board - 31 january 2019 corporate risk register€¦ · 31/01/2019 · board - 31 january 2019...

Agenda Item 11.1

1

BOARD - 31 January 2019 Corporate Risk Register

Presented for: Assurance

Presented by: Julian Hartley, Chief Executive

Dawn Marshall, Interim Chief Nurse

Simon Worthington, Director of Finance

Jenny Lewis, Director of Human Resources and Organisational

Development

Yvette Oade, Chief Medical Officer and Deputy Chief Executive

Simon Neville, Director of Strategy and Planning

Richard Corbridge - Chief Digital and Information Officer

Clare Smith - Director of Operations

Author Craig Brigg, Director of Quality

Previous

Committees

Risk Management Committee 6 December 2018 and 3 January

2019

Key points

1. The Corporate Risk Register has been reviewed. There are currently

22 material risks included in this document for the Board’s

consideration and oversight.

Awareness

2. Members of the Board of Directors are invited to:

(i) consider, challenge and confirm the correct strategy has been

adopted to ensure potentially significant risks are kept under

prudent control

(ii) consider and approve the changes to significant risks following

the meeting of the Risk Management Committee held on

6 December 2018 and 3 January 2019

(iii) advise on any further risk treatment required.

Discussion

Trust Goals

The best for patient safety, quality and experience ✓

The best place to work ✓

A centre for excellence for research, education and innovation ✓

Seamless integrated care across organisational boundaries ✓

Financial sustainability ✓

Agenda Item 11.1

2

1. Summary 1.1 The significant risk profile provides Directors with details on all identified significant risk

exposures throughout Leeds Teaching Hospitals NHS Trust. These risks are currently subject to monthly review and have been reviewed by the Risk Management Committee on two occasions (December 2018 and January 2019) since the last meeting of the Board. This report has been updated to summarise the decisions made by the Risk Management Committee.

1.2 The Trust has identified a range of significant risks, which are currently being mitigated,

whose impact could have a direct bearing on requirements within the NHS Improvement Accountability Framework, CQC registration or the achievement of Trust policies, aims and objectives should the mitigation plans be ineffective. Currently, the significant risks relate to the following areas:

National Standards 18-weeks RTT standard and 52 week RTT standard in

spinal injuries and colorectal services, 62-day Cancer, 6-week diagnostic wait, 28 day cancelled operations and Emergency Care target

Finance Aggregate effect of income volatility, non-delivery of the Waste Reduction Programme in 2018/19, insufficient liquidity and cost pressures and capital equipment replacement, IT infrastructure and the risk of cyber-attack.

Fundamental Standards of Safety & Quality Nurse staffing levels, reducing supply of doctors in training, C.difficile and MRSA targets, violence due to organic, mental health or behavioural reasons, patient flow, bed capacity and emergency admissions, unsustainable levels of medical outliers, inability to deliver a cardiac surgery service, length of time mental health patients wait in the ED, the potential for an influenza pandemic, delays and commercial pressure arising from the capital work at the Generating Station Complex at LGI and risks to service provision in the Pharmacy Aseptic Unit.

Performance & Regulation Corroded pipes in Clarendon Wing, LGI, power failure due to electrical infrastructure and a combination of demand and capacity factors giving rise to unsustainable levels of medical outliers and delayed discharges.

1.3 A summary of the main controls and mitigating actions for the significant risks in each area is available in Appendix A.

1.4 Significant Risks

Risks reviewed at the December 2018 Risk Management Committee The December Risk Management Committee reviewed updated corporate risks CRR 9 - Failure to deliver the financial plan 2018/19, CRR 12 - Failure to deliver the Emergency Care Standard, CRR 31 - Patient flow and capacity for emergency Admissions and CRR 32 - Unsuitable levels of medical outliers. There were no recommended changes to the risk scores. It was noted in relation to CRR 32 that there had been no patients reported to be cared for in non-designated areas since May 2018.

The Committee received a presentation from the Medicines Management and Pharmacy Services management team in relation to risks regarding the aseptic service provision, mainly relating to the available capacity to deliver increasing demand and also the challenges to providing a safe environment and the actions had been taken to

Agenda Item 11.1

3

mitigate this. The Committee agreed to add the risk to the Corporate Risk Register with a score of 15.

Risks reviewed at the January 2019 Risk Management Committee The January Risk Management Committee reviewed the full Corporate Risk Register, focussing on;

• The current relevance and status of the risks

• The risk descriptions

• The risk scores

• Frequency of future reviews of individual risks

• Consideration of new significant operational risks for 2019/20

• Support for an updated corporate risk template

The committee agreed for the revised Corporate Risks to be in the new format for introduction on the 4 April RMC with an interim stage in March where the new risks will be presented to the Executive Team meeting. The Chief Executive highlighted the things for the Executive Leads to consider such as target risk, risk appetite, renumbering and coverage of the CQC recommendations.

2. Background See previous reports to the Board of Directors.

3. Financial Implications and Risk

See specific risks for details (where applicable). 4. Communication and Involvement

The Corporate Risk Register is made available for review to executive directors, corporate teams and CSUs at the monthly Risk Management Committee.

5. Equality Analysis

No adverse implications identified under equality and diversity legislation. 6. Publication Under Freedom of Information Act

This paper is made available under the Freedom of Information Act 2000.

7. Recommendations Members of the Trust Board are invited to:

• consider, challenge and confirm the correct strategy has been adopted to keep potential significant risk under prudent control

• consider and approve the changes to significant risks following the meeting of the Risk Management Committee; and

• advise on any further risk treatment required.

8. Supporting Information Corporate Risk Register - Appendix A.

Craig Brigg Director of Quality January 2019

Agenda Item 11.1

4

CORPORATE RISK REGISTER

January 2019

Appendix A

Agenda Item 11.1

5

Summary Corporate Risk Register December 2018 No. Nature of Risk Date added

to CRR Executive Lead Current

Risk Score

Last Reviewed By RMC

Link to LIM Value

Stream

Safety and Quality Risk

CRR 1 Inadequate nurse staffing levels May 14 Chief Nurse/Deputy CEO 16 Aug 18

CRR 33 Violence due to organic, mental health or behavioural reasons May 15 Chief Nurse/Deputy CEO 16 Aug 18

CRR 36 Inability to deliver a cardiac surgery service July 16 Chief Nurse/Deputy CEO 16 Sept 18 6

CRR 38 Excessive stays in the Emergency Department for patients with Mental Health conditions

Dec 16 Chief Nurse/Deputy CEO 16 Aug 18

CRR 42 Risk of an Influenza Pandemic May 18 Chief Nurse/Deputy CEO 15 May 18

CRR 46 Risk to the delivery of the Aseptic Service Dec 18 Chief Medical Officer 15 Dec 18

Financial Risk

CRR 9 Failure to deliver the financial plan 2018/19 May 14 Director of Finance 20 Aug 18

CRR 40 Insufficient capital resources Mar 18 Director of Strategy and Planning/Director of Finance

16 Nov 18

CRR 6 Unserviceable critical I/T infrastructure and resilience May 15 Chief Digital and Information Officer

15 Nov 18

CRR 39 Loss of data or system outage as a result of a cyber attack Jul 17 Chief Digital and Information Officer

16 Nov 18

CRR44 Risk relating to commercial pressures arising from delays in delivering the refurbishment of the Generating Station Complex (GSC) at LGI

Oct 18 Director of Strategy and Planning 15 Oct 18

People Risk

CRR18 Reducing supply of doctors in training May 14 Chief Medical Officer 16 Sept 18

Performance and Regulation Risk

CRR 12 Failure to achieve Emergency Care Standard May 14 Chief Nurse/Deputy CEO 20 Oct 18 5

CRR 13 18 week RTT target non-compliance May 14 Chief Nurse/Deputy CEO 20 Nov 18 4

CRR 15 62 day cancer target May 14 Chief Nurse/Deputy CEO 20 Oct 18

CRR 22 Patients waiting longer than 6 weeks following referral for diagnostic tests May 14 Chief Nurse/Deputy CEO 15 Nov 18

CRR 23 Failure to achieve 28 day cancelled operations target May 14 Chief Nurse/Deputy CEO 16 Aug 18

CRR 31 Patient flow and capacity for emergency admissions (health economy) Sept 15 Chief Nurse/Deputy CEO 20 Aug 18

CRR 32 Unsustainable levels of medical outliers May 15 Chief Nurse/Deputy CEO 20 Aug 18

CRR 34 Corroded heating pipes in Clarendon Wing, LGI - potential disruption to services Aug 15 Director of Strategy and Planning 16 Jul 18

CRR 35 Power failure/lack of IPS/UPS resilience due to electrical infrastructure Aug 15 Director of Strategy and Planning 16 Jul 18

CRR 45 52 week RTT target non-compliance in spinal injuries and colorectal services Oct 18 Chief Nurse/Deputy Chief Executive

20 Oct 18

Symbols used in this report Inherent and Unmitigated Risk Score Residual Risk Score (Current Risk Exposure) Target Risk / Risk Appetite Threshold

Agenda Item 11.1

6

NATURE OF EXPOSURE S=4

VERY LOW RISK LOW RISK MEDIUM RISK HIGH RISK SIGNIFICANT RISK

Risk CRR1: Inadequate Nurse Staffing Levels 1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=4

Potential Risk Exec Lead(s) Risk Treatment Further Actions Planned Risk Source

Insufficient nurse staffing levels. Caused by inability to recruit to registered nurse vacancies, (particularly in the Emergency and Specialty Medicine, Cardio-respiratory (CSU current risk score 9), Trauma and Related Services and Neurosciences CSU’s) inefficient staff deployment through rosters. May result in an inadequate patient experience; a failure to protect patients or staff from serious harm (including death); loss of stakeholder confidence; and/or a material breach of CQC conditions of registration.

Suzanne Hinchliffe

Controls

• Roster management

• Actions to be taken when the numbers of nurses or midwives per shift falls short of

the agreed roster template - Guidance- updated November 2017

• Annual nurse recruitment plan in place - further campaign material generated June

2018 including promotional film and LTHT recruitment offer agreed April 2018

• Use of temporary workforce (bank and agency)

• Review of skill mix including new roles for Advanced Practitioner, Nursing Associate

and Nursing Apprentice from January 2017

• Recruitment of Allied Health Professionals into ward establishments

• Additional RN school from January 2017

• New Apprentice Nurse cohort from June 2018

• Single Trust wide incentive agreed for RN and CSW during periods of significant

shortfall from April 2018

• Areas of high risk in relation to staffing are monitored and supported

• Review of areas of concern re: staffing/ward metrics by Chief Nurse and Chief

Medical Officer at weekly Quality meeting and reports to every Trust Board

Gaps in controls

• Budget and roster templates do not always align

• Lack of performance management regarding sign off of rosters

• Availability of registered nurses nationally

• Timeliness of supply related to new roles following skill mix review

• Work on going between Corporate Nursing

and CSU’s to update their annual

establishments including Trust wide review

of minimum and optimum staffing levels

by end of Aug 2018

• Consideration of global recruitment-

/exchange programmes. To date -

agreement that 12 Jamaican nurses are

employed by LTHT in 2019

• Consideration of procurement of electronic

staff development/patient dependency

software. Executive and HoN discussion

July 2018

• Leeds wide nursing workforce group in

place from January 2017 reviewing

opportunities for integrated recruitment,

education and training, practice and

development

• Establishment of Local Academic Health

Partnership (LAHP) Nurse Planning Group

from Nov 17 to ensure strategic approach

to maximising recruitment of students

• Leeds wide group and LAHP nurse planning

group reviewing ToR and work streams

August 2018 to maximise impact

• Sanctioned payment above agency cap

Clinical Practice

Review Frequency

Monthly at RMC

Agenda Item 11.1

7



Risk CRR 6: Unserviceable critical IT infrastructure and resilience.

1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=3


The identified most critical IT systems and access to archived medical information may fail without warning, caused by critical systems being held on old platforms and insufficient data storage, system outage or damage, environmental factors, unauthorised access or failed backup arrangements. This may result in errors or delays in diagnoses, a need to repeat tests, invoice failures, reporting failures, and/or unsatisfactory patient experience.

Richard Corbridge

• Access to server rooms and servers is restricted to authorised personnel only and

strictly controlled to eliminate risk of contamination, damage, misuse or sabotage

• Control of computer room environment (cooling with alarm if control parameters

breached, security, UPS backup, fire prevention and detection equipment in place

in main computer rooms

• Back up computer rooms with sufficient redundancy to operate a full service in

the event of failure of 2 out of 3 rooms

• Routine scheduled maintenance of servers in accordance with manufacturers

specifications and relevant guidelines/alerts

• All computer rooms occupied daily to verify the operating environment

• Nagios System alerts are generated in the event of failure

• Critical IT systems on the old platform are being migrated to new IT platform to

reduce exposure and maintain resilience

• Optimised power, performance and stability of old IT platform following migration

of workload to new platform. Expansion of new platform has provided additional

stability

• Out of hours alert notices are escalated to IT personnel or on-call team for

immediate action and Senior Informatics Management notified

• Backup actions from learning following Telepath outage

• Centralisation of I/T staff

• Business Continuity Plan in place for all major I/T systems

Gap in Control I/T ownership and governance No strategic IT equipment replacement plan Due to the agreed £10m reduction in capital spend for 2018/19, several major I/T systems (including PAS, Copath and Telepath) will not be upgraded until 2019/20 with a possible breach of warranty

• Trust reviewing capital requirements.

Outline Business Case (OBC) to support I/T

Infrastructure produced and funding

targeted for March 2019

• Implementation of the recommendations

from the internal and external reviews

carried out following the Telepath system

outage. Digital and Information have

created the ONE Programme to drive this

forward from Summer 2018

• Mersey Internal Audit Agency has carried

out a system resilience review of cyber

security. LTHT is one of the National Cyber

Response Pilots in 2018. The Trust is

working with NHD Digital to secure plans

and manage the impact of this

• Investment in the I/T systems upgrade

deferred from 2018/19 is a priority in

2019/20

• Additional monitoring is now being placed

on all I/T infrastructure and duty on-call

rota in place

IT Risk Assessment

Review Frequency

Monthly at RMC

Agenda Item 11.1

8



Risk CRR 9: Failure to deliver the financial plan for 2018/19 1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=4

Potential Risk Exec Lead(s) Risk Treatment Further Actions Planned Risk

Source

There is a risk that the Trust

does not achieve its

financial targets in 2018/19

Due to the inability to

deliver the Waste

Reduction Programme and

planned activity levels due

to delayed discharges, the

impact of urgent care

pressures on patient flow

and changes to secondary

care provision in other,

local trusts.

May result in the possible

loss of PSF funding from the

DH.

Simon

Worthingto

n

• Board owned financial plans.

• CSU ownership of realistic budgets and run rate based forecasts linked to the

Integrated Accountability Framework launched in 2017.

• Operation of the financial performance framework

• Agreement with Leeds CCG and Specialist Commissioners for Aligned Incentive

based contracts for 2018/19.

• Contract discussions with NHSE to secure final value of the Aligned Incentive

Contract

• Implementation of Finance the Leeds Way Improvement Plan

• The Trust agreed further changes to its Control Target with NHSI to maximise the

potential surplus (October 2018) on the basis of £2 for every £1 overachievement

of the original target. (this is following the earlier Control Total target adjustment

to offset the non-progression of the planned Wholly Owned Subsidiary)

•

Gaps in Control

• Implementation risks for Waste Reduction Programmes

• Impact of Leeds partners response to urgent care pressures

• Although support from the PSF is protected, this does not help the Trust’s

overall cash position

• Transacting the performance management

framework to ensure that CSU’s fully identify and

deliver their waste reduction targets and manage

any pressures within the resources available

(March 2019)

• Work with the Leeds health economy to find a

solution to the severe urgent care pressures

facing the Trust within the resources available to

the economy (Nov 2018)

• Effective implementation of the Aligned incentive

contract with Leeds CCG and NHSE Specialised

Commissioning including effective mechanisms to

re-patriate NHS work currently done in the private

sector (ongoing all 2018/19)

• Implementing the other centrally managed

projects as per the plan (March 2019)

• Work with the Trust’s partners

• Asset sales

Risk

Assessment

Monthly at

RMC

Agenda Item 11.1

9



Risk CRR 12: Emergency Care Standard non-compliance

1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=5

Potential Risk Exec

Lead(s) Risk Treatment Further Actions Planned

Risk Source

Failure to achieve the maximum waiting time of four hours from arrival to admission, transfer or discharge (95% threshold). Caused by an increase in demand and/ or inability to discharge due to high levels of DTOC and MFOD patients. Leading to insufficient patient flow, inadequate patient flow, insufficient staffing levels, delayed transfers of care and repatriation delays. This can lead to congested A&E department, and insufficient beds to care for Acute patients leading to poor outcomes (Potential fatality), patient experience, and a deterioration in LTHT targets and inability to achieve the required standard to release Provider Sustainability Fund.

Suzanne Hinchliffe

• CSM status reports, capacity plan and Bronze, silver and command escalation

process

• Daily monitoring report - 4 hour emergency care performance

• NHSI Tableau Reports

• A dedicated non-elective dashboard to help focus attention on internal

performance areas which support service/standard delivery

• Unplanned Care Group overseeing key flow actions and delivery

• Escalation of repatriation delays to acute Trusts across West Yorkshire

• Weekly review including CMO and CNO - including all potential serious

incidents, complaints, patient harm to ensure appropriate oversight,

investigation and learning

• Focus on ambulatory care. Reduced admissions via A/E and CDU and reduced

length of stay for non-electives

• Review of patient triage and minors reporting

• Patient streaming in place to most appropriate route - GP, assessment, minor

injuries, JAMA etc. to maintain non-admitted performance

• Board to Board meetings with city partners

• Deployment of doctors from other clinical areas at times of extreme demand

• Continued workforce recruitment ie nursing, support, leadership

• Actions agreed with partners following Perfect Week (Oct 2017) and Multi-

Agency Discharge Event (March 2018), focusing on shared risk and

collaborative working

• Whole system review undertaken by Newton Europe September 2018

• Additional Consultant post in ED from January 2019

• Trust wide support for patient referral and acceptance by CSU’s Band 6

reviewing patients who have a GP letter for a specialty to direct them straight to

that specialty

• Establishment of Operations Centre and Internal Professional Standards.

System wide SRAB plans to deliver against external reviews Continued internal improvement work through unplanned care programme board focusing on roll out of SAFER bundle Updated SOP for Internal Winter Plans developed with CSUs ie OPEL, Surge/capacity, investment, Decision Management Tool City Wide winter planning and OPEL escalation agreements to support in periods of high pressure 4 Ophthalmology rooms are being made available to ease the flow in ED through winter (from December 2018) PCAL single point of access being established with LCC and YAS to give specialist telephone advice to avoid ED attendance

Performance Management

Review Frequency

Monthly at RMC

Agenda Item 11.1

10



Risk CRR13: 18-week RTT target non-compliance 1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=4

Potential Risk Exec Lead(s) Risk Treatment Further Actions Planned Risk

Source

Failure to achieve the revised

referral to treatment time

reporting standards at

specialty level with effect

from March 2016 (92% of

patients waiting on an

incomplete pathway less than

18 weeks).

Caused by demand exceeding

planned levels of activity,

insufficient capacity at

specialty level

In key areas and impact of

acute flows on elective

capacity May result in poor

patient experience, poor

quality care, deterioration in

LTHT’s governance rating,

increased external scrutiny

and adverse financial position

through high cost capacity

and/or breach sanctions

Suzanne

Hinchliffe

Maximising the use of elective capacity and flow due to non-elective impact through:

- Continued focus on reducing all 1st Outpatient waits over 18 weeks to a wait time that would support 18 week RTT

delivery for all patients

- Theatres Programme Board focussed on maximising utilisation of inpatient and day case theatre capacity

- Continued use of independent sector capacity and additional weekend clinics

- Formal escalation of constraints to Commissioners through regular meetings.

- Access policy and procedures are in place and up to date with on-going review to ensure policy is applied consistently at

CSU level

- Additional bed capacity in place to support elective flow once acute pressures subside

- Roll out of Trust wide e-referral and e-triage system which should reduce demand

- Joint waiting list to reduce demand. Community patients seen in community

Routine Oversight

- Suite of daily waiting time reports and tools showing key risks

- CSU’s review position weekly through standard access meeting agenda

- CEO meeting

Any area with an over 18 week problem as recovery plan monitored through;

- Bi-monthly review of individual consultant booking order and waiting list management practice

PA Consulting theatre case scheduling tool in place Neighbouring Trusts offering capacity to assist with patients who have been waiting over 38 weeks Cancellation of long waiters is escalated to ADoPfor confirmation

Gaps in Control

• Minimal use of the independent sector in part due to the specialist nature of LTHT work

As part of winter planning

for 2018/19 certain

overnight elective activity

will be switched to O/P or

D/C activity

Performa

nce

Manage

ment

Review

Frequenc

y

Monthly

at RMC

Agenda Item 11.1

11



Risk CRR15: 62-Day Cancer Target 1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=4

Potential Risk Exec Lead(s) Risk Treatment Further Actions Planned

Risk Source

Effective management systems are not in place or sufficiently resilient to ensure treatment within 62 days following receipt of urgent referral by a GP for suspected cancer. Caused by late referral from other providers, ineffective waiting list management, insufficient control over pathways of care or higher than expected urgent care demand. May result in patient fatalities or seriously worsened condition, poor timeliness of care, unsatisfactory patient experience, unacceptable delays for patients, and/or deterioration in LTHT’s governance rating.

Suzanne Hinchliffe

• Access policy and procedures, waiting list management and referral procedures

• Daily procedure to govern cancellations to ensure clinical priority

• Application of cancer waiting time guidance

• MDT patient oversight via weekly PTL review

• Developed Patient Pathway Manager (PPM) system function to support reporting of internal and pre-day 38

performance

• Support the West Yorkshire discussions on agreeing to implement the Breach allocation national guidance from in

place from Sept 2017

• Regular escalation to referring organisations for patients referred after day 38

• Any team with an over 62 day performance issue -

1. Initiate a rolling programme of Full pathway review including pathway performance for all MDTs which are not

performing to 85% internal and by 38 and/ or those 5% or lower than national peer average.

2. Meet with all MDTs which are not performing to 85% internal and by 38 and/ or those 5% or lower than

national. Review recovery plans to realign improvement trajectories and timescales to deliver performance.

3. Weekly performance reporting Trust wide and to Corporate Operations and Executive teams

4. Performance monitoring via weekly escalation, Corporate & Executive Scorecard, Finance & Performance

Committee and Trust Board papers.

5. Internal oversight of performance and supporting work streams to address via Cancer Board

6. Work with Alliance and referring partner organizations

• Discretionary use of Bank/Agency/Locum to address shortfalls in staffing levels

• Escalation system to Medical Director for Operations, Associate Directors of Operations and Deputy CEO

• Ongoing work with external partners (referring Trusts, Lead Clinicians) in Cancer Alliance to reduce the impact of

late referrals to patient care and achieve a shared NHS Constitutional responsibility.

Gaps in control

• The Trust cannot provide extra capacity to address backlog due to bed position and availability of additional

theatres session to address the backlog

• The provision of 5o week Oncology presence in referring Trusts is not available

• Work on-going to confirm if patients are IPT ready

Developing streamlined diagnostic processes through and the LICS early diagnostic programme to get to diagnostics earlier and reduce diagnostic demand WY Alliance supported work re late referrals/IPT to LTHT commenced January 2018 and to conclude April 2019 Regular reviews at Cancer Board and Finance and Performance Committee

Agenda Item 11.1

12



Risk CRR18: Reducing supply of doctors in training 1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=4

Potential Risk Exec


Risk

Source

There is a risk that medical

staffing may not meet the

safest possible levels

Caused by reductions in

trainee placements and

funding which lead to non-

compliant or non-feasible

rotas and a failure to

ameliorate the reduction in

junior doctors entering the

workforce

May result in severe

pressure to deliver safe and

effective clinical services;

delays in responding to the

deteriorating patient;

and/or poor experience in

training for junior doctors

resulting in a further

reduction in posts.

Yvette

Oade

• Workforce planning

• The Trust lobbies the Deanery and Health Education England to secure sufficient

trainee placements to meet expected service demands

• Compliant duty rotas and shift patterns

• Extending and developing roles of Nursing and AHP practitioners and Physicians

Associates

• Improving clinical processes using Leeds Improvement Method (ward rounds etc)

• High quality education placements as evidenced by Improving the trainee experience as

evidenced by the GMC trainee survey 2016

• Attendance Management

• Use of locum doctors and breach of agency capping rules in extreme circumstances

• Consultant delivered care (consultants in place of trainees)

• Diversification of the workforce

• MTI schemes (overseas recruitment)

• Implementation of junior doctor contract, low exception reporting, Guardians of Safe

Working and Junior Doctor Forum

• The Trust has a clear statement of vision for junior doctors with a programme of

engagement e.g. Empowering junior doctors (Junior Doctor Body and Junior Doctor

Forum)

• Review and develop workforce plans alongside

activity forecasts in order to anticipate future

workforce requirements and any adjustments

required to adapt to reducing numbers of junior

doctors and/or retirements (Chief Medical Officer &

Director of Human Resources)

• Working with GSW/CSU teams in problem areas.

Next survey due July 2019

• Process of recruiting an extended Clinical Workforce

e.g. Physician Associates, Advanced Clinical

Practitioners. Aug 2018

• Improving clinical processes using the Leeds

Improvement Method (LIM)

Risk

Assessment

Review

Frequency

Monthly at

RMC

Agenda Item 11.1

13



Risk CRR22: Patients waiting longer than 6 weeks following referral for diagnostic tests

1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=3


Patients waiting longer than 6 weeks following referral for diagnostic tests (in particular Ultrasound, MRI and Endoscopy) Caused by either insufficient capacity at specialty level, demand exceeding planned levels of activity, insufficient control over pathways of care or ineffective waiting list management. May result in unacceptable delays for patients, and/or deterioration in LTHT’s governance rating as well as poor quality care, an unsatisfactory patient experience and possible failure to retain JAG accreditation in Endoscopy

Suzanne Hinchliffe

• Access policy and procedures in place.

• Waiting List management processes including acceptance criteria and

validation.

• Selective use of the independent sector and in-reach services where

required

• JAG accreditation

• Use of Wharfedale Endoscopy service with a partner Trust

• E-booking in place from July 2016

• Weekly access meeting held by every CSU with escalation to DCE where

required.

• Root Cause Analysis for breaches.

• Discretionary use of bank/agency/locum staff to address shortfalls in

capacity

Gaps in Control

• From January 2018, the Echo-Cardiography service will be depleted by

staff shortages

• MRI capacity lost due to work on the Hybrid Theatre at LGI

Risks with MRI and Ultrasound continue to be managed/mitigated in line with rising demand profiles Review overtime enhancements for Echo-Cardiograph staff with HR MRI capacity partly mitigated by the continued use of Leeds University scanners. Note: Last breach was January 2018.

Risk Assessment

Review Frequency

Monthly at RMC

Agenda Item 11.1

14



Risk CRR23: Failure to achieve 28 days cancelled operations target

1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=4


There is a risk that the Trust does not achieve the 28 day cancelled operations target Due to acute activity pressures, critical care capacity, availability of theatre time, patient flow and the impact on elective bed availability Resulting in delays to patient treatment and possible harm and financial penalties

Suzanne Hinchliffe

• Daily 8am capacity planning meeting to prioritise admissions, including patients

who have had operations cancelled and to allocate demand for critical care

capacity.

• Process/tracking for re-booking operations within 28 days.

• Weekly meeting to identify available theatre capacity for additional sessions,

manage risks and review cancellations and discharge and theatres KPI’s using

the PA consultant scheduling tool

• Discretionary use of bank/agency/locum staff to address shortfalls in capacity

• Maximisation of day case capacity and identification of patients who would

normally be treated as inpatients.

• CSU/Senior Ops oversight and Trust internal accountability process and

escalation

• Continue to balance daily pressures of

delivering elective care for patients in

constrained bed/flow conditions

• Winter pressures planning for 2018/19

Agenda Item 11.1

15



Risk CRR31: Insufficient capacity and patient flow across the health care system for emergency admissions

1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=4

Potential Risk Exec Lead(s)

Risk Treatment Further Actions Planned Risk Source

There is a risk of insufficient capacity in the Trust and across the health care system for emergency admissions due to demand for inpatient capacity out-stripping capacity, greater numbers of older patients with 3 or more co-morbidities and more patients requiring on-going or social care input This may result in (i) High numbers of patients in the bed

base who are medically fit for

discharge as services not available in

community and social care

(ii) Failure to deliver 4 hr emergency

care standard

(iii) Elective admission cancellations and

cancelled operations

(iv) Failure to transfer patients out of

critical care (step down)and provide

capacity for patients who require

high dependency or critical care

(v) Failure to respond to peaks in

emergency care demand

(vi) Poor patient experience, high

number of outliers and potential

harm to patients

(vii) Poor staff morale and well-being at

work.

Suzanne Hinchliffe

Internal

• Pathways for rapid referral to specialty services

• Clinical Site Managers - out of hours support and co-ordination

• Processes for collation and capture of Delayed Transfers of Care

• Escalation process and full capacity plans by CSU - bronze, silver and gold command;

DOP, on-call rota

• Updated SOP including risk assessment and escalation procedure in place for patients in

non-designated areas.

• Intentional rounding in place

• Introduction of Decision Management Tool

• Monitoring trolley waits between 8 and 12 hours and development of a risk assessment

and escalation procedure including RCA review for addressing bed pressure issues

• Mitigations in place including cancellation of routine operations and outpatients

appointments and impact on mixed sex wards, in times of extreme demand

• Rollout of the SAFER bundle, via 6 work streams post MADE to support the system

aspiration to reduce Super Stranded patients by 50%.

• Introduction of monitored internal professional standards.

• Demand prediction model established and winter plan provisionally matched against key

pressure points.

External

• Regional escalation process and system wide OPEL agreement

• Development of a “Trusted Assessor” model to support discharge processes and reduce

delays across the health system

• System Resilience Group and plan (with partner organisations

• System-wide Early Discharge Assessment Team (MDT - OT, physio, social worker,

geriatrician, discharge nurse)

• Admission avoidance schemes including expansion of the Frailty Service

• Additional capacity in partnership with Villa care to provide a ward on Beckett Wing in

times of extreme demand

Other See Risk Treatment for Emergency Care Standard risk CRR12

Tender for the provision of Community Intermediate Care concluded Sept 2017, outcome for LTHT to be assessed Winter Plan 2017/18 Risk Assessment Decision Making Tool developed for ‘in extremis’ decision support Perfect Week (Oct 2017) outcome

CSU’s Risk Assessment

Review Frequency

Monthly at RMC

Agenda Item 11.1

16



Risk CRR32: Unsustainable levels of medical outliers and patients waiting in non-designated areas

1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=5


Current high volume of medical outliers and patients in non-designated bed areas. Caused by demand outstripping capacity and reduced outflow, resulting in reduced quality of care, increased out of hours transfers, patients waiting on trolleys and reduced patient experience Impact on non-delivery of the Emergency Care Standard and hospital surgery cancelations which could cause potential harm to patients. (Cross Reference Acute Medicine Risk 9070)

Suzanne Hinchliffe

• Rollout of the SAFER bundle, via 6 work streams post MADE to support the

system aspiration to reduce Super Stranded patients by 50%.

• Introduction of monitored internal professional standards.

• Demand prediction model established and winter plan provisionally matched

against key pressure points.

• Increased assessment services and ambulatory care capacity co-located

within ED footprint to support increased ambulatory care pathways, use of

virtual ward and hot clinics to reduce admissions and therefore medical

outliers.

• Resilience plan in the CSU aligned to OPEL levels across Leeds Health System

• Surge actions in place including additional beds

• Agreed approach for the management of outliers by consultants and relevant

specialties including timeliness of review, escalation, and which team covers

what ward

• Recruit junior doctors to cover outliers to increase cover at the weekends

• Weekly review of delays via the Operational Delivery Group and during

winter months the Operational Winter Group which is focused on key

themes with senior system partners.

• Two wards at Wharfedale Hospital (56 beds) to remain in place to help

alleviate the acute pressure on the main sites Support from Corporate

Nursing Team and wider trust staff for pressurred areas.

• Additional capacity to open on ward 32 in January 19 and provide day to

management to Ward 11

• See Risk Treatment for Emergency Care Standard risk CRR12

• Social Media messages from Trust Doctors to patients encouraging

LIM (Virginia Mason) Value Stream 5 - Programme looking at DOH 7 day standards in particular consultant review within 14-hours of acute admission. Risk Assessment Decision Making Tool developed for ‘in extremis’ decision support

CSU Risk Assessment

Review Frequency

Monthly at RMC

Agenda Item 11.1

17

NATURE OF EXPOSURE S=4 VERY LOW RISK LOW RISK MEDIUM RISK HIGH RISK SIGNIFICANT RISK

Risk CRR33: Violence due to organic, mental health or behavioural reasons

1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=4

Potential Risk

Exec Lead(s)


There is a risk of violence towards patients, visitors and staff due to organic, mental health or other behavioural reasons, resulting in the potential for a fatality, serious harm or litigation against the Trust

Suzanne Hinchliffe

Emergency Specialty Medicine CSU

• Procedure in place for the management of violence in clinical areas

• 24/7 support from Acute Liaison Psychiatry Service (ALPS) and escalation; links to Crisis Assessment Service

(Becklin Centre)

• Out of hours on-call psychiatry staff located at St James’s hospital

• CROMA - Risk Assessment Tool in place from April 2017 which determines when external expertise is required.

Vigilant staff provide 1:1 supervision. CROMA can only be engaged through CARPS booking system

• KPI in place for referral and assessment within 3 hours agreed with CCG’s

• Strategic partnership group established with LYPFT to oversee implementation and governance of the Mental

Health Crisis Care Concordat and support staff working with patients at risk of violent behaviour

• Personal safety training including conflict resolution and MCA training in place

• Shorter stays in ED to reduce exposure

• Symphony system flags identify known aggressors

• First Responder role established at StJUH

• Each CSU has produced a Training Needs Assessment for conflict resolution training

Trust wide

• Established a strategic partnership with LYPFT and a team of MH nurses to provide a 24 hour in-reach patient

assessment service to nursing teams

• SLA with LYPFT in place for Liaison Psychiatry and a range of DoL’s policies and procedures in place

• Security patrols over all zones at StJUH and LGI increased.

• Remote lockdown capability at both LGI and StJUH in place

• First Responder role not yet established at LGI

• Restraint Policy in place

• Flag system introduced to PPM+

Gap in Control

• Use of soft restraint and other de-escalation techniques still being considered

Emergency Specialty Medicine

• Developing care plans in conjunction

with LYPFT -

• Respond to the outcomes of reports

relating to SI’s (J19 - Feb/Mar 2015 and

suicide - Mar 2016)

• Reviewing the possibility of employing

MH trained nurses in the CSU

Trust wide

• Reviewing MH/MHA/Deprivations of

Liberty Team (DoL’s) requirements and

developing a case for investment in the

team with expert resources following a

change in legislation.

• First Responder role recruitment for LGI

(Underway May 2018)

• Encourage more comprehensive

reporting of incidents by wider

promotion of actions taken in response

to untoward events (Ongoing)

• Use of soft restraint and other de-

escalation techniques under

consideration by the Trust (Following

RMC April 2018)

Acute Medicine and Urgent Care CSU’s Risk Assessment

Review Frequency

Monthly at RMC

Agenda Item 11.1

18



Risk CRR34: Corroded heating pipes, Clarendon Wing LGI - potential risk of disruption to clinical services

1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=4

Potential Risk Exec Lead(s)


There is a risk of disruption to clinical services on Clarendon Wing, LGI, due to corroded heating pipes resulting in delayed treatment and a poor patient experience

Simon Neville

• An Nvar system has been installed which cleans contaminated water in

the system and slows down corrosion

• In each of the last 3 years the Trust has spent around £300,000 from

capital on a number of high risk areas including Neonatal, I/T hubs, MRI

Scanner, high voltage transformers and where leaks had occurred in the

previous year

• Reports receive a high priority when leaks occur and repairs are

undertaken quickly

• Continue to fund the rolling programme

from capital

• Concentration on high risk areas Estates and Facilities

Monthly at RMC

Agenda Item 11.1

19



Risk CRR 35: Power Failure due to Electrical Infrastructure/lack of IPS/UPS resilience

1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=4

Potential Risk

Exec Lead(s)


There is a risk of power failure at a Trust site (ward or clinical area) Due to failure to comply with HTM 06 01 caused by outdated electrical infrastructure and the absence of a complete IPS/UPS resilience May result in a poor patient experience; a failure to protect patients or staff from serious harm or fatality; loss of stakeholder confidence; and/or a material breach of CQC conditions of registration or HSE prosecution

Simon Neville

Emergency generator power provision across all sites. The sites typically benefit from n+1 power resilience in terms of emergency generator power provision across all sites Independent battery back-up in clinical areas and use of battery operated equipment Estates staff escalate high level concerns/incidents out-of-hours to Clinical Site Manager/On-call Management Team as per the Estates Major Incident Handbook updated for emergency plans (June 2017) Comprehensive review across the Trust completed which documents precise location of all electrical equipment Business Continuity Plans reviewed and updated with every CSU (Sept 2016) and a comprehensive review of electrical resilience has been compiled and is located in both Gold Command Rooms Increased interleaving of circuits on Clarendon Wing i.e. there is now more flexibility as to the where power to wards/depts. Is directed from, increasing resilience (Sept 2016) Full emergency power resilience to whole of LGI and phase 3 emergency generator work completed. Additional switching in place (Nov 2016) Golden Boxes have been identified and returned to Medical Physics and Theatres and Anaesthetics CSU advised accordingly Complete assessment of telephony resilience in terms of UPS protection and autonomy (up to 4 hours) Isolated power supplies (IPS) are fitted to some of the Trusts clinical category 5 areas The electrical autonomy on J54 Critical Care has been increased from 10 minutes to 1 hour from June 2017 Infrastructure to support Geoffrey Giles theatre and J54 (ICU) has been installed . This will include enabling works to 2 theatres at StJUH allowing Ophthalmology to move to one of those theatres and the current Ophthalmology theatre to be used for decant. Gap in Control: Awaiting capital resources for final connection

Interleaved electrical supplies and IPS to be installed for all future ward refurbishments Theatre upgrade of £1m a year built into capital programme from 18/19

Estates and facilities

Review Frequency

Monthly at RMC

Agenda Item 11.1

20



Risk CRR 36: Inability to deliver a cardiac surgery service 1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=4

Potential Risk

Exec Lead(s) Risk Treatment (Controls) Further Actions Planned Risk Source

There is a risk that the CSU can no longer provide an adult cardiac surgery service sufficient to meet Commissioner requirements or the needs of the Cardiology and Cardiology Intervention Services Due to; lack of dedicated theatre capacity, insufficient cardiac theatre staff (nursing/ODP), critical care capacity/flow, and the continued necessity to undertake all the least complex cases in the private sector (Nuffield). Resulting in; damaged reputation, poor patient experience and outcome (e.g. cancelled operations), a decreasing range of cardiac surgery available in LGI, only the most complex electives and all acute cases are performed at LGI (suboptimal case mix), severely restricted service development in Cardiac Surgery and interdependent services such as Cardiology (including development of clinical expertise).

Suzanne Hinchliffe

• Even out demand for critical care across the working week to enable improved

access.

• Clear clinical pathways across CSU's and monitored compliance through audit.

• 2 first cases to start at 8am prior to critical care bed confirmation.

• CSU participating in TPOT and 642 Monday meetings with other LGI Surgical CSU's

to identify and reallocate theatre capacity and improve service delivery.

• High Observation Beds (HOB's) established on ward L16.

• Full time Business Manager in place to work with Matrons to improve cancellation

rate.

• Clear escalation processes to line manager prior any cancellation of patients.

• Cardiac Surgery Improvement Programme

• Electronic patient referral

• Cross cover from

Cardiology being

assessed

• Value Stream 6 to reduce

cancellations Sept 2018

• Exploring waits in other

centres

Clinical practice

Review Frequency

Monthly at RMC

Agenda Item 11.1

21



Risk CRR 38: Excessive stays in the Emergency Department for patients with Mental Health conditions

1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=4


There is a risk that patients with mental health issues who present to the ED may spend excessive periods of time in the ED’ due to lack of suitable MH treatment options and time taken to access appropriate MH services, changes to the Mental Health Act 1983 (s135/136 MHA) through the Policing and Crime Act 2017 (place of safety), December 2017 resulting in a poor patient experience with potential impact on the patients long term condition

Suzanne Hinchliffe

• Identification of high risk patients on assessment and move to Room 3

(distant from exits)

• Delivery of 1:1 care during patients stay in ED where demand allows

although this impacts on care of other patients and performance of the

department

• LYPFT encouraged to develop alternative arrangements for a more

rapid review of mental health patients presenting to ED

• LYPFT to be asked to ensure that patients requiring mental health

inpatient care are allocated appropriate beds quickly and that transport

is provided within an hour

• Lockdown capability now possible at both LGI and SJUH.

• Identified local health based places of safety - S136 suite at Becklin

Centre; ED department at SJUH (although not legally designated)

• CAMHS S136 procedure (flow chart) - Police to liaise with CAMHS or on-

call consultant prior to S136

• Inter-agency guidance - consultation with street triage team or defined

professional prior to S136

• Patient Information leaflet and rights of patients document

• Escalation procedure (S136)

• Multi-agency group meetings (monthly) - review use of S136, impact on

capacity, flow, waiting times and emerging risks

See also Controls for CRR 33

• Mental Health Specials can be requested

• National CQUIN is focussing on reducing

attendances to the ED. This is a partnership

with LYPFT, YAS, Commissioners and local

stakeholders

• Respond to the changes to the Mental

Health Act 1983 (s135/136 MHA) through

the Policing and Crime Act 2017 (place of

safety), December 2017, working with

multi-agency partners to agree plan to

meet the potential demands for local

health based places of safety.

• Review local health based place of safety

for people < 18 years.

Risk assessment

Agenda Item 11.1

22



Risk CRR 39: Data loss or system outage as a result of a cyber attack

1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=4

Potential Risk


There is a risk of loss of data or system outage due to a cyber attack resulting in significant service disruption, harm to patients and financial loss

Richard Corbridge

• The NHS N3 network is a private ring fenced network with production/security at all entry

and exit points. There is no direct access into the network from the wider world, however it

does provide outbound access for NHS organisations

• External penetration testing - a penetration test is proactive and authorised attempt to

evaluate the security of an I/T infrastructure by safely attempting to exploit system

vulnerabilities

• Firewalls - The N3 network is protected from individual end users and vice-versa by firewalls

which only allow certain types of data to pass through

• Anti-virus/anti-worm /denial of service attack measures - N33P monitors the network for

unusual activity which may indicate virus or denial of service activity

• Web filtering - communication with the internet is further protected through the use of

web filtering. All web traffic is passed through a web filter system which checks both the

source and destination

• Password management - All those granted authorised access to the Trust’s computer

system are issued with a personal password

• Access to the network (desktop) is only permitted to authorised staff who have completed

the registration process and obtained their own personal user name and password

• System resilience review of cyber security at the Trust by the Mersey Internal Audit Agency

carried out in April 2017.

• Audit as part of the national Chief Information Officer Cyber Essentials 2 initiative

completed and returned to NHSE - July 2018

• Cyber response function and governance in place from summer 2018

• Cyber Security Oversight Group in place accountable to Digital Informatics Committee

Gaps in Control No identifiable Cyber Response Team

SBAR on the approach to cyber security issued May 2017, incorporating recommendations and potential costs. Cyber response function and governance being designed. Implementation Spring 2019 LTHT is one of the National Cyber Response Pilots in 2018. The Trust is working with NHD Digital to secure plans and manage the impact of this

Review Frequency

Monthly at RMC

ANTICIPATED EFFECT ON CONTROL / COMMENT

Agenda Item 11.1

23



Risk CRR 40: Insufficient capital resources 1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=4

Potential Risk


There is a risk to the continuity of clinical services due to the Trust having insufficient capital resources in the current and future financial years to replace ageing equipment and maintain the estate building and engineering infrastructure across clinical and support departments, resulting in potential significant harm to patients and unsafe conditions for staff, visitors and residents.

SN/SW

• Capital programme - priority bidding process for clinical services/specialty teams overseen

by Head of Medical Physics & Engineering and Deputy Chief Medical Officer/Medical

Director (Operations)

• Risk adjusted backlog maintenance register to prioritise annual investment

• Asset register also helps to prioritise investment

• Contingency in the capital programme for emergency situations

Gaps in Control

• Backlog maintenance surveys are lengthy to complete and therefore infrequent

• Although spend in 2018/19 will be £62m this is £10m less than had been planned.

Five year financial plan, projecting year end surpluses with greater scope for capital spend Refresh of the backlog maintenance register to take place in 2018 Building the Leeds Way which will significantly reduce the backlog maintenance requirement £6m of the £10m reduction in the capital programme in 2018/19 will be re-provided in 2019/20 and a full quality impact assessment will be carried out.

Review Frequency

Monthly at RMC


Agenda Item 11.1

24



Risk CRR 42: Risk of an influenza Pandemic 1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=3

Potential Risk


There is a risk that the Trust may have to invoke its Emergency Preparedness Plan due to an influenza pandemic which could cause potential multiple fatalities, significant delayed treatment and financial loss. SH

• Pandemic Influenza Plan

• CSU Business Continuity Plans

• Vaccination programme

• Surge and escalation arrangements

• Infection Control procedures (including Personal Protective Equipment)

• Leeds Outbreak Plan (operational response guidance)

• Major Incident Plan

Gaps in Control

• Not all CSU Business Continuity Plans are up to date

Performance manage Business Continuity Plans Surge and escalation plans to form part of winter planning and preparedness Establish a Standing Emerging Infection Diseases and Pandemic Flu Steering Group (June 2018)

Review Frequency

Monthly at RMC


Agenda Item 11.1

25



Risk CRR 44: Risk of further delays in delivering the refurbishment of the Generating Station Complex (GSC) at LGI

1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=3

Potential Risk


There is a risk of further delays in delivering the refurbishment of the Generating Station Complex at LGI due to the performance of the contractor which could result in commercial pressure, financial loss and damaged relationship/disputes with the contractor over the remaining period of the 25 year partnership

Simon Neville

• Director level meetings with contractor

• Weekly liaison meetings attended by technical and contract managers

• Joint Project Board with University

• Legal and technical advice

Gaps in Control

• Uncertainty over future construction and design details

Independent specialist engineering

advice in the event of disputes with

the contractor will be taken

Review Frequency

Monthly at RMC


Agenda Item 11.1

26



Risk CRR45: 18-week RTT target non-compliance

in spinal injuries and colorectal services for

patients waiting over 52 weeks

1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=4

Potential Risk Exec


Risk

Source

Failure to treat spinal

injuries and colorectal

patients within 52

weeks of referral

Caused by demand

exceeding planned

levels of activity,

insufficient capacity

at specialty level

In key areas and

impact of acute flows

on elective capacity

May result in poor

patient experience,

poor quality care,

deterioration in

LTHT’s governance

rating, increased

external scrutiny and

adverse financial

position through high

cost capacity and/or

breach sanctions

Suzanne

Hinchliffe

General controls relating to all services;

Maximising the use of elective capacity and flow due to non-elective impact through:

- Continued focus on reducing all 1st Outpatient waits over 18 weeks to a wait time that would support 18 week

RTT delivery for all patients

- Theatres Programme Board focussed on maximising utilisation of inpatient and day case theatre capacity

- Continued use of independent sector capacity and additional weekend clinics

- Formal escalation of constraints to Commissioners through regular meetings.

- Access policy and procedures are in place and up to date with on-going review to ensure policy is applied

consistently at CSU level

- Additional bed capacity in place to support elective flow once acute pressures subside

- Roll out of Trust wide e-referral and e-triage system which should reduce demand

- Joint waiting list to reduce demand. Community patients seen in community

Routine Oversight

- Suite of daily waiting time reports and tools showing key risks

- CSU’s review position weekly through standard access meeting agenda

- CEO meeting

Any area with an over 18 week problem as recovery plan monitored through;

- Bi-monthly review of individual consultant booking order and waiting list management practice

PA Consulting theatre case scheduling tool in place Cancellation of long waiters is escalated to ADoP for confirmation Specific controls relating to spinal injuries and colorectal services; Continued re-allocation of all available internal surgical lists to spinal and colorectal services through weekly prioritisation and theatre capacity oversight meeting led by the ADoP Maximisation of the use of the independent sector and other hospitals to support the improvement of 52 and 38 week position

As part of winter planning

for 2018/19 certain

overnight elective activity

will be switched to O/P or

D/C activity

All Trusts have been contacted to request assistance with Derby identifying spinal capacity

In October 2018 discussions

began with CHFT regarding

delivery of additional spinal

capacity

Performance

Management

Review

Frequency

Monthly at

RMC

Agenda Item 11.1

27



Risk CRR 46: Risk to the delivery of the Aseptic Service 1 2 3 4 5 6 8 9 10 12 15 16 20 25

L=3

Potential Risk


There is a risk of medicines-related errors or denial of IV additive chemotherapy and parenteral nutrition treatments Due to shortage of staffing required to prepare products following increased clinical demands, unpreventable environmental control issues and increasing external audit recommendation demands Resulting in unmet clinical need or patient safety risk from product errors of contamination as well as poor staff experience and working conditions

Yvette Oade

• Internal movement of staff

• Increased outsourcing of preparation

• Pathway planning and ways of preparing products

Gaps in Control

• To facilitate controlling the risk there would need to be an internal movement of

staff to mitigate the risk described with staffing; this may result in staff with less

expertise becoming involved in validation and preparation of high risk products.

Staff re-deployment impacts in other service areas such as inpatient care with

medicines and discharge flow. Locum staff with necessary skills are in limited

supply.

• Greater numbers of commercially prepared ready to administer products to be

considered; not all products required are available commercially and this supply

sector is fragile and becoming increasingly so. This process also puts additional

demand on the Quality Assurance service.

• Demands are heightened by significant issues with patient pathway planning and

a common failure to integrate blood results as a key control step at an

appropriate and/or prioritised time. The availability and commissioning of

immunotherapy treatments in addition to the fragile outsourced supply chains

mean that there is a 19% increase in demand for chemotherapy at AP06 18/19.

Partial removal of aseptics commitments from

oncology team members by employing agency staff

and sharing remaining sessions amongst aseptics

management team. Working with Cancer services to

explore changes to current pathways that can

support pressures. Chemocare scheduler

implemented September 2018 but compliance is not

satisfactory at present (69% prescribed >48hrs

before treatment). New funding agreed with LCC for

2 x 8A pharmacists and 2 x band 6 technicians - in

recruitment (Oct 2018). Locum specialist aseptic

technicians recruited x 2WTE in November 2018

Further expansion in availability of premade

products is unlikely while the sector is not robust in

order to avoid excess exposure to risks associated

with a failure in contingency arrangements LTHT is

already acknowledged in the Carter Review (NHS

Improvement Model Hospital - reduction in

unwarranted variation) as a leading centre for dose

standardisation of chemotherapy and has released

24% extra chemotherapy capacity from the aseptic

units.

Work with clinical teams across the organisation to

improve patient pathways and reduce the risk of

delayed treatment. Active project underway with

LCC and Pathology. On-going discussions with AMS

CSU and Children's Services regarding Parenteral

Nutrition demand management.

Review Frequency

Monthly at RMC


board - 31 january 2019 corporate risk register€¦ · 31/01/2019 · board - 31 january 2019...

Documents