

iona

l Hea

lth S

uppo

rt (a

s req

uire

d)

He

alth

& W

ellb

eing

team

in p

lace

Rew

ards

& re

cogn

ition

i.e.

ann

ual s

taff

cele

brat

ion;

car

ds

At

tend

ance

Man

agem

ent p

roce

dure

s

Staf

f sur

vey

resu

lts id

entif

y ar

eas f

or fu

rthe

r im

prov

emen

ts

Stre

ngth

en a

nd b

oost

ov

ersig

ht o

f OD

deliv

ery

via

Wor

kfor

ce A

ssur

ance

Co

mm

ittee

SL

T Le

ad: D

ir HR

Ti

mes

cale

s: F

rom

Apr

il’19

Leve

l 1

Di

visio

nal p

erfo

rman

ce re

view

s – w

orkf

orce

met

rics (

mon

thly

)

Wor

kfor

ce st

eerin

g gr

oup

– al

l KPI

’s (m

onth

ly)

Leve

l 2

W

orkf

orce

/ OD

stra

tegy

& p

lan

Q

ualit

y an

d Pe

rfor

man

ce d

ashb

oard

- Wor

kfor

ce m

etric

s (m

thly

);

Re

port

of W

orkf

orce

Ass

uran

ce C

omm

ittee

to B

oard

(Mon

thly

); Le

vel 3

Nat

iona

l Sta

ff Su

rvey

(Mar

19)

;

CQ

C Re

port

(Mar

’18)

;

Med

ical

eng

agem

ent s

urve

y

Non

e id

entif

ied

U

nsus

tain

able

leve

ls of

sic

knes

s abs

ence

Prox

imity

of t

hrea

t

Emer

genc

y Pl

anni

ng, R

esili

ence

& R

espo

nse

(EPR

R)

arra

ngem

ents

for t

empo

rary

loss

of e

ssen

tial s

taffi

ng

(incl

udin

g in

dust

rial a

ctio

n &

ext

rem

e w

eath

er e

vent

)

The

LHRP

co-

ordi

nate

d re

spon

se

Lim

its to

the

exte

nt

cont

inge

ncie

s can

pro

vide

the

stat

e re

quire

d in

em

erge

ncy

Test

EPR

R ar

rang

emen

ts fo

r w

ides

prea

d di

srup

tion

to

avai

labi

lity

of st

aff

SLT

Lead

: CO

O

Tim

esca

les:

Nex

t tes

t by

Q3

‘19

Leve

l 2

Re

silie

nce

Assu

ranc

e re

port

to R

MC

(Mar

; Sep

t 19)

Le

vel 3

Conf

irm a

nd C

halle

nge

by N

HS E

ngla

nd R

egio

nal t

eam

and

CCG

s;

LH

RP

Assura

nce P

rocess

Non

e id

entif

ied

19/2

0 20

/21

21/2

2 22

/23

23/2

4

Item

10.

5 -

Rev

iew

of B

oard

Ass

uran

ce F

ram

ewor

k

Page 108 of 120

Boar

d As

sura

nce

Fram

ewor

k (B

AF):

2019

/20

(Dra

ft –

val

id a

s of 0

1 Ap

ril 2

019)

Pa

ge 6

of 1

7

Thre

at:W

orkf

orce

bec

omes

des

kille

d du

e to

incr

easin

g de

pend

ence

on

tech

nolo

gy/ d

imin

ishin

g tr

aini

ng

budg

et a

nd o

r ina

bilit

y to

com

plet

e m

anda

tory

or r

ole

spec

ific

trai

ning

In

duct

ion;

Man

dato

ry &

role

spec

ific t

rain

ing

prog

ram

mes

;

Corp

orat

e te

ams p

rovi

de su

ppor

t and

trai

ning

as r

equi

red

Ex

erci

ses t

o te

st b

usin

ess c

ontin

uity

and

inci

dent

m

anag

emen

t pla

ns in

clud

ing

loss

of t

echn

olog

y

ESR

trai

ning

reco

rd

Pr

otec

ted

budg

ets f

or tr

aini

ng &

dev

elop

men

t

Prac

tice

educ

ator

s

Diffi

culti

es in

rele

asin

g st

aff

from

war

ds

Deliv

er 8

0% o

f man

dato

ry

trai

ning

as a

n e-

lear

ning

op

tion

for s

taff

SL

T Le

ad: H

R Di

r Ti

mes

cale

s: B

y en

d Q

1 ‘1

9

Leve

l 2

Q

&P

Dash

boar

d- M

anda

tory

trai

ning

(mon

thly

);

R

epor

t of W

orkf

orce

Ass

uran

ce C

omm

ittee

to B

oard

(mon

thly

) Le

vel 3

St

aff s

urve

y (M

ar ’1

9)

Non

e id

entif

ied

Effe

ctiv

enes

s of m

anda

tory

tr

aini

ng (k

now

ledg

e &

skill

ac

quisi

tion

and

tran

sfer

into

pr

actic

e)

Intr

oduc

e kn

owle

dge

acqu

isitio

n te

sts f

or th

ose

–

e-

lear

ning

opt

ions

ava

ilabl

e fo

r pra

ctic

al sk

ills-

base

d tr

aini

ng, *

***

BLS,

test

all

staf

f at p

oint

of t

rain

ing.

Re

view

role

of p

ract

ice

educ

ator

s SL

T Le

ad: H

R Di

r Ti

mes

cale

s: B

y en

d Q

1 ‘1

9

Prox

imity

of t

hrea

t 19

/20

20/2

1 21

/22

22/2

3 23

/24

Page 109 of 120

Boar

d As

sura

nce

Fram

ewor

k (B

AF):

2019

/20

(Dra

ft –

val

id a

s of 0

1 Ap

ril 2

019)

Pa

ge 7

of 1

7

Key

risk

indi

cato

rs (K

RIs)

Dat

a up

date

d 21

/03/

19

051015202530354045

Live

em

ploy

ee re

latio

ns ca

ses

Actu

als

UCL

LCL

3.00

%

3.50

%

4.00

%

4.50

%

5.00

%

5.50

%

6.00

%

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Sick

ness

Abs

ence

- ro

lling

12

mon

th a

vera

ge %

Actu

als

Targ

etU

CLLC

L

70%

75%

80%

85%

90%

95%

100%

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Appr

aisa

l Com

plia

nce

Actu

als

Targ

etU

CLLC

L

Staf

f sur

vey

2018

To

be

deve

lope

d –

esta

blish

ed n

ursin

g po

sts v

s sta

ff in

pos

t

4%6%8%10%

Nur

se V

acan

cy ra

te

Actu

als

Targ

etU

CLLC

L

4%6%8%10%

Cons

ulta

nt V

acan

cy ra

te

Actu

als

Targ

etU

CLLC

L

Item

10.

5 -

Rev

iew

of B

oard

Ass

uran

ce F

ram

ewor

k

Page 110 of 120

Boar

d As

sura

nce

Fram

ewor

k (B

AF):

2019

/20

(Dra

ft –

val

id a

s of 0

1 Ap

ril 2

019)

Pa

ge 8

of 1

7

Risk

Vec

tor

(wha

t mig

ht c

ause

this

to h

appe

n)

Prim

ary

risk

cont

rols

(c

ontr

ols/

syst

ems/

pro

cess

es a

lread

y in

pla

ce to

ass

ist in

m

anag

ing

the

risk

& re

duci

ng th

e lik

elih

ood/

impa

ct o

f the

thre

at)

Gap

s in

cont

rol

(are

furt

her c

ontr

ols p

ossib

le i

n or

der t

o re

duce

ris

k ex

posu

re w

ithin

tole

rabl

e ra

nge?

)

Plan

s to

impr

ove

cont

rol

Sour

ce o

f ass

uran

ce (&

dat

e)

(Evi

denc

e th

at th

e co

ntro

ls/ sy

stem

s whi

ch w

e ar

e pl

acin

g re

lianc

e on

are

effe

ctiv

e)

Gap

in A

ssur

ance

/ Ac

tion

to a

ddre

ss

gap

Assu

ranc

e ra

ting

Thre

at: I

ncre

ased

cos

t & in

com

e vo

latil

ity a

s a

resu

lt of

tarif

f cha

nges

; det

erio

ratin

g co

nditi

on o

f clin

ical

est

ate;

dep

ende

ncy

on

tem

pora

ry st

affin

g; g

row

th in

com

petit

ion

from

the

priv

ate

heal

th se

ctor

; con

trac

t pe

nalti

es/ f

ines

lead

ing

to u

neco

nom

ic

serv

ices

An

nual

pla

n, in

clud

ing

cont

rol t

otal

con

sider

atio

n;

redu

ctio

n of

und

erly

ing

finan

cial

def

icit

SF

I’s a

utho

risat

ion

limit

(sch

eme

of d

eleg

atio

n)

Co

re fi

nanc

ial c

ontr

ol P

olic

ies /

Pro

cedu

res

Ac

cess

to W

orki

ng C

apita

l sup

port

Budg

etar

y co

ntro

ls/Bu

dget

at W

ard

& D

ept l

evel

Trai

ning

for b

udge

t hol

ders

Proc

urem

ent p

roce

sses

and

Tea

m

Ri

sk b

ased

ann

ual c

apita

l pla

nnin

g pr

oces

s

N

ot a

ll bu

dget

hol

ders

hav

e co

mpl

eted

trai

ning

Lack

of a

ccur

acy

of w

ard/

dept

bu

dget

s

Com

plia

nce

with

esc

alat

ion

as p

er

SFI

M

TFM

not

yet

agr

eed

Ef

fect

iven

ess o

f bud

get

man

agem

ent @

Divi

siona

l/ Co

rpor

ate/

War

d/ D

ept

O

pera

tiona

l pro

duct

ivity

impa

ctin

g ad

vers

ely

on in

com

e an

d ex

pend

iture

Robu

st c

apac

ity p

lan

Jo

b pl

anni

ng a

nd e

-ros

ter

Embe

d S/

L re

port

ing

& e

stab

lish

stee

ring

grou

p

SLT

Lead

: MD

Tim

esca

les:

End

of S

epte

mbe

r ‘19

Leve

l 1

Di

visio

nal r

isk re

port

s to

Risk

Com

mitt

ee b

i-an

nual

ly;

Leve

l 2

Fi

nanc

e re

port

pre

sent

ed to

Boa

rd (m

onth

ly)

Si

gnifi

cant

risk

repo

rt to

RM

C (m

onth

ly);

Ch

airs

repo

rt e

scal

ated

to F

BPAC

& B

oard

;

Q&

P Da

shbo

ard

(mon

thly

)

Annu

al re

port

& A

ccou

nts

Leve

l 3

In

tern

al a

udit;

Exte

rnal

aud

it;

Non

e id

entif

ied

Robu

st c

apac

ity p

lan/

job

plan

ning

and

e-r

oste

r-

add

on re

quire

d - e

ffici

ent d

eplo

ymen

t of

staf

f acr

oss o

rgan

isatio

n (IT

sol

utio

n )

SLT

Lead

: Ch.

Nur

se

Tim

esca

les:

End

of S

epte

mbe

r ‘19

En

sure

all

budg

et h

olde

rs re

ceiv

e re

fres

her

trai

ning

on

budg

et m

gmnt

& S

F1 c

ompl

ianc

e

SLT

Lead

: FD

Tim

esca

les:

End

of J

uly

‘19

Deve

lop

& a

gree

acc

urat

e pa

y &

non

-pay

bu

dget

s SL

T Le

ad: F

D

Tim

esca

les:

End

of A

pril

‘19

Prox

imity

of t

hrea

t De

velo

p &

agr

ee M

TFM

SL

T Le

ad: F

D

Tim

esca

les:

End

of J

uly

‘19

19/2

0 20

/21

21/2

2 22

/23

23/2

4

Thre

at: I

nsuf

ficie

nt C

IP d

eliv

ered

due

to la

ck

of in

tern

al c

apac

ity to

iden

tify

and

deliv

er

recu

rren

t sav

ings

; com

petin

g pe

rfor

man

ce

prio

ritie

s; re

lianc

e on

syst

em-w

ide

chan

ge;

com

petin

g re

gula

tory

prio

ritie

s or

unex

pect

ed sp

end

to a

ddre

ss q

ualit

y/

com

plia

nce

issue

s

CI

P pl

anni

ng p

roce

sses

and

coo

rdin

atio

n of

de

liver

y

Agre

ed C

IP p

lans

at D

ivisi

onal

and

Dep

t lev

el

Ac

cess

to W

orki

ng C

apita

l sup

port

Prog

ram

me

Boar

d

SRO

’s id

entif

ied

for C

IP p

rogr

amm

e

CIP

plan

ning

; sco

ping

; app

rova

l and

initi

atio

n pr

oces

s in

plac

e w

ith Q

IA a

nd c

linic

al si

gn-o

ff

U

nide

ntifi

ed C

IP in

yea

r

Effe

ctiv

enes

s of o

vers

ight

Es

tabl

ishm

ent o

f CIP

del

iver

y m

onito

ring

mee

tings

SL

T Le

ad: F

D Ti

mes

cale

s: E

nd o

f Apr

il ‘1

9

Leve

l 1

Di

visio

nal r

epor

ts to

Pro

gram

me

Boar

d;

Leve

l 2

Fi

nanc

e re

port

pre

sent

ed to

Boa

rd (m

onth

ly)

Ch

airs

repo

rt e

scal

ated

to F

BPAC

& B

oard

;

Q&

P Da

shbo

ard

(mon

thly

)

Annu

al re

port

& A

ccou

nts

Leve

l 3

In

tern

al a

udit/

Ext

erna

l aud

it;

Non

e id

entif

ied

Prox

imity

of t

hrea

t 19

/20

20/2

1 21

/22

22/2

3 23

/24

Th

reat

: Gro

wth

in th

e bu

rden

of b

ackl

og

mai

nten

ance

and

med

ical

equ

ipm

ent

repl

acem

ent c

osts

to u

naffo

rdab

le le

vels

T

reas

ury

loan

pro

cess

/NHS

I Cap

ital a

ppro

val

proc

ess.

Plan

ned

and

prev

enta

tive

mai

nten

ance

regi

me

in

plac

e ba

sed

on c

ompl

ianc

e

Reac

tive

mai

nten

ance

regi

me

to re

pair

imm

edia

te

issue

s as t

hey

arise

with

ded

icat

ed B

udge

t for

Ba

cklo

g m

aint

enan

ce -

circ

a £1

.2 m

illio

n

Dedi

cate

d Ca

pita

l Bud

get f

or im

prov

emen

t wor

ks

on th

e Ph

ysic

al E

nviro

nmen

t- v

ario

us.

The

cond

ition

of t

he c

urre

nt e

stat

e an

d ag

eing

med

ical

dev

ices

pre

sent

s a

signi

fican

t mai

nten

ance

and

af

ford

abili

ty b

urde

n in

a re

stra

ined

op

erat

ions

env

ironm

ent

Esta

blish

a tr

ust w

ide

6 fa

cet s

urve

y an

d re

port

on

the

phys

ical

env

ironm

ent t

o id

entif

y ar

eas o

f con

cern

and

repl

acem

ent

cost

s SL

T Le

ad: C

OO

Ti

mes

cale

s: M

ay ‘1

9

Leve

l 1

Di

visio

nal r

isk re

port

s to

RMC

(mon

thly

)

Back

log

repo

rt p

rese

nted

to R

MC

-Mar

ch 1

9;

Co

mpl

ianc

e Au

dit u

nder

take

n (e

very

6m

ths)

Le

vel 2

Sign

ifica

nt ri

sk re

port

to R

MC

(mon

thly

) Le

vel 3

PLAC

E au

dits

(ann

ually

)

6 Fa

cet s

urve

y

Envi

ronm

enta

l Hea

lth re

port

s

NHS

Pre

mise

s As

sura

nce

Mod

el

Deve

lope

d to

id

entif

y ar

eas o

f ris

k an

d re

view

ed

annu

ally

.

Prox

imity

of t

hrea

t 19

/20

20/2

1 21

/22

22/2

3 23

/24

Stra

tegi

c pr

iorit

y PE

RFO

RMAN

CE: C

onsis

tent

ly d

eliv

er fi

nanc

ial s

usta

inab

ility

and

per

form

ance

stan

dard

s Le

ad C

omm

ittee

FB

PAC

Curr

ent r

isk

expo

sure

To

lera

ble

risk

Risk

Tre

atm

ent

Stra

tegy

: M

odify

/ Tr

ansf

er

Prin

cipa

l ris

k (w

hat c

ould

pre

vent

us

achi

evin

g th

is st

rate

gic

prio

rity)

PR 3

: Fai

lure

to a

chie

ve a

nd/o

r mai

ntai

n fin

anci

al su

stai

nabi

lity

In

abili

ty to

del

iver

the

annu

al c

ontr

ol to

tal r

esul

ting

in a

failu

re to

ach

ieve

and

mai

ntai

n fin

anci

al su

stai

nabi

lity.

Exec

utiv

e le

ad

Fina

nce

Dir.

Like

lihoo

d:

3. P

ossib

le

2. U

nlik

ely

Initi

al d

ate

of

asse

ssm

ent

01/0

4/20

19

Cons

eque

nce

5.V.

Hig

h 4.

Hig

h Ri

sk a

ppet

ite

Ope

n

Last

revi

ewed

01

/04/

2019

Ri

sk ra

ting

15. S

igni

fican

t 8.

Med

ium

Last

cha

nged

01

/04/

2019

An

ticip

ated

cha

nge

Inte

nsify

ing

Deta

ils o

f cha

nge

Revi

sed

BAF

for B

oard

con

sider

atio

n

Page 111 of 120

Boar

d As

sura

nce

Fram

ewor

k (B

AF):

2019

/20

(Dra

ft –

val

id a

s of 0

1 Ap

ril 2

019)

Pa

ge 9

of 1

7

Thre

at:In

crea

sing

cost

of c

linic

al a

nd c

ivil

liabi

lity

insu

ranc

e du

e to

non

-com

plia

nce

with

Hea

lth &

Saf

ety

legi

slatio

n; le

vels

of

harm

ful a

nd in

defe

nsib

le c

are

and

incr

easin

gly

litig

ious

soci

ety

Sp

ecia

list H

&S

advi

sors

& le

gal t

eam

em

ploy

ed

M

embe

rshi

p of

CN

ST sc

hem

e

H&S

polic

ies a

nd p

roce

dure

s/ st

aff t

rain

ing

In

vest

igat

ion

proc

esse

s; a

ctio

n pl

anni

ng a

nd

shar

ing

less

ons l

earn

t to

redu

ce li

kelih

ood

of

recu

rren

ce

Cl

inic

al a

udit

and

effe

ctiv

enes

s pro

gram

me

O

ther

insu

ranc

e po

licie

s

M

atur

ity o

f the

safe

ty m

anag

emen

t sy

stem

is c

urre

ntly

at ‘

emer

ging

’ lev

el

Li

mite

d m

onito

ring

of c

ompl

ianc

e w

ith

H&S

requ

irem

ents

Rest

ricte

d ad

aptiv

e ca

paci

ty

De

laye

d re

spon

ses t

o no

n-cl

inic

al

inci

dent

s

Com

miss

ion

an in

depe

nden

t saf

ety

man

agem

ent a

udit

and

deve

lop

a pl

an to

take

w

hate

ver s

teps

are

nec

essa

ry to

stre

ngth

en

the

Safe

ty m

anag

emen

t sys

tem

s SL

T Le

ad: D

ir Q

&G

Ti

mes

cale

s:M

ay 2

019

Leve

l 2

H&

S re

port

to R

MC

(6 m

onth

ly)

SI

RG re

ceiv

es a

ll cl

aim

s/ R

IDDO

R in

cide

nts

Leve

l 3

Au

thor

ised

engi

neer

s rep

orts

; UKA

S

NHS

R cl

aim

s pro

file;

MHR

A in

spec

tion

repo

rts;

HSE

insp

ectio

n/ E

nviro

nmen

tal

Heal

th in

spec

tions

; CQ

C in

spec

tion

repo

rts

Prox

imity

of t

hrea

t 19

/20

20/2

1 21

/22

22/2

3 23

/24

Item

10.

5 -

Rev

iew

of B

oard

Ass

uran

ce F

ram

ewor

k

Page 112 of 120

Boar

d As

sura

nce

Fram

ewor

k (B

AF):

2019

/20

(Dra

ft –

val

id a

s of 0

1 Ap

ril 2

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Pa

ge 1

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risk

indi

cato

rs (K

RIs)

Dat

a up

date

d

.

Regi

onal

Com

paris

on o

f num

ber o

f EL/

PL cl

aim

s

Re

gion

al c

ompa

rison

of R

PST

cont

ribut

ion

and

leve

l of c

ompe

nsat

ion

paid

Regi

onal

Com

paris

on o

f num

ber o

f CN

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s

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ree

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vers

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spita

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unda

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tess

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NHS

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Hosp

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NHS

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s and

Know

sley

Teac

hing

Hosp

itals

NHS

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t

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ringt

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NHS

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thly

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orm

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0

500

1000

1500

2000

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Perf

orm

ance

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alPl

an

0

200

400

600

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1000

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genc

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form

ance

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Page 113 of 120

Boar

d As

sura

nce

Fram

ewor

k (B

AF):

2019

/20

(Dra

ft –

val

id a

s of 0

1 Ap

ril 2

019)

Pa

ge 1

1 of

17

Stra

tegi

c pr

iorit

y PA

TIEN

TS: P

ursu

ing

qual

ity im

prov

emen

t Le

ad C

omm

ittee

Q

ualit

y Cu

rren

t ris

k ex

posu

re

Tole

rabl

e ris

k Ri

sk T

reat

men

t Str

ateg

y:

Mod

ify

Prin

cipa

l ris

k (w

hat c

ould

pre

vent

us

achi

evin

g th

is st

rate

gic

prio

rity)

PR 4

: Cat

astr

ophi

c fa

ilure

in S

tand

ards

of C

are

A

Cata

stro

phic

failu

re in

stan

dard

s of s

afet

y an

d qu

ality

of p

atie

nt

care

acr

oss t

he T

rust

resu

lting

in m

ultip

le in

cide

nts o

f sev

ere,

av

oida

ble

harm

and

poo

r clin

ical

out

com

e

Exec

utiv

e le

ad

Med

ical

Dire

ctor

Li

kelih

ood:

4.

Som

ewha

t lik

ely

3. P

ossib

le

Risk

app

etite

M

inim

al

Initi

al d

ate

of

asse

ssm

ent

01/0

4/20

19

Cons

eque

nce

4. H

igh

3.M

oder

ate

Last

revi

ewed

01

/04/

2019

Ri

sk ra

ting

16. H

igh

9. M

ediu

m

Last

cha

nged

01

/04/

2019

An

ticip

ated

cha

nge

Unc

erta

in

Deta

ils o

f cha

nge

Revi

sed

BAF

for B

oard

con

sider

atio

n

Risk

Vec

tor

(wha

t mig

ht c

ause

this

to h

appe

n)

Prim

ary

risk

trea

tmen

t (w

hat c

ontr

ols/

syst

ems &

pro

cess

es d

o w

e al

read

y ha

ve in

pla

ce to

ass

ist u

s in

man

agin

g th

e ris

k an

d re

duci

ng th

e lik

elih

ood/

impa

ct o

f the

thre

at)

Gap

s in

cont

rol

(Spe

cific

are

as /

issue

s whe

re

furt

her w

ork

is re

quire

d to

m

anag

e th

e ris

k to

acc

epte

d ap

petit

e/ to

lera

nce

leve

l)

Plan

s to

impr

ove

cont

rol

(are

furt

her c

ontr

ols p

ossib

le i

n or

der

to re

duce

risk

exp

osur

e w

ithin

tole

rabl

e ra

nge?

)

Sour

ce o

f ass

uran

ce (&

dat

e)

(Evi

denc

e th

at th

e co

ntro

ls/ sy

stem

s whi

ch w

e ar

e pl

acin

g re

lianc

e on

are

effe

ctiv

e)

Gap

in A

ssur

ance

/ Ac

tion

to a

ddre

ss g

ap

(Insu

ffici

ent e

vide

nce

as to

ef

fect

iven

ess o

f the

con

trol

s or

nega

tive

assu

ranc

e)

Assu

ranc

e ra

ting

An o

utbr

eak

of in

fect

ious

dise

ase

(suc

h as

pan

dem

ic in

fluen

za;

noro

viru

s; in

fect

ions

resis

tant

to

antib

iotic

s) th

at fo

rces

clo

sure

to o

ne

or m

ore

area

s of t

he h

ospi

tal a

nd/o

r ca

uses

avo

idab

le se

rious

har

m o

r de

ath

to se

rvic

e us

ers

• Ch

ief N

urse

iden

tifie

d as

DIP

C •

IPC

serv

ice

prov

ided

Tru

st w

ide

by th

e IP

C Te

am in

cl.

seve

n da

y ou

t of h

our’s

on-

call

serv

ice;

IPC

Prog

ram

me

of w

ork

• In

fect

ion

Prev

entio

n &

Con

trol

pol

icie

s/ p

roce

dure

s •

Staf

f tra

inin

g •

Antib

iotic

stew

ards

hip

• En

viro

nmen

tal c

lean

ing

Proc

edur

es /

Stan

dard

s in

all a

reas

•

Deco

ntam

inat

ion

stan

dard

s – C

SSD;

Flu

vac

cina

tion

prog

•

Stric

t adh

eren

ce to

sing

le u

se it

ems

• Be

d oc

cupa

ncy

man

aged

by

lead

s tha

t att

empt

s to

min

imis

e ris

k of

cro

ss c

onta

min

atio

n •

Mat

tres

s dec

onta

min

atio

n / d

ispos

al &

repl

acem

ent

Uns

usta

inab

le le

vels

of

bed

occu

panc

y (s

uffic

ient

to

con

trol

infe

ctio

ns)

Infe

ctio

n pr

even

tion

cont

rol

impr

ovem

ent p

lan

to b

e fu

lly

impl

emen

ted

SLT

Lead

: Ch.

N

Tim

esca

les:

Aug

ust ‘

19

Leve

l 1

Pe

rfec

t war

d/ w

ard

accr

edita

tion

audi

ts; D

ivisi

onal

re

port

s to

IPO

RT

Leve

l 2

In

fect

ion

Prev

entio

n &

Con

trol

Per

form

ance

Re

port

to B

oard

; Inf

ectio

n Pr

even

tion

and

Cont

rol

- Im

prov

emen

t Pla

n –

PSQ

B/Q

ualit

y; Q

ualit

y

Perf

orm

ance

Das

hboa

rd; W

eekl

y es

cala

tion

repo

rt

IPC

spec

ific;

IPCG

/ PSQ

B ov

ersig

ht

Leve

l 3

IPC

Impr

ovem

ent p

lan;

MIA

A In

tern

al a

udit

repo

rts;

PH

E re

port

s

Lack

of a

ssur

ance

re

stan

dard

of c

lean

ing

Actio

n:

A re

view

of h

otel

serv

ices

to

be

unde

rtak

en

SLT

Lead

: CO

O

Tim

esca

les:

End

of A

ug 1

9

Inad

equa

te h

and

hygi

ene

com

plia

nce

in c

linic

al

area

s (w

ards

) M

attr

ess r

epla

cem

ent/

de

cont

amin

atio

n/ d

ispos

al

Prox

imity

of t

hrea

t 19

/20

20/2

1 21

/22

22/2

3 23

/24

A w

ides

prea

d lo

ss o

f org

anis

atio

nal

focu

s on

patie

nt sa

fety

and

qua

lity

of c

are

lead

ing

to in

crea

sed

inci

denc

e of

avo

idab

le h

arm

, ex

posu

re to

‘Nev

er E

vent

s’, h

ighe

r th

an e

xpec

ted

mor

talit

y, a

nd

signi

fican

t red

uctio

n in

pat

ient

sa

tisfa

ctio

n

Cl

inic

al se

rvic

e st

ruct

ures

, acc

ount

abili

ty &

qua

lity

gove

rnan

ce

arra

ngem

ents

at T

rust

, div

ision

& se

rvic

e le

vels

incl

udin

g •

Mon

thly

Pat

ient

Saf

ety

& Q

ualit

y Bo

ard

(PSQ

B) w

ith w

ork

prog

ram

me

alig

ned

to C

QC

regi

stra

tion

regs

•

Clin

ical

pol

icie

s, p

roce

dure

s, g

uide

lines

, pat

hway

s,

supp

ortin

g do

cum

enta

tion

& IT

sys

tem

s •

Clin

ical

aud

it pr

ogra

mm

e &

mon

itorin

g ar

rang

emen

ts

• Cl

inic

al st

aff r

ecru

itmen

t, in

duct

ion,

man

dato

ry tr

aini

ng,

regi

stra

tion

& re

-val

idat

ion

• De

fined

safe

med

ical

& n

urse

staf

fing

leve

ls fo

r all

war

ds &

de

part

men

ts

• W

ard

assu

ranc

e/ m

etric

s & a

ccre

dita

tion

prog

ram

me

• CA

S Im

plem

enta

tion

proc

ess

• M

orta

lity

revi

ew p

olic

y &

pro

cess

Curr

ent l

evel

s of m

orta

lity

revi

ew a

nd st

ruct

ured

ju

dgem

ent r

evie

w w

here

th

ese

are

indi

cate

d

Furt

her d

evel

op &

stre

ngth

en

Lear

ning

from

dea

ths p

roce

ss

SLT

Lead

: MD

Tim

esca

les:

By

end

Q1

‘19

Leve

l 1

Pe

rfec

t war

d/ w

ard

accr

edita

tion

audi

ts (o

ngoi

ng)

Leve

l 2

Q

ualit

y Pe

rfor

man

ce D

ashb

oard

(mon

thly

);

PSQ

B re

port

s (m

onth

ly)

Q

ualit

y Ac

coun

t (an

nual

);

KLO

E in

spec

tions

loca

l ins

pect

ions

;

Wee

kly

esca

latio

n ar

eas r

epor

t Le

vel 3

CCG

over

sight

of S

I’s (m

onth

ly)

C

QC

Insig

ht to

ol(m

onth

ly);

Dr

Fos

ter u

pdat

es;

In

tern

al A

udit

SI’s

(mon

thly

)

Patie

nt/ S

taff

surv

eys

Non

e id

entif

ied

Ti

mel

ines

s of e

nd to

end

VT

E as

sess

men

t thr

ough

to

trea

tmen

t

Cons

isten

tly d

eliv

er a

t lea

st

90%

com

plia

nce

with

VTE

as

sess

men

t with

in 1

2 ho

urs o

f ad

miss

ion.

SL

T Le

ad: M

D Ti

mes

cale

s: B

y en

d Q

1 ‘1

9

Prox

imity

of t

hrea

t

19/2

0 20

/21

21/2

2 22

/23

23/2

4

Item

10.

5 -

Rev

iew

of B

oard

Ass

uran

ce F

ram

ewor

k

Page 114 of 120

Boar

d As

sura

nce

Fram

ewor

k (B

AF):

2019

/20

(Dra

ft –

val

id a

s of 0

1 Ap

ril 2

019)

Pa

ge 1

2 of

17

Adop

tion

of n

ew te

chno

logi

es a

s a

clin

ical

or d

iagn

ostic

aid

(suc

h as

: el

ectr

onic

pat

ient

reco

rds,

e-

pres

crib

ing

and

patie

nt tr

acki

ng;

artif

icia

l int

ellig

ence

; tel

emed

icin

e;

geno

mic

med

icin

e)

Key

Mea

sure

s - W

e ha

ve th

e ab

ility

to m

easu

re m

etric

s sho

wn

in

the

rest

of t

he B

AF e

g VT

E an

d M

UST

Tr

aini

ng –

end

use

rs a

re n

ot p

rovi

ded

acce

ss u

nles

s the

y ar

e tr

aine

d Co

ntin

uous

impr

ovem

ent o

f the

EPR

Re

spon

se to

div

ision

s abo

ut u

sabi

lity

and

func

tion

Exte

nded

mea

sure

s The

re

are

othe

r are

as to

mon

itor

e.g

fluid

bal

ance

or I

Vs

Trai

ning

– a

dopt

ion

of a

ne

w w

ay o

f tra

inin

g de

scrib

ed in

pap

er to

WAC

w

hich

incl

udes

regu

lar

upda

tes

Inno

vatio

n –

The

way

in

nova

tions

are

intr

oduc

ed

into

the

Trus

ts n

eeds

mor

e of

a fr

amew

ork

to m

anag

e pr

iorit

ies,

cos

ts a

nd

sust

aina

bilit

y

Cern

er O

ptim

isat

ion

– ad

dres

s sp

ecifi

c ar

eas f

or im

prov

ed u

sage

SL

T Le

ad: D

ir IT

& In

fo

Tim

esca

les:

30/

09/2

019

Leve

l 1

Digi

tal M

atur

ity a

sses

smen

ts d

one

as se

lf-as

sess

men

ts w

ith p

eer r

evie

w

Com

pete

ncy

base

d as

sess

men

t of t

rain

ing

/ kn

owle

dge/

skill

s Pe

rfec

t War

d as

sess

men

ts o

f com

plia

nce

Le

vel 2

M

IAA

Audi

ts o

n us

e of

the

syst

em a

nd a

ccur

acy

of

data

Le

vel 3

GD

E au

dits

for m

ilest

one

paym

ents

HI

MSS

ass

essm

ent

Curr

ently

no

mec

hani

sm

to d

eter

min

e su

cces

s of

trai

ning

Ac

tion:

M

easu

re o

bjec

tive

feed

back

e.g

. im

med

iate

ly

afte

r tra

inin

g an

d ag

ain

late

r In

trod

uce

test

s of

know

ledg

e to

see

how

m

any

peop

le k

now

wha

t th

ey sh

ould

. SL

T Le

ad: D

ir IT

& In

fo

Tim

esca

les:

Sep

t 19

New

Tra

inin

g - a

dopt

ion

of a

new

w

ay o

f tra

inin

g to

be

reso

urce

d an

d de

liver

ed

SLT

Lead

: Dir

IT &

Info

Tim

esca

les:

30

June

19

End

user

Sur

vey

and

benc

hmar

k re

port

on

end

user

exp

erie

nce

SLT

Lead

: Dir

IT &

Info

Tim

esca

les:

June

19

Pr

oxim

ity o

f thr

eat

In p

artn

ersh

ip w

ith A

HSN

, de

velo

p an

d ap

prov

e m

odel

for

inno

vatio

n an

d ad

optio

n m

odel

SL

T Le

ad: D

ir IT

& In

fo

Tim

esca

les:

By

end

Q1

‘19

19/2

0 20

/21

21/2

2 22

/23

23/2

4

Page 115 of 120

Boar

d As

sura

nce

Fram

ewor

k (B

AF):

2019

/20

(Dra

ft –

val

id a

s of 0

1 Ap

ril 2

019)

Pa

ge 1

3 of

17

50%

60%

70%

80%

90%

100%

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Elig

ible

pat

ient

s rec

eivi

ng V

TE ri

sk

asse

ssm

ents

with

in 1

2 ho

urs o

f dec

isio

n to

adm

it

Actu

als

Targ

etU

CLLC

L

0%20%

40%

60%

80%

100%

Wee

kly

MU

ST A

sses

smen

t Co

mpl

ianc

e Co

mpl

ianc

eU

CLLC

L

0%20%

40%

60%

80%

100%

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Med

icin

es S

tora

ge a

reas

- %

of a

reas

fully

co

mpl

iant

Actu

als

Targ

etU

CLLC

L

50%

60%

70%

80%

90%

100%

110%

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Hand

Hyg

iene

% C

ompl

ianc

e

Actu

als

Targ

etU

pper

Lim

itLo

wer

lim

it

-4-20246810

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

E. C

oli b

acte

raem

ia b

lood

stre

am in

fect

ion

- Hos

pita

l Acq

uire

d Ca

ses

Actu

als

Targ

etU

pper

Lim

itLo

wer

lim

it

0510152025

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19CP

E Co

loni

satio

ns/I

nfec

tions

Actu

als

Targ

et

Upp

er L

imit

Low

er li

mit

-4-2024681012

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Clos

trid

ium

Diff

icile

Hos

pita

l Acq

uire

d Ca

ses

Actu

als

Targ

etU

pper

Lim

itLo

wer

lim

it

-1-0

.8-0

.6-0

.4-0

.200.

20.

40.

60.

811.

2

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

MRS

A Ba

cter

aem

ia H

ospi

tal A

cqui

red

Case

s

Actu

als

Targ

etU

pper

Lim

itLo

wer

lim

it

Key

risk

indi

cato

rs (K

RIs)

- Da

ta u

pdat

ed 2

1/03

/19

02468101214161820

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Serio

us In

cide

nts o

pene

d pe

r mon

th

Actu

als

Targ

etU

CLLC

L

86889092949698100

Aug-12

Nov-12

Feb-13

May-13

Aug-13

Nov-13

Feb-14

May-14

Aug-14

Nov-14

Feb-15

May-15

Aug-15

Nov-15

Feb-16

May-16

Aug-16

Nov-16

Feb-17

May-17

Aug-17

Nov-17

Feb-18

May-18

Aug-18

Nov-18

Feb-19

Harm

Fre

e Ca

re (a

ll ha

rms)

Nat

iona

lW

UTH

Med

ian

Co

mp

lain

ts W

ee

kly

Pe

rfo

rma

nc

e

Item

10.

5 -

Rev

iew

of B

oard

Ass

uran

ce F

ram

ewor

k

Page 116 of 120

Boar

d As

sura

nce

Fram

ewor

k (B

AF):

2019

/20

(Dra

ft –

val

id a

s of 0

1 Ap

ril 2

019)

Pa

ge 1

4 of

17

Stra

tegi

c pr

iorit

y AL

L ST

RATE

GIC

OBJ

ECTI

VES

Lead

Com

mitt

ee

FBPA

C Cu

rren

t ris

k ex

posu

re

Tole

rabl

e ris

k Ri

sk T

reat

men

t St

rate

gy:

Mod

ify

Prin

cipa

l ris

k (w

hat c

ould

pre

vent

us

achi

evin

g th

is st

rate

gic

prio

rity)

PR 5

: Maj

or d

isru

ptiv

e in

cide

nt (l

eadi

ng to

rapi

d op

erat

iona

l ins

tabi

lity)

A

maj

or in

cide

nt re

sulti

ng in

tem

pora

ry h

ospi

tal c

losu

re o

r a p

rolo

nged

disr

uptio

n to

the

cont

inui

ty o

f cor

e se

rvic

es a

cros

s the

Tru

st, w

hich

also

impa

cts s

igni

fican

tly o

n th

e lo

cal

heal

th se

rvic

e co

mm

unity

Exec

utiv

e le

ad

COO

Li

kelih

ood:

3.

Pos

sible

1.

V. U

nlik

ely

Initi

al d

ate

of a

sses

smen

t 01

/04/

2019

Co

nseq

uenc

e 5.

V. H

igh

5. V

. Hig

h Ri

sk a

ppet

ite

Min

imal

Last

revi

ewed

01

/04/

2019

Ri

sk ra

ting

15. S

igni

fican

t 5.

Med

Last

cha

nged

01

/04/

2019

An

ticip

ated

cha

nge

Inte

nsify

ing

Deta

ils o

f cha

nge

Revi

sed

BAF

for B

oard

con

sider

atio

n

Stra

tegi

c th

reat

(w

hat m

ight

cau

se th

is to

hap

pen)

Prim

ary

risk

cont

rols

(w

hat c

ontr

ols/

syst

ems &

pro

cess

es d

o w

e al

read

y ha

ve in

pla

ce to

ass

ist u

s in

man

agin

g th

e ris

k an

d re

duci

ng th

e lik

elih

ood/

impa

ct o

f the

thre

at)

Gap

s in

cont

rol

Pl

ans t

o im

prov

e co

ntro

l (a

re fu

rthe

r con

trol

s pos

sible

in

orde

r to

redu

ce

risk

expo

sure

with

in to

lera

ble

rang

e?)

Sour

ce o

f ass

uran

ce (&

dat

e)

(Evi

denc

e th

at th

e co

ntro

ls/ sy

stem

s whi

ch w

e ar

e pl

acin

g re

lianc

e on

are

ef

fect

ive)

Gap

in

Assu

ranc

e/

Actio

n to

add

ress

ga

p

Assu

ranc

e ra

ting

Thre

at: A

larg

e-sc

ale

cybe

r-at

tack

th

at sh

uts d

own

the

IT n

etw

ork

and

seve

rely

lim

its th

e av

aila

bilit

y of

es

sent

ial i

nfor

mat

ion

for a

pr

olon

ged

perio

d

• Da

ta S

ecur

ity A

ssur

ance

Fra

mew

ork

(IGAF

) •

Fire

wal

l con

trol

s •

Acce

ss c

ontr

ols

• VP

N a

cces

s •

Anti

viru

s and

upd

ates

•

Man

dato

ry D

ata

Secu

rity

Trai

ning

•

Busin

ess C

ontin

uity

pla

ns &

BIA

– D

ivisi

onal

& IT

spec

ific

• Pi

lot s

ite u

nifie

d cy

ber r

isk fr

amew

ork

Lack

of c

o-or

dina

tion

of

inci

dent

resp

onse

acr

oss

regi

on

Impl

emen

t fun

ded

prog

ram

to c

o-or

dina

te c

yber

secu

rity

acro

ss th

e M

erse

y in

liai

son

with

NHS

(E)

SLT

Lead

: Dir

IT &

info

Ti

mes

cale

s: B

y en

d Q

1 ‘1

9

Leve

l 1

IG

& C

linic

al C

odin

g Gr

oup

Leve

l 2

Da

ta S

ecur

ity a

nd p

rote

ctio

n to

olki

t sub

miss

ion

to B

oard

; Le

vel 3

Busin

ess C

ontin

uity

Con

firm

and

Cha

lleng

e N

HSE;

LH

RP

Assura

nce P

rocess

Non

e

Prox

imity

of t

hrea

t 18

/19

19/2

0 20

/21

21/2

2 22

/23

Th

reat

: A c

ritic

al in

fras

truc

ture

fa

ilure

cau

sed

by a

n in

terr

uptio

n to

th

e su

pply

of o

ne o

r mor

e ut

ilitie

s (e

lect

ricity

, gas

, wat

er),

an

unco

ntro

lled

fire

or se

curit

y in

cide

nt o

r fai

lure

of t

he b

uilt

envi

ronm

ent t

hat r

ende

rs a

sig

nific

ant p

ropo

rtio

n of

the

esta

te

inac

cess

ible

or u

nser

vice

able

, di

srup

ting

serv

ices

for a

pro

long

ed

perio

d

• Em

erge

ncy

Prep

ared

ness

, Res

ilien

ce &

Res

pons

e (E

PRR)

ar

rang

emen

ts a

t reg

iona

l, Tr

ust,

divi

sion

and

serv

ice

leve

ls •

Ope

ratio

nal s

trat

egie

s & p

lans

for s

peci

fic ty

pes o

f maj

or

inci

dent

(e.g

. fue

l sho

rtag

e; p

ande

mic

dise

ase;

pow

er

failu

re; s

ever

e w

inte

r wea

ther

; eva

cuat

ion;

CBR

Ne)

•

Stra

tegi

c, T

actic

al, O

pera

tiona

l co

mm

and

stru

ctur

e fo

r m

ajor

inci

dent

s •

Busin

ess C

ontin

uity

, Em

erge

ncy

Plan

ning

& se

curit

y po

licie

s •

Pow

er fa

ilure

act

ion

card

s •

Busin

ess I

mpa

ct a

sses

smen

ts

• M

ajor

inci

dent

pla

n an

d ac

tion

card

s

Dete

riora

tion

of p

lant

eq

uipm

ent &

Fab

ric o

f bu

ildin

g du

e to

age

of e

stat

e an

d av

aila

bilit

y of

fund

ing

&

exte

nt o

f wor

k re

quire

d.

6 Fa

cet s

urve

y co

mm

issio

ned

SLT

Lead

: CO

O

Tim

esca

les:

May

‘19

Leve

l 1

EP

RR T

wic

e ye

arly

repo

rt to

RM

C Le

vel 2

Mon

thly

Sig

nific

ant R

isk R

epor

t to

Risk

Com

mitt

ee

EP

RR a

nnua

l rep

ort (

Sept

)

Com

mun

icat

ion

test

ing

(eve

ry 6

mon

ths)

Le

vel 3

EPRR

Cor

e st

anda

rds c

ompl

ianc

e ra

ting

(+ve

);

Facet surv

ey (

May ’19)

M

IAA

Inte

rnal audit r

eport

– E

merg

ency p

lannin

g (

May 1

9)

Non

e

Prox

imity

of t

hrea

t 18

/19

19/2

0 20

/21

21/2

2 22

/23

Th

reat

: A c

ritic

al su

pply

cha

in

failu

re (i

nclu

ding

the

pote

ntia

l im

pact

of B

rexi

t on

supp

liers

) tha

t se

vere

ly re

stric

ts th

e av

aila

bilit

y of

es

sent

ial g

oods

, med

icin

es o

r se

rvic

es fo

r a p

rolo

nged

per

iod

CA

S al

ert s

yste

m –

Disr

uptio

n in

supp

ly a

lert

s

Proc

urem

ent

Ac

coun

t Man

agem

ent

Su

pplie

r Ass

uran

ce

Co

ntin

genc

ies –

Sto

ck c

ontr

ol

‘N

o de

al’ E

U E

xit P

lann

ing

Team

est

ablis

hed

SR

O &

EU

Exi

t lea

d id

entif

ied

for E

xit p

repa

ratio

n

Risk

ass

essm

ent a

nd b

usin

ess c

ontin

uity

pla

nnin

g

EU E

xit O

pera

tiona

l Re

adin

ess G

uida

nce

iden

tifie

s a n

umbe

r of

actio

ns T

rust

s mus

t tak

e in

pr

epar

atio

n fo

r Bre

xit

EU E

xit p

lann

ing

team

to re

view

O

pera

tiona

l gui

danc

e an

d en

sure

all

actio

ns c

ompl

eted

with

in ti

mes

cale

s SL

T Le

ad: C

OO

Ti

mes

cale

s: A

s det

erm

ined

by

Parli

amen

t (Re

view

end

Q1

’19)

Leve

l 2

EU

Exi

t pap

er to

TM

B (F

eb 1

9)

EU

Exi

t pre

para

tion

upda

te to

Boa

rd (M

ar 1

9)

EP

RR T

wic

e ye

arly

repo

rt to

RM

C (M

ar; S

ept)

EPRR

Ann

ual R

epor

t Le

vel 3

Lett

er o

f ass

uran

ce, D

oH

Prox

imity

of t

hrea

t 18

/19

19/2

0 20

/21

21/2

2 22

/23

Page 117 of 120

Boar

d As

sura

nce

Fram

ewor

k (B

AF):

2019

/20

(Dra

ft –

val

id a

s of 0

1 Ap

ril 2

019)

Pa

ge 1

5 of

17

Key

risk

indi

cato

rs (K

RIs)

Dat

a up

date

d 17

/03/

19

EPRR

Co

nfirm

and

Cha

lleng

e by

NHS

Eng

land

Reg

iona

l tea

m a

nd C

CGs

Sept

embe

r 201

8:

Fu

ll Co

mpl

ianc

e

Subs

tant

ial C

ompl

ianc

e Pa

rtia

l Com

plia

nce

Not

Com

plia

nt

Cybe

r Sec

urity

mea

sure

s

Pl

anne

d Pr

even

tativ

e M

aint

enan

ce

per

form

ance

mea

sure

– to

be

deve

lope

d

Publ

icat

ion

date

Oct

ober

201

8

Item

10.

5 -

Rev

iew

of B

oard

Ass

uran

ce F

ram

ewor

k

Page 118 of 120

Boar

d As

sura

nce

Fram

ewor

k (B

AF):

2019

/20

(Dra

ft –

val

id a

s of 0

1 Ap

ril 2

019)

Pa

ge 1

6 of

17

Stra

tegi

c pr

iorit

y PA

RTN

ERSH

IPS:

Impr

ove

serv

ices

thro

ugh

clos

er in

tegr

atio

n Le

ad C

omm

ittee

Bo

ard

Curr

ent r

isk

expo

sure

To

lera

ble

risk

Risk

Tre

atm

ent

Stra

tegy

: Se

ek,

Mod

ify,

Acce

pt

Prin

cipa

l ris

k (w

hat c

ould

pre

vent

us

achi

evin

g th

is st

rate

gic

prio

rity)

PR 6

: Fun

dam

enta

l los

s of s

take

hold

er c

onfid

ence

Pr

olon

ged

adve

rse

publ

icity

or r

egul

ator

y at

tent

ion

resu

lting

in a

fund

amen

tal l

oss o

f co

nfid

ence

in th

e Tr

ust a

mon

gst r

egul

ator

s, p

artn

er o

rgan

isatio

ns, p

atie

nts,

staf

f and

the

gene

ral p

ublic

Exec

utiv

e le

ad

CEO

Li

kelih

ood:

3.

Pos

sible

1.

V. U

nlik

ely

Initi

al d

ate

of a

sses

smen

t 01

/04/

2019

Co

nseq

uenc

e 5.

V. H

igh

5. V

. Hig

h Ri

sk a

ppet

ite

Ope

n

Last

revi

ewed

01

/04/

2019

Ri

sk ra

ting

15. S

igni

fican

t 5.

Med

ium

Last

cha

nged

01

/04/

2019

An

ticip

ated

cha

nge

Unc

erta

in

Deta

ils o

f cha

nge

Revi

sed

BAF

for B

oard

con

sider

atio

n

Stra

tegi

c th

reat

(w

hat m

ight

cau

se th

is to

hap

pen)

Prim

ary

risk

cont

rols

(w

hat c

ontr

ols/

syst

ems &

pro

cess

es d

o w

e al

read

y ha

ve in

pla

ce to

ass

ist u

s in

man

agin

g th

e ris

k an

d re

duci

ng th

e lik

elih

ood/

impa

ct o

f the

thre

at)

Gap

s in

cont

rol

Pl

ans t

o im

prov

e co

ntro

l (a

re fu

rthe

r con

trol

s pos

sible

in

orde

r to

redu

ce

risk

expo

sure

with

in to

lera

ble

rang

e?)

Sour

ce o

f ass

uran

ce (&

dat

e)

(Evi

denc

e th

at th

e co

ntro

ls/ sy

stem

s whi

ch w

e ar

e pl

acin

g re

lianc

e on

are

ef

fect

ive)

Gap

in

Assu

ranc

e/

Actio

n to

add

ress

ga

p

Assu

ranc

e ra

ting

Thre

at: C

hang

ing

regu

lato

ry

dem

ands

(inc

ludi

ng p

oten

tial

impa

ct o

f Bre

xit)

or r

educ

ed

effe

ctiv

enes

s of i

nter

nal c

ontr

ols

resu

lting

in fa

ilure

to m

ake

suffi

cien

t pro

gres

s on

agre

ed

qual

ity im

prov

emen

t act

ions

; O

r wid

espr

ead

inst

ance

s of n

on-

com

plia

nce

with

regu

latio

ns a

nd

stan

dard

s

Q

ualit

y &

cor

pora

te g

over

nanc

e &

inte

rnal

con

trol

ar

rang

emen

ts

Co

nflic

ts o

f int

eres

t & w

hist

lebl

owin

g m

anag

emen

t ar

rang

emen

ts

Ro

utin

e ov

ersig

ht o

f qua

lity

gove

rnan

ce a

rran

gem

ents

&

mai

nten

ance

of p

ositi

ve re

latio

nshi

ps w

ith re

gula

tors

Form

al n

otifi

catio

n pr

oces

s of s

igni

fican

t cha

nges

(Rel

atio

nshi

p m

anag

er, C

QC;

Chi

ef In

spec

tor o

f Hos

pita

ls)

In

tern

al K

LOE

insp

ectio

ns in

clin

ical

are

as

Ex

ec v

isibi

lity

& v

isits

Clin

ical

& m

anag

emen

t aud

it

Polic

ies a

nd p

roce

dure

s

Com

plia

nce:

-

Infe

ctio

n pr

even

tion

M

edic

ines

stor

age

Es

tate

Con

ditio

n

ED T

riage

with

in 1

5 m

ins

arriv

al

As p

er C

QC

Actio

n pl

an –

refe

r to

Boar

d re

port

Le

vel 1

War

d ac

cred

itatio

n m

etric

s Le

vel 2

CQC

Actio

n Pl

an P

rogr

ess R

epor

t

PSQ

B Re

port

to Q

ualit

y Co

mm

ittee

Qua

lity

Perf

orm

ance

Das

hboa

rd

Leve

l 3

C

QC

Insp

ectio

n re

port

Non

e id

entif

ied

Prox

imity

of t

hrea

t 19

/20

20/2

1 21

/22

22/2

3 23

/24

Th

reat

: Fai

lure

to ta

ke a

ccou

nt

of sh

ifts i

n pu

blic

& st

akeh

olde

r ex

pect

atio

ns re

sulti

ng in

un

popu

lar d

ecisi

ons a

nd

wid

espr

ead

diss

atisf

actio

n w

ith

serv

ices

with

pot

entia

l for

su

stai

ned

publ

icity

in lo

cal,

natio

nal o

r soc

ial m

edia

that

has

a

long

-ter

m in

fluen

ce o

n pu

blic

op

inio

n of

the

Trus

t

Co

mm

unic

atio

ns d

epar

tmen

t to

hand

le m

edia

rela

tions

:

Esta

blish

ed re

latio

nshi

ps w

ith re

gula

tors

Trus

t web

site

& so

cial

med

ia p

rese

nce

In

tern

al c

omm

unic

atio

ns c

hann

els

Co

ntin

ued

publ

ic &

stak

ehol

der e

ngag

emen

t util

ising

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Page 120 of 120

Documents

Public Board of Directors 1 May 2019 · Board with a detailed overview of her families experience of poor patient care from attending A&E and then across Wards 19 and 23. There were