nhs rushcliffe ccg assurance framework · the ccg and other services 2015/16 amber 3 3 high low...

NHS Rushcliffe CCG Assurance Framework

March 2016

Date placed

on

Assurance

Framework

L I

GB35

Director Outcomes

and Information

Director Nursing and

Quality

Governing Body

May-13

Failure to achieve the EMAS performance

targets with a disproportionate performance

between city and county. This means

patients in the county may be at greater risk

of harm. In addition, the nature of

complaints received by EMAS demonstrate

a growing concern around quality

RED 5 4 HIGH HIGH

GB36

Director Outcomes

and Information

Director Nursing and

Quality

Governing Body

12-Nov-13Failure to achieve the 4 hour ED

performance targetRED 5 4 HIGH HIGH

GB39Director of Nursing

and Quality 19-Nov-15

LA budget constraints: Following LA budget

constraints, there is a miss-match in the

resources available to fund health and

social care services and the demand on

those services which may affect patient

experience, the quality of service

provision and outcomes for patients.

RED 4 4 HIGH HIGH

GB40Director of Nursing

and Quality 19-Nov-15

Home care quality monitoring: There are

not currently well established processes for

monitoring the quality of home care

providers which means that patients may be

receiving inappropriate and/or poor quality

care

AMBER/

RED3 4 HIGH HIGH

ASSURANCE FRAMEWORK SUMMARY

Trend since

last GB

meeting

Risk scoreRisk

No.

Lead & Sub

CommitteeRisk narrative

Residual

Risk rating

Risk rating

19

November

2015 GB

meeting

Risk rating

17 March

2016 GB

meeting

Date placed

on

Assurance

Framework

L I

Trend since

last GB

meeting

Risk scoreRisk

No.

Lead & Sub

CommitteeRisk narrative

Residual

Risk rating

Risk rating

19

November

2015 GB

meeting

Risk rating

17 March

2016 GB

meeting

Chief Finance Officer 19-Nov-15

Financial position at NUH may affect

system resilience resulting in extra costs to

the CCG and other services 2015/16AMBER 3 3 HIGH LOW

Chief Finance Officer 19-Nov-15

Financial position at NUH may affect

system resilience resulting in extra costs to

the CCG and other services 2016/17

AMBER/

RED4 3 HIGH HIGH

GB43Director of Outcomes

and Information30-Mar-16

Year to date the CCG is below standard on

certain cancer waiting times. The CCG is

working with the wider footprint on overall

performance and a remedial action plan has

been agreed. Specific indicators below

standard include Cancer 2ww breast

symptoms 85.22%; 62d Urg RTT Screening

75%; and Cancer 31d DTT 95.84%, 31d

DTT surgery 92%

AMBER/

GREEN3 2 LOW LOW

GB42

L I L I

GB 35

Director Outcomes and

Information

Director Quality and Patient

Safety

Governing Body

Failure to achieve the EMAS performance targets with a disproportionate performance

between city and county. This means patients in the county may be at greater risk of

harm. In addition, the nature of complaints received by EMAS demonstrate a growing

concern around quality

RED 5 5 RED 5 4

Better Patient Care Programme Board to monitor progress against the QIP.

The formal monitoring of the QIP is by the 'Oversight Group', led by the Trust Development Authority with NHSE, Lead Commissioner and EMAS.Ongoing

Bi-monthly Governing Body report and discussion Ongoing

Prolonged Wait Report - clinical audit on patients experiencing missed response times - reviewed by Quality and Risk Committee 01-Jan-15

Clinical Risk Summit reported to Governing Bodies and EMAS recovery plan produced following Summit 01-May-15

01-Dec-15

Ten minute protocol reviewed and relaunched 01-Mar-16

GB 35 RISK DETAIL

Strategic Objective 2 Improve the quality of health services in relation to health inequalities, health outcomes, patient safety, access and patient experience.

Controls Date

Assurance Domain 3 Delivering better outcomes for patients.

Risk

No.Lead & Sub Committee Risk narrative

Residual

Risk rating

Risk scoreInitial Risk

Rating

Risk Score

Contract Review Process led by Hardwick CCG on behalf of associate CCGs. Mansfield and Ashfield CCG lead for Nottinghamshire Ongoing

Director of Outcomes and Information, Head of Outcomes and Information and Senior Service Improvement Manager attend regular divisional monitoring meetings Ongoing

Deep Dive Review at Governing Body 19-6-15 and Audit Committee 12-1-15 and 27-1-16 Ongoing

EMAS Better Care Programme and Quality Improvement Plan following Clinical Risk Summit (October 2013) 01/10/2014/Ongoing

First responder operational plan implemented to establish pathway for first responder scheme 01-Mar-16

Commissioners' Report - produced monthly by NHS Hardwick CCG and shared with contract associates Ongoing

External/Internal Assurance Date

Provider met with commissioners to share issues and discuss support for financial position, improvement of current performance levels, and reducing the level of clinical risk

associated with prolonged waits.

Root Cause Analysis of missed Red 1 and Red 2 8 minute response times - reviewed by Quality and Risk Committee 01-Jan-15

Harm review now formalised and undertaken regularly

A harm review has been undertaken by EMAS Medical Director and Rushcliffe Governing Body GP of Red 1 breaches for Q.1. No adverse harm identified and process established

for ongoing review and assurance to associate commissioners. EMAS action includes staff recruitment, fleet replacement, expansion of first responder scheme in rural areas.

01-Jan-16

Action plan target date

Date info addedADDITIONAL INFORMATION e.g. The considerations taken when deciding on the risk rating or information to further inform the governing body on risks which remain

high despite on-going actions

CQC report awaited.

Gaps in controls and assurance and the action plans in place

01-Oct-15

01-Mar-16

CQC inspection completed mid November 2015. 15-Nov-15

L I L I

GB 36

Director Outcomes and

Information

Director Quality and

Patient Safety

Failure to achieve 4 hour ED performance targetAMBER

RED5 3 RED 5 4

Audit Committee Deep Dive review of ED Performance 27 January 2016

Urgent care centre opened Oct-15

Performance delivered in quarter 1 2015/16 was above the 95% target; Standard not achieved in Quarters 2 and 3

Ongoing

Urgent Care Daily Sit Rep to NHS England Ongoing


Urgent care dashboard produced on a daily basis to support daily conference calls that include all health and social care organisations Sep-15

Escalation telephone calls for Chief Officers and NUH Senior Management at 5 pm each day that performance is below 85% Jan-16

Remedial Action Plan agreed with NUH which includes financial sanctions for non-delivery of specific actions or non-delivery of required performance improvement. RAP

monitored and escalated through Contract Executive Board.Jan-16

CCGs continue to impose fines against the provider for the under delivery of the performance standard as defined in the NHS Standard Contract On-going

Friends and Family test response performance reported within Quality Premium section of Quality and Performance Report; outcome monitored through Quality Scrutiny Panel Ongoing

Assurance Domain Delivering better outcomes for patients.

Strategic Objective Improve the quality of health services in relation to health inequalities, health outcomes, patient safety, access and patient experience.

GB 36 RISK DETAIL

Risk


Initial Risk

rating

Risk Score Residual

Risk rating

Risk score

CCG Quarterly Assurance Meetings Ongoing

Controls Date

System Resilience Implementation Group meeting weekly across south UOP. Workstreams: admission avoidance; effective rehabilitation and discharge; demand and capacity -

with comprehensive work programme and sub-groups to oversee service improvement, transformation and performance Ongoing

Oct-15

NHS England Scrutiny meetings attended by Chief Officer Ongoing

Date info

added

Urgent care centre opened Oct-15

May-15Director of Urgent Care and two Project Managers to support implementation of System Resilience Implementation Group

ADDITIONAL INFORMATION e.g. The considerations taken when deciding on the risk rating or information to further inform the governing body on risks which

remain high despite on-going actionsDate info added

Gaps in controls and assurance and the action plans in placeAction plan target

date

Detailed joint analysis completed to determine the benefit and risks of reducing elective capacity beyond that historically carried out. This analysis determined that the level of

benefits of freed bed capacity did not outweigh the risk of subsequent delays to elective patients and the subsequent risk of failure of the NHS Constitution Standards.Jan-16

Detailed analysis of 150 patients deemed to be'stranded' to System Resilience Implementation Group and action plan is being developed Mar-16

L I L I

GB 39 Director Quality and

Patient Safety

LA budget constraints: Following LA budget constraints, there is a miss-match in the

resources available to fund health and social care services and the demand on those

services which may affect patient experience, the quality of service

provision and outcomes for patients.

RED 4 4 RED 4 4

Action

plan

target

date

Date info

added

Nov-15

Awaiting final details of proposals following closure of consultation. Health implications of final proposals to be assessed once known. Jan-16



In 15/16 BCF scheme to protect social services Jan-16

BCF 16/17 in development including an evaluation of the impact of 2015/16 BCF Jan-16

Health implications of final proposals to be assessed once known.


Local Authority update to Governing Body Dec-15

CCG response to proposals submitted as part of consultation process and Governing Body paper in Jan 2016 on proposed budget changes Jan-16

Greater Nottingham Board working as a unit of planning with all stakeholders to ensure development of sustainable models for future health and social care Ongoing


Controls Date

Social Care Director is member of CCG Governing Body Ongoing

Better Care Fund plan in place and monitored by BCF Programme Board Ongoing

Nottingham County Council presented budget proposals ahead of formal consultation Jan-15

GB 39 RISK DETAIL

Risk


Initial Risk

Rating

Risk Score Residual

Risk

rating

Risk score

Assurance Domain 1

Assurance Domain 3

Clinically commissioned, high quality services

Better outcomes for patients

Strategic Objective 4 Design, procure and monitor services to achieve the best possible clinical and patient experience outcome

L I L I

GB40 Director Quality and

Patient Safety

Home care quality monitoring: There are not currently well established processes for

monitoring the quality of home care providers which means that patients may be receiving

inappropriate and/or poor quality careAMBER

RED3 4

AMBER

RED3 4

Action

plan

target

date

Date info

added

Nov-15

Nov-15

Joint quality assurance processes with the LA still need to be developed.



Quality Improvement Forum to be established by CityCare


Work continues by contracting team to establish the new contracts with all providers. Nov-15


Controls Date

Meeting regularly with new homecare providers and the County Council to mobilise the new contracts which include a quality schedule as quickly as possible. Nov-15

Audit tool to monitor provider quality being devised for use by CHC Jan-16

GB40 RISK DETAIL

Risk


Initial Risk

Rating

Risk Score Residual

Risk

rating

Risk score

Assurance Domain 1

Assurance Domain 3




L I L I

Financial position at NUH may affect system resilience resulting in extra costs to the CCG

and other services 2015/16AMBER

RED4 3 AMBER 3 3

Financial position at NUH may affect system resilience resulting in extra costs to the CCG

and other services 2016/17AMBER

RED4 3

AMBER

RED4 3

Action

plan

target

date

Date info

added

Financial penalties as outlined in contract are routinely imposed and this is reported to the Governing Body Ongoing

Cancer performance forms part of regular discussions with NHS England Locality Team as part of regular assurance meetings Ongoing

OngoingNottingham City CCG lead commissioner hold fortnightly discussion with NUH cancer leads and attend the Patient Target List meeting

Three Remedial Action Plans have been agreed and implemented Ongoing

Remedial Action Plan includes financial consequences of non-delivery Ongoing


Quality Team has undertaken harm reviews which has identified a low level of clinical risk associated with the delays

Remedial Action Plan has an agreed date for recovery which is 1st April 2016 Feb-16

Contract Monitoring Meetings with providers Ongoing

Contract Executive Boards/ Meetings Ongoing


Chief Finance Officer financial scenario planning presentation to Governing Body Nov-15

The Contract Executive Board and the Quality and Performance Committee will monitor performance against the Remedial Action Plans. The CCG will have oversight Ongoing

Controls Date

Monthly performance and finance reporting to the Governing Body Ongoing

Detailed reports to QIPP group for rigorous performance monitoring Ongoing

GB42 RISK DETAIL

Risk


Initial Risk

Rating

Risk Score Residual

Risk

rating

Risk score

Assurance Domain 1

Assurance Domain 3




GB42 Chief Finance Officer

Feb-16

Risk scoring reduced for 2015/16 to 3*3=9, remains at 4*3=12 for 2016/17 Jan-16

Deep dive planned for Audit Committee on 30th March 2016



GB43 Chief Finance Officer

GB43 RISK DETAIL

Risk

No.Lead & Sub Committee

Nottingham City CCG lead commissioner hold fortnightly discussion with NUH cancer leads and attend the Patient Target List meeting

Assurance Domain 1

Assurance Domain 3

Strategic Objective 4

Controls

The Contract Executive Board and the Quality and Performance Committee will monitor performance against the Remedial Action Plan. The CCG will have oversight


Three Remedial Action Plans have been agreed and implemented

Cancer performance forms part of regular discussions with NHS England Locallity Team as part of regular assurance meetings

Remedial Action Plan includes financial consequences of non-delivery

Financial penalties as outlined in contract are routinely imposed and this is reported to the Governing Body

External/Internal Assurance

Remedial Action Plan has an agreed date for recovery which is 1st April 2016

ADDITIONAL INFORMATION e.g. The considerations taken when deciding on the risk rating or information to further inform the governing body on risks which remain




Year to date the CCG is below standard on certain cancer waiting times. The CCG is

working with the wider footprint on overall performance and a remedial action plan has been

agreed. Specific indicators below standard include Cancer 2ww breast symptoms 85.22%;

62d Urg RTT Screening 75%; and Cancer 31d DTT 95.84%, 31d DTT surgery 92%

RED

GB43 RISK DETAIL

Risk narrativeInitial Risk

Rating

Nottingham City CCG lead commissioner hold fortnightly discussion with NUH cancer leads and attend the Patient Target List meeting



Design, procure and monitor services to achieve the best possible clinical and patient experience outcome

Controls

The Contract Executive Board and the Quality and Performance Committee will monitor performance against the Remedial Action Plan. The CCG will have oversight


Three Remedial Action Plans have been agreed and implemented

Cancer performance forms part of regular discussions with NHS England Locallity Team as part of regular assurance meetings



External/Internal Assurance

Remedial Action Plan has an agreed date for recovery which is 1st April 2016





L I L I

5 4AMBER/

GREEN3 2

Action

plan target

date

Date info

added

GB43 RISK DETAIL

Risk Score Residual

Risk

rating

Risk score

Nottingham City CCG lead commissioner hold fortnightly discussion with NUH cancer leads and attend the Patient Target List meeting Ongoing



Design, procure and monitor services to achieve the best possible clinical and patient experience outcome

Controls Date

The Contract Executive Board and the Quality and Performance Committee will monitor performance against the Remedial Action Plan. The CCG will have oversight Ongoing

Quality Team has undertaken harm reviews which has identified a low level of clinical risk associated with the delays Feb-16

Three Remedial Action Plans have been agreed and implemented Feb-16

OngoingCancer performance forms part of regular discussions with NHS England Locallity Team as part of regular assurance meetings



Feb-16

Ongoing


Remedial Action Plan has an agreed date for recovery which is 1st April 2016 Feb-16


high despite on-going actionsDate info added

Deep dive planned for Audit Committee on 30th March 2016 Feb-16


LIST OF RISKS ARCHIVED

L I

GB37Director of

Finance

QIPP 2014/15 - Expenditure will exceed budget and

the CCG will not deliver its required surplus due to

QIPP not delivered or not delivered recurrently

2 1 1

Transferred to risk

register as no longer high

risk

Mar-15 Sep-15

GB38 Chief Officer

Failure to put in place appropriate arrangements for

the management of the Better Care Fund could impact

on the financial position of the CCG and the services

commissioned for our patients

4 2 2

Transferred to risk


risk

Mar-15 Sep-15

GB16

Director of

Nursing and

Quality

Quality assurance and monitoring resources are

limited and the risk it that these are targeted at some

providers and not others where there are equal or

greater risks. The impact would be on individual

patients and also on the reputation of the CCG and

confidence in the wider public

9 3 3

Transferred to risk


riskNov-15 Jan-16

GB41Chief Finance

Officer

The CCG fails to keep within the Revenue Resource

Limit and is unable to pay for services it has

commissioned due to higher levels of activity than

expected and/ or undelivered QIPP schemes

9 3 3

Transferred to risk


riskJan-16 Mar-16

Date of

removal

Risk

No.Lead Risk narrative

Risk

rating

Risk scoreReason for removing

from the assurance

framework

Date

completed

Likelihood

score1 2 3 4 5

Descriptor Rare Unlikely Possible LikelyAlmost

certain

Frequency

How often

might it

happen

Impact

score1 2 3 4 5

DescriptorInsignificant

or minorModerate Significant

Very

significantMajor

Impact

should it

happen

No or slight

impact on the

CCG objectives

Moderate impact

on the CCG

objectives

Significant impact

on the CCG

objectives

Impact on the

CCG objectives

affecting delivery

over several areas

Impact on the

CCG

objectives

requiring

radical review

InjuryMinor injury not

requiring first aid

Minor injury or

illness, first aid

treatment needed

Over three days

off “sick” =

RIDDOR

reportable. 10

days to report to

the HSE.

Major injuries, or

long term

incapacity /

disability (loss of

limb)

Death or major

permanent

incapacity

Patient

Experience

Unsatisfactory

patient

experience not

directly related to

patient care

Unsatisfactory

patient experience

- readily

resolvable

Mismanagement

of patient care –

short term effects

Mismanagement

of patient care –

long term effects

Totally

unsatisfactory

patient

outcome or

experience

Service/

Business

Interruption

Loss/interruption

> 8 hours

Loss/interruption >

1 day

Loss/interruption

1 week

Loss/interruption

over a week

Permanent

loss of service

or facility

Late delivery of

key objective/

service due to

lack of staff

(recruitment,

retention or

sickness). Minor

error due to

insufficient

training. Ongoing

unsafe staffing

level

Inspection/

Audit

Minor

recommendation

s. Minor non-

compliance with

standards

Recommendation

s given. Non-

compliance with

standards

Reduced rating.

Challenging

recommendations.

Non-compliance

with core

standards

Enforcement

Action. Low

rating. Critical

report. Multiple

challenging

recommendations.

Major non-

compliance with

core standards

Prosecution.

Zero Rating.

Severely

critical report

DETERMINING THE RISK RATING

Ongoing low staffing level reduces

service quality

Local Media interest

Financial

Adverse

Publicity/

Reputation

Non-delivery of

key objective/

service due to

lack of staff.

Loss of key

staff. Very

high turnover.

Critical error

due to

insufficient

training

B - What is the severity of the impact

Complaint/

Claim

potential

Locally resolved

complaint

Justified

complaint

peripheral to

clinical care

Justified complaint

involving lack of

appropriate care

Multiple justified

complaints

Multiple claims

or single major

claim

Human

Resources/

Organis-

ational

Development

Rate as 1

(significant): Local

media interest for

over a month

National media

interest < 3

days MP

To the value of

the

contingency

held for the

financial year

13/14

Approx £4.5m

>50% of

contingency

Approx £2.75m

Up to 10% of

contingency

Up to Approx

£450k

<1% of

contingency

Approx £45k

10% of

contingency

Approx £450k

National media

interest < 3 days

Rate as 1

Uncertain delivery

of key objective/

service due to

lack of staff.

Serious error due

to insufficient

training

Additional narrative to support identification of the severity of the impact added below

Consider Table A - Likelihood, Table B - Severity and then review the matrix for a final score

A - What is the likelihood that harm, loss or damage from the identified hazard will

occur

This probably

will never

happen

Do not expect it

to happen but it

is possible it

may do so

Possibly may

happen

Highly probable

that it will

happen

Likely

Major

Very

significant

(High)

Significant

Moderate

Insignificant/

minor

1 2 3 4 5

RARE UNLIKELY POSSIBLE LIKELYALMOST

CERTAIN

NB

The following risks go on the assurance framework - Amber/red and red

The following risks go on the risk register - Amber, Amber/green and green

A&B - Likelihood and severity RAG rating matrix

IMP

AC

T

5 A R R R

(Very high)

4 R

3 A

R

AA/G

A/R

A/RA

G

A

A/G

A/G

LIKELIHOOD

A/R A/R

RISK MATRIX SCORING

A(Low)

1 G G G G G

(Very Low)

(Medium)

2

A

Risk Management Action Guide

Governing

Body

Review and challenge of all

strategic risks and mitigating

actions provided by all the CCG

Committees

Red and Amber

Red

CCG Assurance

Framework

Audit

Committee

Interrogation of strategic risks

through mechanisms such as

the Internal Audit Plan and

requests for full reporting to the

Audit Committee by the Finance

and QIPP, Quality & Risk

Committee and IGMT Commitee

Red and Amber

Red

CCG Assurance

Framework

Leadership

TeamSub Committee

Finance and

QIPP

Risk registers and CCG

Assurance Framework

Quality &

Risk

Committee

IGMT

Committee

NB

The following risks go on the assurance framework - Amber/red and red

The following risks go on the risk register - Amber, Amber/green and green

Committee Risk RatingDocument to capture

risk

Identification and management

of operational and strategic

risks. Action planning to ensure

mitigating factors and controls

are implemented and tracked.

Maintenance of the sub-

committee risk register and

signposting to the assurance

framework

All risk ratings

Remit

nhs rushcliffe ccg assurance framework · the ccg and other services 2015/16 amber 3 3 high low...

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