agenda item: tb 195/11 subject: assurance framework report board/trust board documents... · agenda...

AGENDA ITEM: TB 195/11

SUBJECT: Assurance Framework Report

DATE OF MEETING: 06 December 2011

PREPARED BY: Jane Burke, Assistant Company Secretary

FOIA STATUS: No exemption Choose an item.

Part exemption applies to page:

REVIEW DATE: 06 December 2012

LINK TO VALUES: Accountability

LINK TO STRATEGIC PRIORITIES: 6. Quality & Governance

LINK TO NHS CONSTITUTION: Quality of Care & Environment

LINK TO BOARD RISK REGISTER: 8. Maintain an effective system of internal control

1.0 BOARD ACTION The Board are asked to review the Assurance Framework and to confirm agreement with the content and the assurances described.

2.0 INTRODUCTION The paper provides the revised Assurance Framework which outlines the high level risks to the organisations strategic objectives.

Effective governance and assurance arrangements are essential to providing confidence that the organisation is focused effectively on the delivery of its objectives. Boards are required to seek regular assurance to satisfy them that systems of internal control are functioning effectively to manage risks to delivery of objectives.

The Board Assurance Framework is a key document whose purpose is to provide the Board with reasonable assurance around the management of strategic risks and that internal control systems are functioning effectively.

The Department of Health guidance, Building an Assurance Framework (2003) describes how Boards should seek assurances against the effectiveness of the controls in place to mitigate key risks The maintenance and monitoring of the Board Assurance Framework will provide confidence that there are robust risk management arrangements, that these arrangements are subject to appropriate scrutiny and that the Board can be confident that there is evidence that risks to achieving its objectives are appropriately managed.

3.0 BACKGROUND

During 2009 the Board led the overall programme of work to embed the Enterprise Assurance Management approach within the Trust. This commenced with the Board identifying its risk appetite and defining risk tolerances across key areas of Business Activity.

The Assurance Framework will be informed by the identification of risks that fall outside of the Board’s risk appetite and have been escalated through governance systems to the appropriate Executive Directors. The Board considered risks associated with the development of strategic plans and horizon scanning at a special session held on 1st November 2011. To enable transparency around this process of escalation of risks from within the organisation an Executive Risk Register is now in place and has recently been reviewed by the Executive Team. The full Executive Risk Register is shown at Appendix 2. As a result of this review the Executive Team are recommending that the following risks should be included on the Board Assurance Framework.

Risk Ref

Executive Lead

Objective Risk Gross Net

051 D Tomlinson Ensure unqualified annual accounts are submitted

Shortened timescale of accounts preparation not achievable

90 50

052 Unforeseen or late changes to guidance

90 80

054

D Tomlinson Ensure adequate CIPs are in place to deliver target financial performance

Required CIP not achievable 80 60

062

D Tomlinson Improve relationships between LCFT and commissioners

Discontinuity amongst commissioners

63 45

064

D Tomlinson Maintain assurance processes regarding LCFT’s performance against Monitors compliance framework

Inadequate support systems for community service indicators

80 50

066

Unacceptable performance levels

70 50

032

082

P Sullivan

M Hindle

To ensure the Trust has systems and processes in place to

Insufficient ability to define and communicate business continuity arrangements

80 60

support Emergency Planning and business continuity

Table 1

The starting point for any assurance framework is the identification of the organisation’s goals/priorities and key objectives for the year. The previous Assurance Framework reported to the Board in June 2011 has been revised to clearly map risks to the current priorities.

4.0 ISSUE The starting point for any assurance framework is the identification of the organisation’s goals/priorities and key objectives for the year. The previous Assurance Framework reported to the Board in June 2011 has been revised to clearly map risks to the current priorities Following the Internal Audit Review of the Assurance Framework completed in June 2011 several areas for improvement where recognised. To address these issues a Sub group of the Board involving Executives and Non-Executive Directors reviewed the full Assurance Framework, including the scoring of risks, the robustness of controls and assurances in place and the actions required to close any gaps. The resulting Assurance Framework is aligned to the Trusts Priorities developed in 2011 and all controls and assurances have been updated where appropriate. This iteration of the Assurance Framework includes the additional element of risk proximity. This defines risks in relation to the timeframe in which it is believed they will occur. The table below details the defined parameters.

Business Area Short Term Medium Term Long Term

Corporate and Operations

Could happen in the coming year

Could happen within a 3 year business cycle

Could happen after 3 years

Programme/Project

Related to forthcoming key milestones

Related to the next key milestones

Related to final project deliverables

Table 2 Risk proximity

This measure of risk proximity will allow the Board to establish the risks that are likely to happen in the long term and therefore do not need immediate action but their occurrence may be catastrophic and therefore any controls in place should be tested. This coupled with a measure of controls effectiveness will determine where the Board should ask for additional assurances. When controls are weak and the

net risk is high, the Board should consider this exposure and require appropriate controls to be demonstrated.

5.0 FUTURE REPORTING Through the development of an IT platform to support the roll out of Enterprise Assurance Management future reports will contain greater detail and allow the Board to gain confidence that Enterprise Assurance Management is becoming embedded throughout the Trust. Appendix 3 demonstrates the current figures of risk reporting via the EAM system however this should be seen as illustrative of the future reporting that will be available to the Board. At this stage the data is not yet validated and further progress has been made since the report was created. It is planned to report progress to the Board in March 2012 together with the revised Assurance Framework.

6.0 SUMMARY AND CONCLUSIONS The Assurance Framework has now been reviewed in full. It includes risks relevant to the enlarged organisation. The introduction of risk proximity will provide the Board with an additional dimension to risk management focussing attention on controls when impacts are high or risks are faced in the short term. This approach allows the Board to gain assurance that its strategic aims are deliverable as risks in the long term are also identified and controlled appropriately.

The Board can conclude that the key risks to delivery of the strategic aims have been identified through a systematic and robust top down and bottom up process, that controls have been identified that mitigate the risks, that plans to improve the control environment where appropriate are in place and that the assurance regime is being developed to provide assurance at the point of delivery. The Board’s attention is drawn to the following risks where the net risk score falls outside of the Boards defined tolerance levels. The Board is asked to consider the escalation of these risks to the Assurance Framework.

Business Activity

Risk Ref

Descriptor Exec Lead Net Score

Governance 001 Lack of engagement and support from networks, clinicians and corporate services for care pathway work

Medical Director 50

Reputation 030 GP survey shows that GP satisfaction does not improve despite launch of GP Charter

Medical Director 63

Governance 032 Insufficient ability to define and communicate business continuity arrangements

Director of Nursing

Governance 051 Shortened timescale of accounts preparation not achievable

Director of Finance

50

Governance 052 Unforeseen or late changes to guidance

Director of Finance

80

Governance 054 Required CIP not achievable Director of Finance

60

Reputation 062 Discontinuity amongst commissioners

Director of Finance

45

Governance 064 Unacceptable performance levels against Monitors compliance framework

Director of Finance

50

Governance 065 Inadequate support systems for community service indicators

Director of Finance

50

Strategy 080 Insufficient ability to understand service capacity and demand and co-ordinate workforce to benchmark costs

Director of Service Delivery

63

Strategy 082 Limited organisational ability to maintain the quality of service delivery whilst undergoing significant organisational change

Director of Service Delivery

64

Table 3 – risks for escalation

Trust Board Risk tolerance

Governance Compliance &Reporting

Strategy & Strategic Initiatives

Operations/ Infrastructures

Clinical Quality &Patient Care

Impact of External Environment

Stakeholder Management Reputation

Up to 40 Up to 60 Up to 60 Up to 60 Up to 60 Up to 40 Table 4 – Board Risk tolerance

7.0 RECOMMENDATIONS

The Board is asked to:

Review and approve the revised Assurance Framework Note the assurances identified Make any recommended changes to the register

Space for Board member’s comments/questions/prompts

26%

25%

15%

11%

9%

7%

7%

Current Risk By Type

Service delivery

Organisational

Reputational

Governance

Financial

Workforce

Environmental

0 2 4 6 8 10 12 14 16

Compliance

Governance

Patient experience

Workforce

Financial

Reputational

Service delivery

Physical harm/injury

Risk Consequences

Total

ServiceDelivery

&Transformation

AdultMentalHealth

AdultCommunity

Children&

Families

OlderAdultMentalHealth

Finance&

BusinessOperations

Workforce & OD

MedicalDirector

NursingTransition

NotDefined

Clinical CorporateNot

Defined

Total 7 5 2 2 1 14 4 3 2 1 14

0

2

4

6

8

10

12

14

16

Ope

n Risks

Current Risks By Directorate

0

10

20

30

40

50

60

Oct Nov

Current RisksFirst Recorded

Total

Executive Risk Register

Risk_ID EMT Bu

sine

ss Activ

ExecName Objective Principal Risk Consequence GrossRisk

NetRisk

Control Assurance Action to close Gaps Due Date

001 Governan

ce

Max Marshall

Quality Improvement Strategy: Ensure all

care pathways are NICE compliant and

ensure all patients allocated to a pathway

Care pathways with TCS services have not

been defined or assessed for NICE

compliance.

At present such pathways fall

outside the Trust Quality Strategy,

and so data may not be recorded or

reported. 49 28

Clinical Governance will assess

TCS services for new care

pathways and assess them for

NICE compliance.

Quarterly Quality

Report will contain

details of new

pathways identified.

Ongiong

monitoring

002 Governan

ce

Max Marshall




Lack of engagement and support from

networks, clinicians and corporate services

for care pathway work

Can't move forward on quality

strategy, impairs quality of PbR

data, impairs ability to marry up

financial and quality data 100 50

PbR clustering tool pathway

allocation, training and policy

Progress reports on

allocation of patients

to care pathway

Assurance from NDs that

there is a sound control

process in place regarding

allocation of patients to care

pathways 02.04.2012

003 Governan

ce

Max Marshall




Care pathway allocation system prevents

allocation to multiple pathways, or to new

pathways within provider services, or

discourages changes to pathway allocation

Impairs quality of PbR data, impairs

ability to marry up financial and

quality data 20 20 None None

Tolerate low level risk, to be

reviewed in future 30.04.2012

004 Operations

Max Marshall

Define and agree detail of conditions

necessary to implement Service Line

Management and begin implementation ‐

definition of clinical leadership model and

authorityLack of Associate Medical Director in

Children and Families Network

Problems implementing appraisal.

Lack of clinical leadership for

CAMHS services. 36 6

Lead consultant available in

Early Intervention Service ‐ no

other controls at present.

Close liaison with

Network Director

Need to write job

description and advertise 30.12.2011

005 Operations

Max Marshall





authority

Implementation of SLM delayed by

disagreements on professional leadership

model, that may necessitate a further

consultation

Delay in implementation as

disagreements are resolved 20 10

has been agreed and discussed

at EMT. Professional leadership

issues will be resolved

independently of clinical

leadership implementation.

Director of SDR issues

directive that networks

can proceed with

implementation

network directors and make

final amendments to text of

document. Professional

leadership issues not to form

part of this document. 31.10.2011

006 Operations

Max Marshall





authority

Implementation of service line

management delayed by lack of process to

appoint clinical directors

Implementation of service line

management is delayed while

appointment process is worked out. 50 10

Process to appoint clinical

directors needs to be

developed.

application to be a

clinical director has

been placed, and

contains details of

appointments process.

A process needs to be

developed and agreed for

appointing clinical directors 13.11.2011

007 Operations

Max Marshall

Define Medical Director's requirements in

terms of performance/quality standards of

the Service Networks

Overspend on medical agency costs may

not be sufficiently actively managed

Above budget spend on agency

doctors is contributing to a general

overspend 28 10

Associate Medical Directors are

required to monitor locum

spending and to take action

when it is above budget

Overspend is

monitored by finance

and overbudget

spending for more

than 3 consecutive

months leads to

appearence of

network on weekly

performance

monitoring. None

008 Operations

Max Marshall




Overspend on medical agency costs may

not be sufficiently actively managed

Financial ‐ Above budget spend on agency doctors is contributing to a

general overspend 28 10

Associate Medical Directors are

required to monitor locum

spending and to take action

when it is above budget.

Overspend is

monitored by finance

and overbudget

spending for more

than 3 consecutive

months leads to Weekly performance Ongoing

009 Governan

ce

Max Marshall




Doctors in networks are not having timely

annual appraisals

Doctors are not meeting the

standards for revalidation with the

GMC 35 7

Number of doctors having

annual appraisals is monitored

Regular monitoring

reports are submitted

for SHA audit

Dr. Kaushal needs to ensure

that associate medical

directors receive list of

number of doctors who have

not completed annual

appraisal in their network

and that this is shared across

networks and with Network

Directors 13.11.11

010 Operations

Max Marshall

Determine the information requirements of

assessing service performance against

Medical Director requirements

Trust is unable to supply data on patient

pathways on an annual cohort basis

We will be unable to implement a

key component of the quality

strategy which is to see whether

outcome is improving for pathway

groups on an annual basis 35 35 There is no control at present

Data is delivered on a

cohort basis for key

pathways

Need to meet with Sue Rigg

to discuss how and when

this can be delivered 31.03.2012

1


011 Operations

Max Marshall




We are unable to put outcome measures in

place to examine the extent of annual

improvement of patients on key care

pathways

We cannot show improvement or

practice quality improvement on

key care pathways 36 36

The Advancing Quality initiative

will provide these data for two

care pathways

The Advancing Quality

Reports will describe

the improvement for

annual cohorts of

clients on at two major

care pathways.

However further

assurance is required

for other care

pathways.

Networks need ensure a

good response to advancing

quality. Networks need to

assure themselves that

annual outcome assessment

is taking place across all care

pathways. 31.03.2012

2


012 Operations

Max Marshall




Lack of capacity and capability to analyse

the data produced by allocation of patients

to care pathways and annual outcome

assessment.

Data is available but cannot be

analysed in a meaningful or timely

manner. 56 48

There is not control at present,

other than for the advancing

quality initiative ‐ where the

analysis is preformed by a

consultancy company.

Annual reports on

outcome for cohorts

on key pathways are

available

Discussion with Sue Rigg

about capability of existing

resources and future

requirements 30.11.11

013 Operations

Max Marshall

Promote medical engagement in the

Appreciative Leadership programme

Doctors fail to be nominated for the

programme or do not participate fully

Reputation: Key medical staff do not

identify with the values and

strategic direction of the Trust. 42 12

Network Directors are

encouraged to nominate

doctors. Doctors have been

asked to put themselves

forward at Medical Advisory

Committee. I can nominate

doctors and get nomination

Nomination lists and

attendance records are

available.

Need a regular written

report of the number of

doctors completing

Appreciate Leadership 30.11.11

014 Governan

ce

Max Marshall

Strengthen the reporting process around

clinical information governance and the

systematic learning arising

There may be an insufficiently systematic

process for addressing of where actual

clinical practice may fall short of

Information Governance standards.

Reputation, Inspection/Audit,

Patient Experience, Complaints: Loss

of reputation or litigation arising

from poor handling of clinical

information. 42 12

Caldicott Log in place for

reporting incidents and actions.

MM and JMcK have attended

Caldicott training. SIRO,

Caldicott Report to be

produced annually for

Trust Board.

Information Govern

policies and toolkit.

Need to clarify with J

McKenna and Peter Holden

when Caldicott report will be

produced and when J McK

will complete assessment of

current practice against

issues raised in Caldicott 31.03.2012

015 Operations

Max Marshall

Ensure adequate arrangements are in place

to respond appropriately to uncertainty

regarding non‐consultant medical

workforce meeting Trust needs

A sudden reduction in trainee numbers

because of reduced numbers of

applications to training posts.

Night time and weekend medical on

call rotas will come under severe

pressure and may collapse 48 16

John McKenna chairing Medical

Workforce Group monitoring

the situation with input from HR

and Finance and Clinical Tutor

A workforce plan has

been produced to deal

with future

contingencies.

The workforce plan needs to

be adopted and

implemented, but so far

there has been little buy‐in

from the Networks. 31.01.2012

016 Operations Ensure adequate arrangements are in place




The current junior doctor rota in Lancaster

is on the verge of EWTD non‐compliance,

and is generating substantial locum costs.

We are at risk of being fined for

EWTD non‐compliance or having to

raise banding payments. Substantial

sums of money are being spent for

little clinical benefit. 48 42 Compliance is monitored by HR.

Medical Workforce

Group is aware of the

problem with the rota

and receives

compliance data.

Adult mental health and

older adult networks need

to implement the Workforce

group's suggestions to

stabilise the rota. 30.11.2011

017 Operations Ensure adequate arrangements are in place




A Deanery Inspection of the Trust is taking

place in Feb 2012.

A poor inspection report could lead

to loss of trainees and damage to

the Trust's reputation. 40 10

The Trust clinical tutor, Venu

Duddu, is leading the

preparation for the visit.

Oversight of the plan is

provided by the

Medical Workforce

Development Group,

chaired by Dr. J.

McKenna and

containing

Dr. Duddu needs to provide

execs with a regular monthly

update on preparation for

the visit, highlighting

progress and any issues that

need to be resolved. 30.11.2011

018 Service delivery

Max Marshall

Ensure there is appropriate assurance on

the impact on quality of CIPs and transition

programme

Insufficient attention will be paid to the

views of senior clinicians because of

pressure to complete the transition

programme

Physical harm/injury Senior

clinicians will not support the

transition programme, or will point

out potential clinical risks that will

not be resolved. 30 18

Clinical Directors in place in the

Networks and involved in

Transition Planning. Senior

clinicians in the Networks are

being meaningfully consulted

on the plan.

Director of Nursing

and Medical Director

are meeting with

senior clinicians and

clinical directors and

are aware that they

are backing the

transition plan.

MM to meet regularly with

the new AMDs in the adult

network to ensure they

support the transition plan.

The transition plan should

include specific reference to

the concerns of clinicians

and how they have been

addressed. 30.11.20.11

3



Max Marshall

Ensure there is appropriate assurance on

the impact on quality of CIPs and transition

programme

CIPs may be implemented that have a

major impact on quality or safety

Physical harm/injury Serious

deterioration in quality of care or

safety. 40 8

All CIPs assessed in meeting

between clinical execs and

network directors

Reported to Board as

RAG rating. Red plans

cannot proceed

without further

assurance.

I am unclear whether new

CIPS are arising and what

changes have been made to

any CIPs rated red or amber

since last meeting. Director

of Nursing and I need to

review the process. 20.12.11


Max Marshall

Maintain performance against corporate

priorities (CIP, policy, etc)

Quality Improvement Strategy does not

consider the requirements of the new TCS

services.

Service Delivery ‐ Trust lacks a

coherent quality improvement

strategy that includes all services

that it provides ‐ this could lead to

poor quality care, or missed

opportunities to demonstrate high

quality work. 56 16

The Quality Improvement

Strategy.

Quarterly Quality

Reports, Quality

Account, Oversight of

Quality

Implementation Group

that contains Mark

Hindle and Janet

Quality Strategy Needs to be

Refreshed 31.01.2012

021 Service Delivery


priorities (CIP, policy, etc)

Overspending on the drug budget impinges

on the delivery of CIPs

Financial ‐ Rising expenditure on

anti‐dementia drugs creates a £200‐

400k deficit in drugs budget. 36 12

Drug expenditure is monitored

by finance department and

chief pharmacist.

Drug expenditure is

discussed at D&T

committee.

Report required into causes

of increased expenditure

and measure taken to bring

it under control. More

accurate projection of

pressure required. 30.12.2011

022 Service Delivery

Max Marshall

Enhance organisational capacity to

innovate and ensure that implementation

of the innovation programme is carried out

Networks and clinicians fail to engage with

the programme

The Trust falls behind competitors in

terms of cost‐effectiveness and

quality improvement, staff with

good ideas are disenchanted and

disempowered. 45 10

Programme of Innovation

appendix to Quality Strategy.

Quality Strategy

Implementation Group

Ideas for innovations

are identified and

evaluated in line with

the plan laid out in the

programme. Progress

will be posted online

as the strategy

Need to agree funding to

support 4 innovations put

forward by the networks as

part of the programme. In

region of £200k. It is

proposed that this should

come from CQUIN funds. 27.04.2012


Max Marshall

Increase numbers of research

studies/participants from TCS services

Senior clinicians in community services will

perceive that LCFT has failed to deliver one

of the key anticipated benefits of

integration.

Organisational ‐ Staffing &

Competence: Recruitment to NIHR

portfolio studies falls, FSF income

falls, the Trust loses top quality

clinicians or cannot recruit. 28 4

R&D have been identifying

research active clinicians in TCS

services. Away day planned

with new services. Plan for

integration with current R&D

activity will follow.

R&D Annual Report to

Board. Monitoring of

NIHR Portfolio

(recruitment) by R&D

manager.

Adult Community and

Children and Families

Network should report new

research activity at Chief

Exec's Challenge 31.03.12

024 Governan

ce

Max Marshall

Fully implement enhanced medical

appraisal

The Share Point system for supporting

medical appraisal is not fully functional and

will require updating and maintenance.

Doctors may be reluctant to use the

system because of security fears or

because it is hard to access. This

would make it difficult monitor the

success of the revalidation

programme. 42 7

Monitoring of number of

doctors using the database and

number of appraisals completed

in time.

ORSA audit. AMD for

revalidation satisfied

that system is

effective. Medical

Advisory Committee

satisfied that system is

effective.

Need to ensure that

sufficient IT support is

available to maintain the

system. 30.11.2011

025 Governan

ce

Max Marshall


appraisal

The administrative support available to

support revalidation may not be adequate,

especially given the increased requirements

following transfer of community services.

Revalidation process may cease to

function, leading to major

difficulties with SHA and regulators. 28 7

AMD for Revalidation (Ashu

Kaushal) asked to produce

written case for additional

resources.

Case received and

reviewed by medical

director.

Validated care needs to be

submitted as a pressure. 06.01.2012

026 Governan

ce

Max Marshall


appraisal

The process for dealing with concerns

about doctors is not sufficiently systematic.

Exposure to legal challenge from

doctors. Doctors performance

concerns not adequately addressed. 28 7

Policy in place for Maintaining

High Professional Standards in

the Modern NHS

Performance issues

kept under review by

Director of HR and

Medical Director

An operating procedure

needs to be developed that

specifies in detail how

concerns about doctors are

managed. 30.03.2012

027 Operations

Max Marshall

Ensure that the views of clinicians are

actively taken into account in the design of

reconfigured inpatient services

Clinical engagement diminishes as the

capital programme enters its later stages.

Clinical support for the programme

is lost and mistakes are made

through lack of clinical input. 40 8

The capital programme provides

evidence that there is an

ongoing detailed clinical review

of the acute care model.

Regular meetings with

the Associate Medical

Director for Tier 5.

Director of Nursing

and Medical Director

to review the evidence

of clinical engagement.

Capital Programme needs to

provide ongoing evidence

(suggest quarterly) of

successful clinical

engagement. 30.11.2011

028 Reputational

Max Marshall

Design GP engagement process including

clinical interface

There is no clinical content available for the

GP portal

The Trust commitment to make

online self help material available to

GPs is not met None None

Communications and IT

need to work with clinicians

in the network to deliver

clinical content ‐ at the

moment the vehicle for this

co‐operation is unclear. 29.02.2012

4


029 Reputational

Max Marshall

Design GP engagement process including

clinical interface

New GP advisors are not sufficiently

integrated into the organisation

Services do not benefit from GP

input leading to reduce quality and

potential loss of business 30 6

Job plan in place. Line

management clarified

Not adequate at

present, but not yet in

post

Director of SDR and Medical

Director need detailed plan

about deployment and

supervision of GP advisors 31.12.2011

5


030 Reputational

Max Marshall

Ensure appropriate implementation of GP

engagement process

GP survey shows that GP satisfaction does

not improve despite launch of the GP

Charter.

Trust is seen to have failed to

deliver on its promises to GPS,

leading to substantial reputation

damage and possible loss of

business 72 63

GP survey will be launched in

November and repeated in

November 2012

Survey has been

publicised internally to

staff. Networks have

specified the

interpretation of the

standards internally, to

be posted on the Trust

Internet site

Networks must have robust

assurances in place that they

are delivering against the

charter standards. 30.12.2011

031 Patrick Sullivan

To define and communicate appropriate

service performance, quality, patient

experience and governance standards

Sufficient management capacity and

capability to ensure that we interpret and

adapt statutory and regulatory and

professional guidance into service

standards

We fail to determine the required

service standards which result in

service failure 21 7

Management structures to

support the process,

underpinned by regular 1:1.

Quality strategy outlining the

priorities. effective professional

leadership arrangements.

Patient Experience Strategy

1:1 meetings and

performance reviews.

Performance and

Quality report and

quarterly analysis of

complaints, incidents

and claims. Quarterly None

032 Governan

ce

Patrick Sullivan

To define and communicate appropriate

service performance, quality, patient

experience and governance monitoring

arrangements

Sufficient management capacity and

capability to ensure that we interpret and

adapt statutory and regulatory and

professional guidance and define

monitoring arrangements

Services cannot provide evidence of

performance standards 42 14

Network Governance meetings,

Oversight of agendas,

Annual Governance

Statements, Chief

Execs challenge None

033 Governan

ce

Patrick Sullivan

To ensure appropriate and robust

assurances are provided regarding service

performance, quality, patient experience

and governance

Variable compliance across and within

Networks

Compliance with regulatory

standards is limited 42 14



Annual Governance

Statements, Chief


034 Governan

ce To ensure appropriate and robust

assurances are provided regarding service

performance, quality, patient experience

and governance

Variable evidence provided across and

within Networks

Compliance with regulatory

standards is limited 42 14



Annual Governance

Statements, Chief


035 Governan

ce

Patrick Sullivan

To learn the lessons resulting from Serious

Untoward Incidents and feedback from

service users (includes claims)

Adequate systems to ensure that lessons

learned become embedded

Patient harm ‐ potential that we

repeat incidents and do not improve

services 48 SUI investigation process,

SUI quarterly reports,

SUI Analysis group,

Governance reports to

the Board, Meetings

between the Director

of Nursing and Medical

Director None

036 Governan

ce

Patrick Sullivan

To ensure that effective systems and

processes are in place to quality assure

Clinical Services and to promote a culture

of continuous improvement

A lack of capacity and/or capability to

clearly define the standards

The organisation is unaware if there

are significant risks to clinical

services &0 30

Key Performance indicators,

Priorities as defined in the

quality Strategy, Clinical audit

programme, Evidence to

support compliance with CQC

standards,

Professional leadership

structures which ensure

appropriate standards are set,

Quality and

Performance Report

Governance Report

Feedback from the

CQC eg QRP and

reports from any

reviews

Quality Account None

037 Patrick Sullivan


processes are in place to quality assure

Clinical Services and to promote a culture

of continuous improvement

Systems and processes that are not able to

provide the necessary assurance and

promote a culture of continuous

improvement Poor quality services are delivered, im 70 30

Key Performance indicators,

Priorities as defined in the

quality Strategy, Clinical audit

programme, Evidence to

support compliance with CQC

standards

Professional leadership

structures which ensure

appropriate standards are set

Quality and

Performance Report

Governance Report

Feedback from the

CQC eg QRP and

reports from any

reviews

None

038 Operational

Patrick Sullivan


priorities (CIP, policy, etc.)

Capacity and capability to manage the

range of organisational objectives

Directorate fails to meet its defined

objectives 30 12

Team and 121 meetings with

Senior management team

Performance Review

Performance management of

objectives

Regular reports on key

areas of activity e.g.

finance, workforce None None

039 Governan

ce

Patrick Sullivan


processes are in place to promote a

culture of continuous improvement and

compassionate servicesPoor service quality and risk of service

failure

Impact on service users and carers

and organisational reputation 35 21 Quality strategy and associated q

Quality reporting

processes from team

through to the board None None

6


040 Operational

Patrick Sullivan

To ensure that the impact on quality of

Trust CIPs is properly assessed and signed

off

CIP planned and implemented in a way that

impacts negatively on service quality

Negative impact on service quality

and organisational reputation 28 14

Monitoring system in place

ensuring all CIPs with significant

clinical implications are

reviewed and approved by the

clinical executives on the board

Control plans in place

at network level and

assurances provided to

Clinical executives None None

041 Operational

Dave Tomlinson

Source required capital funding for

inpatient reconfiguration and ensure this

represents VFM

Acceptability to Monitor of proposed

inpatient funding and lease arrangements Scheme delayed or unaffordable 42 28

Discussion with Monitor of

proposed inpatient funding and

lease arrangements

Confirmation from

Monitor of no issues of

principle re proposed

inpatient funding and

lease arrangements

Confirm exact lease/funding

arrangements regarding

inpatient reconfiguration

and discussion of these with

Monitor 31.12.11

7


042 Operational

Dave Tomlinson

Source required capital funding for

inpatient reconfiguration and ensure this

represents VFM

Interest from the market in funding

inpatient reconfiguration Scheme delayed or unaffordable 64 32

Soft market sounding with

funders for inpatient

reconfiguration

Supportive letters

from a number of

potential funders

regarding inpatient

reconfiguration

Confirmation of offer from

potential funder regarding

the inpatient reconfiguration 31.12.11

043 Operational

Dave Tomlinson

Support delivery of financially sustainable

inpatient reconfiguration business case

Inability to agree inpatient reconfiguration

revenue funding envelope with

commissioners Scheme delayed or unaffordable 64 48

Negotiation with commissioners

re inpatient reconfiguration

revenue funding envelope

Broad agreement in

principle of inpatient

reconfiguration

revenue funding

envelope and

commitment to work

together to resolve risk

Formalise agreement with

commissioners re inpatient

reconfiguration revenue

funding envelope 30.11.11

044 Operational

Dave Tomlinson

Support delivery of financially sustainable

inpatient reconfiguration business case

Management capacity and capability to

agree inpatient reconfiguration revenue

funding envelope Scheme delayed or unaffordable 36 24

Review of progress against

capital project gantt chart

EMT discussion

regarding inpatient

reconfiguration

revenue funding

envelope

045 Operational

Dave Tomlinson

Develop and implement a business plan for

Red Rose Corporate Services identifying

benefits to be gained by LCFT

Difficulty with reconciling objectives of

Ryhurst and LCFT Missed business opportunities 30 18

Ryhurst, LCFT and RRCS board

discussion of objectives

Prepare transparent

summary of benefits and

costs to LCFT of RRCS 30.12.11

046 Governan

ce

Dave Tomlinson

Ensure effective implementation of PbR for

mental health

Lack of agreement with commissioners over

approach to PbR implementation or issues

with tariff

Wasted time and effort in abortive

work 38 18

Process of discussion and

agreement over PbR with

commissioners

Indication of broad

agreement from

commissioners

regarding PbR

implementation

Establish ongoing PbR forum

with commissioners and

seek formal confirmation of

agreement 30.11.11

047 Governan

ce

Dave Tomlinson

Ensure effective implementation of PbR for

mental health

Lack of effective engagement of clinicians

in clustering of patients

Lack of progress with

implementation of PbR 48 30

PbR Clustering tool, training and

policy

Progress reports

demonstrating

performance against

standard 31.12.11

048 Governan

ce

Dave Tomlinson

EAM system too complicated or otherwise

not fit for purpose

EAM system not used and delay in

adoption 42 28

Piloting and usage of EAM

system None

Feedback from users of EAM

system

049 Governan

ce

Dave Tomlinson

Visible commitment of Execs to EAM

process

Delays to EAM process, and loss of

legitimacy 28

Regular review at EMT and

Audit Committee

Completion of

Executive EAM

assessments 42

050 Governan

ce

Dave Tomlinson

Ensure unqualified annual accounts are

submitted to target timescale

Differences of opinion between external

auditors and Management

Monitor intervention, reputational

damage 30

Progress review at Audit

Committee None 60

051 Governan

ce

Dave Tomlinson


submitted to target timescale

Shortened timescale of accounts

preparation not achievable


damage 50


Committee

Progress report,

External Audit

comment None 90

052 Governan

ce

Dave Tomlinson


submitted to target timescale Unforeseen or late changes to guidance


damage 80


Committee

Progress report,

External Audit

comment None 90

053 Governan

ce

Dave Tomlinson

Ensure adequate CIPs are in place to deliver

target financial performance

Lack of management information to

monitor progress with CIPs Unacceptable financial risk rating 63 27 CIP Addendum Report to Board

Confirmation of

acceptability by CIP

sub group

Widened reporting and

evaluation 30.11.11

054 Governan

ce

Dave Tomlinson

Ensure adequate CIPs are in place to deliver

target financial performance Required CIPs not achievable Unacceptable financial risk rating 80 60 CIP sign off process

Confirmation of CIP

deliverability from

budget holders

Increased rigour in CIP

evaluation process 31.03.12

055 Operations

Dave Tomlinson

Make and implement recommendations

regarding procurement function and

process

Affordability of procurement improvement

recommendations Internal control issues, lack of VFM 56 35 Progress review by EMT

Progress report against

project plan N/A

056 Operations

Dave Tomlinson

Ensure the development of appropriate

IM&T development business case

Delays to implementation, clinician

dissatisfaction

Review of progress against IM&T

development plan 56 28

Confirmation of progress

against IM&T development plan

Formal progress

review and corrective

action 28.02.2012

057 Operations

Dave Tomlinson

Ensure the development of appropriate

IM&T development business case

Acceptability to or commitment of

clinicians to IM&T development business

case

Delays to implementation, clinician

dissatisfaction 56 28


IM&T development plan

Confirmation of

progress against IM&T

development plan

Formal progress review and

corrective action 28‐Feb‐12

Introduce system for monitoring and

review of Enterprise Assurance

Management

8


058 Operations

Dave Tomlinson

Lead the estate rationalisation programme

and deliver agreed benefits Affordability and financial constraints Delays to implementation 81 45


IM&T development plan

Commitment of Board

to financial envelope

059 Operations

Dave Tomlinson

Lead the estate rationalisation programme

and deliver agreed benefits

Acceptability to or commitment of

clinicians and managers Unachieved CIP 64 48

CIP Sub Group review, Estate

Strategy Group review, Site

Utilisation Group review

CIP Addendum report,

progress against estate

strategy

Trust wide review and

agreement to estate

rationalisation plan 31‐Jan‐12

060 Operations

Dave Tomlinson

Implementation difficulties (consultation,

implementation cost, shortfalls) Unachieved CIP

CIP Sub Group review, Estate

Strategy Group review, Site

Utilisation Group review 60 40

CIP Addendum report, progress

against estate strategy

Trust wide review and

agreement to estate

rationalisation plan 31‐Jan‐12

061 Opera

Dave Tomlinson

Ensure clarity on implications of mental

health and community service contracts Unacceptable performance levels Loss of income 56 40

Contract review and

dissemination

Contract agreed and

signed off with

Formal contract review

reports 30.11.2011

062 Operations

Dave Tomlinson

Improve relationships between LCFT and

commissioners Discontinuity among commissioners

Loss of income, commissioner

dissatisfaction 63 45

Sense check of quality of

relationship

Review of status by

Reputation

Management Board

Formal review and

assessment of quality of

relationship 30‐Nov‐11

063 Operations

Dave Tomlinson

Definition of solution and review of

progress Affordability/financial constraints 56 42

Delays to or flaws in

implementation of intelligence

factory None

Definition of solution and

review of progress 31.01.12

064 Operations

Dave Tomlinson

Definition of solution and review of

progress

Management capacity and

capability 56 48

Delays to or flaws in

implementation of intelligence

factory None

Definition of solution and

review of progress 31‐Jan‐12

065 Operations

Dave Tomlinson

Development and implementation of plan

to address community information shortfall

Inadequate support systems for community

service indicators Breach of authorisation 80 50

Weekly performance review,

Monthly Board performance

Report

Review of

performance at weekly

meeting, monthly

Board and quarterly

data Quality Group 30‐Nov‐11

066 Dave Tomlinson

Maintain assurance processes regarding

LCFT performance against Monitor’s

compliance framework Unacceptable performance levels Breach of authorisation 70 50

Weekly performance review,

Monthly Board performance

Report

Review of

performance at weekly

meeting, monthly

Board and quarterly

data Quality Group N one

067

Ope

ratio

ns

Joan

ne M

arshall

Oversee the implementation of the OD

Framework and component programmes

linked embedding the organisations vision,

values and behaviours

Insufficent capability and capacity Workforce ‐ competence and

capacity; staff morale 15 12

OD Action Plan underpinned by

OD Framework;

OD Action Plan ‐

achievement of

milestones reviewed

by HR Strat4egy

Group; Staff Attitude

Survey ; PDR rates;

Improvement in

Quality Training CQUIn

results

Leadership Strategy and OD

Strategy. Talent

Management succession

planning , Staff Engagement

test indicator, Modern

Manager concept to be

rolled out.

01.03.2013

Lead the definition, design and

implementation of the ‘intelligence factory’

9


068

Ope

ratio

ns

Joan

ne M

arshall

Oversee the implentation of the OD

Framework and component programmes

linked embedding the organisations vision,

values and behaviours

Economic climate & CIP programme

workforce ‐ competence and

capacity; Service disruption;

Reputational ‐ potential closures

damage reputation, staff morale

15 12

ESR controls and Annual

Workforce Plan; Specialist

Capability contracted,

~Individual Network Workforce

Plans

ESR Staff in Post

reports to Managers

monthly . HR Strategy

Group ‐ Qrtlerly Trust

Board receiving Annual

Workforce report and

Strategy

Workforce Strategy in

development ; Further work

on Network Workforce Plans

Enhanced ESR reports linked

to establishment controls

01.03.2013

069

Ope

ratio

ns

Joan

ne M

arshall To develop a robust workforce for the

organisation and implement new ways of

working/workforce redesign to support the

achievement of the organisations

transformation programme and its strategic

aims and objectives

External demands around service provision

workforce ‐ competence and

capacity; Service disruption;

Reputational ‐ potential closures

damage reputation, staff morale

35 25

Robust Internal Workforce

Plans, Clear Stakeholder

Engagement Strategy,

Commissioning

Organisations plans,

demand management

Performance reports

around bed utilisation,

Waiting time data and

contact figures Quality

Report

Relationship

Management ‐

GP's . Data

Quality.

070

Ope

ratio

ns

Joan

ne M

arshall

To provide high quality professional HR and

L&OD service to support the delivery of the

organisations strategic objectives, by March

2012

Capability & capacity to support major

change programme and maintain

HR competence & capacity non

achievement of objectives inc in ET's

& SA etc

25 20

Staff survey, WF reports, ESR

reports, World class HR survey,

Individual objectives/team

meetings/HR strategy etc

Staff survey

turnover/workforce

report Objectives

being met

Managers actions not in line

with policy/good practice.

Robust PDR Establishment

control

Ongoing

monitoring

071 Ope

ratio

ns

Joan

ne

Marshall

To reduce sickness absence to 4.5% by

March 2012 and Bank & Agency spend.

Managers do not adhere to policy.

Economic climate and change programme70 35

SA policy, ESR reports, SA action

plan including individual

monthly meeting with Network

Director

Workforce reports to

Board. ESR data

reports,

Managers adhering to policy

, establishment control, and

use of OHIO

31.03.2012

072

Ope

ratio

ns

Joan

ne M

arshall

To provide high quality professional

communications and PR service to support

the delivery of the organisations strategic

objectives, by March 2012

Economic climate and major change

programme. Capability and capacity of

staff

Reputational ‐ loss of stakeholder

confidence 49 35

Stakeholder mapping,

reputation strategy. Complaints

& compliments. Press usage

reports. Quality reports

Press reports,

complaints data,

feedback from

governors , GP Survey,

Stakeholder database

requires up to datedta,

reputation strategy

required.

Stakeholder

database

requires up to

datedta,

reputation

strategy

required.

073

Ope

ratio

ns

Joan

ne M

arshall

Fully utilise the ESR system to support the

organisations strategic aims and objective

including implementation of integrate NCRS

Capability of staffStaff do not utilize new system

therefore cost savings not made!40 25

ESR group reports to IM & T

strategy Group

Staff survey

Achievement of key

milestones in action

plans. Reports to HR

strategy committee &

IM & T committee

Capability of staff. Culture

to support implementation

Ongoing

monitoring

074

Ope

ratio

ns

Joan

ne M

arshall

Fully utilise the ESR system to support the

organisations strategic aims and objective

including implementation of integrate NCRS

Demerge / Merge EventDuplication nof effort, efficiencies

not achieved 45 20 ESR Action Plan

Achievement of

milestones in action

plan

Financial support in place,

capacity of teams

Ongoing

monitoring

075

Ope

ratio

ns

Joan

ne M

arshall

To support the wider organisation in its

achievement of the organisations corporate

strategic objectives including CIP's.

Insufficient capability and capacity

Service disruption; Reputational ‐

potential closures damage

reputation, staff morale

45 20Workforce Reports and

Assurance EMT Governance

ESR Staff in Post

reports to Managers





Strategy. Quality

report and

performance reports

Work programme in place Ongoing

monitoring

10


076

Ope

ratio

ns

Joan

ne M

arshall

To develop and implement robust

integration plans in line with

Transformation and Integration

Programme.

Insufficient capability and capacity in

economic climate

Service disruption; Reputational ‐

potential closures damage

reputation, staff morale

49 35

Transformation Plans and

Programme , Organisational

Change Policy and HR

Framework

ESR Staff in Post

reports to Managers





Strategy. Quality

report and

performance reports

Managers adhering to policy

and robust engagement

strategy. Develop on new

Organisational Change

policy.

31.03.2012

077

Ope

ratio

ns

Joan

ne M

arshall

Define and communicate standards for

usage of temporary staff (bank, agency and

locums)


, capability and capacity , managers

following policy

Reputational ‐ damaged reputation,

quality and service provision issues

84 49

Temporary staffing policy, ESR

reports, action plan including

individual monthly meeting with

Network Director

Workforce reports to

Board. ESR data

reports feedback /

evaluations from

customers 31.03.2012

078

Ope

ratio

ns

Joan

ne M

arshall

Define, develop and communicate robust

stakeholder engagement processes and

standards


, capability and capacity

Reputation ‐ Loss of stakeholder

confidence

56 40

Stakeholder mapping,

reputation strategy. Complaints

& compliments. Press usage

reports. Quality reports

Press reports

complaints number of

survey's, COG

31.03.2013

079

Strategy

Mark Hindle

Oversee the integration, formation and re‐

structuring of all networks

Consultation processes prevent alignment

of management structures in a timely

manner

Financial ‐ CIPS and achievement of

targets not achieved ; Reputational ‐

loss of Stakeholder confidence;

Board ‐ confidence

63 42

Consultation Document,

Conversation with the Network

Directors, commitment to

timescales, agreement with

Exec colleagues , conversation

with staff side, budgetary sign

off

Organisational Change

Policy, CIP, Reporting

to the CIP Group and

agreement of group

Non‐compliance to agreed

process, Transformation

Director not in post.

Earned autonomy and

relationship management

31.01.2012

080

Strategy

Mark Hindle



Implications of Ability to understand service

capacity and demand and co‐ordinate

workforce to benchmark costs

Financial ‐ loss of income , Patient

Experience ‐

81 63

SLM, Ref costs, Entrusted Health

data, Transition plan for

inpatient reconfiguration,

workforce plan

Performance reviews

with ND's, objective

setting, workforce

planning, inpatient

transition board,

evidence based

benchmarked data to

plan

We haven't got the

Transformation Director,

haven't undertaken

systematic demand and

systems and information,

evidence based decision

making, haven't got capacity

in place in some areas,

consultation with staff.

Utilising data to develop

implementation plans.

31.01.2012

081

Strategy

Mark Hindle



Organisational ability to manage transition

in a period of cultural change


targets not achieved ; Reputational ‐loss of Stakeholder confidence;

Board ‐ confidence Regulatory

compliance CQC, Contracts, Clinical

Commissioning Grups CQUIN

64 36

Identification of key transitional

areas, Management

Organisational change policy ,

Appreciative Leadership , Team

Programme, Team to Team with

key stakeholders , The

information Centre ‐

Performance data,

Board reporting,

Monitor Returns, CQC,

registration, Delivery

of organisational

change in place.

Management

restructures

completed

Director of Transformation

not in Post, Capacity, Full

overarching plan, Master

Control Plans around all key

transitions capability in

some areas. EAM not fully

embedded Some key

strategies/work programmes

are work in progress

commercial experience not

fully in place Implications of

PBR Evidenced based

evaluation of what has been

achieved

31.01.2012

11


082

Strategy

Mark Hindle



Limited organisational ability to maintain

the quality of service delivery whilst

undergoing significant organisational

change

Services do not meet user needs.

Capacity does not broadly meet

demand Reputation of organisation

compromised IP build programme

compromised

72 64

Transition Plan, Transitional

plan EAM Programme,

Appreciative Leadership

Integrated SUI monitoring

Business continuity Planning in

place and tested Engage event

Network engage event Team

Brief Evidence produced for

Lancashire and locality service

Transformation group Staff

survey

Conversation with Key

reports, Service visits,

Board reporting,

Monitor Returns, CQC,

registration, Contract

negotiations Contracts

Performance wall CE

challenge Business

Planning process

underway and agreed

Commissioning system in

period of considerable

transition GP (clinical

commissioning consortia)

fragmented and immature

Multiple demands for

customised services balance

of economies of larger

organisation

Transformation Director not

in place. Fragmented

commissioning landscape

Implementation of

stakeholder management

strategy Not aware of who

new GP players are Threat

to existing service delivery

e.g. section 75 Management

capacity/alignment

31.01.2012

083

Mark Hindle

Identify key network transformation

priorities for the organisation

Management Capacity to design an

adequate system of transformation

Services do not modernise to deliver

commissioner intentions

and/patient needs. Failure to

deliver planned capacity and/or not

delivering financial targets

56 35

Transformation Director

resourced Business Change

forum established to exercise

gateway control IP transition

plan agreed and under

document control Management

capacity broadly aligned to

priorities Robust structure

Management

restructures

completed

Conversations and

objective

setting/measurement

with direct reports,

Progress against

agreed priorities,

Delivery of CIP plans


in place Overarching MCP

not complete Business

planning not complete.

Compliance not consistent

Capability Issues in some

areas. Key senior

management posts still not

filled or capability issues

Less experienced managers

dealing with difficult issues

Full engagement with clinical

colleagues to deliver

changes Sufficient evidence

based decision making (skills

or actual)

084

Mark Hindle

Identify, and monitor key network

transformation priorities for the

organisation

Robust data, appropriately benchmarked

and evidence based to support design of

system

Poor non evidenced decision

making, leading to poor service

quality and/or not focussing on the

areas that will deliver the biggest

cost, quality and activity benefits

72 56

Reference cost analysis Board

reporting of ref costs and plans

to address. Agreement on SLM.

Entrusted health analyse.

Work/review programme with

each network Aqua

benchmarking data

Reference cost data,

Papers and analysis

discussed at board CIP

sub group Network

meeting to discuss

variance and

subsequent planning

statistical process

management skills numerate

evidence based decision

making use of existing data

e.g. reference cost to drive

cost effective service

delivery, understanding of

where additional costs

compared to reference costs

deric=ve from, engagement

with commissioners to

accurately specify service

models, understanding of

implications of reducing to

reference e cost Insufficient

sophisticated targets and

measurement of leading

indicators Variable data

collections sources and

systems Variable assurance

that all activity is being

counted Other value added

activity variably measured

External benchmarking data

largely not available

benchmarking leading

indicator data not defined

12


085

Mark Hindle

Management Capacity and capability to

implement and monitor transformation

priorities


targets and prioritised evidence

based services not targeted Needed

service transformation not delivered

81 48

, Appreciative Leadership , Team

Programme, , The information

Centre ‐ Performance data,

Board reporting,

Management

restructures

completed

Conversation with

regarding service

delivery Transition

plan

Identification of key

transformation priorities,

Management skills

development plans

recruiting for capability and

competence Director of

Transformation not in Post,

Capacity, Full overarching

plan, Master Control Plans

around all key transitions

capability in some areas.

EAM not fully embedded

management by assurance

Evidenced based evaluation

of what has been achieved

086

Mark Hindle

Investigate Entrusted Health data and

benchmarking principles

Lack of co‐ordinated systems across 4

organisations

Activity is not counted and recorded

in consistent manner undermining

evidence based decision making

72 42

Reference costs alignment in

progress Entrusted health

analysis undertaken Resource

utilisation plan in place Dir.

Transition in place Board

reporting undertaken SLM

agreed

Reference cost

reporting Entrusted

health report CIP sub

group Conversations

regarding moving to

integrated system

leading indicators used

to influence activity

planning gateway

review process set up

electronic data recording

systems in community

systems variable care

pathways reporting low not

all activity counted

Reference costs narrow

aspect of benchmarking

timescale for system

integration. EAM not fully

embedded Some key

strategies/work programmes

are work in progress

commercial experience not

fully in place Implications of

PBR Analysis of capability

required and plans to

address Transformation

director not in place

business planning not in

place decision making

variably not evidence based

01/03/2012

087

Strategy

Mark Hindle

Define and deliver organisational targets

based on benchmarking principles

Lack of co‐ordinated systems across 4

organisations

CIPs not delivered in systematic

manner with minimal benefit for

improved quality and productivity

and reputation management

64 48

Reference cost RUP developed

from community services top

priorities identified CIP board

sub committee CIP reporting in

place Longer term planning

agreed

Reference cost

reporting Entrusted

health report CIP sub

group Conversations

with AND, CE

challenge, financial

reporting Network

business planning and

Information systems Work

programmes to project

manage programmes

Performance management

framework to measure

programmes CIP plans are

generally not eveidence

based i.e. do not focuss on

benchmarked opportunities

for improvement. Work

programmes not thoroughly

scoped Implications

unknown Targets generally

input absed and do not

relate to service quality

Internal quality targets not

fully developed

01/03/2012

13


088

Strategy

Mark Hindle

Develop external relationships focussed on

robust engagement to inform and support

organisational transformation

Organisational capacity to implement the

Stakeholder Strategy

Reputation damage, loss of service

provision Loss of income

63 40

GP charter inmpelemtaion plans

Reputation management board

appt of Director of

Transformation Stakeholder

map Stakeholder management

committee

Coomission

conversations.,

Locality and

lancashoire level

service redesign

groups Mgt

restructures focussed

at delivering efficency

effectivenss and

stakehoolder

intentions

Relationship management

plan with identified clear

leadership Operational

management structure

refocused and reskilled to

manage external world

Multiple stakeholder

management media in place


in place C. Roles not fully

worked through linked top

formal governance

procedure Unknown key

stakeholders at ,moment

particularly around clinical

commissioning groups

Organisational expertise

Styakeholder map not

allocated systematically

Transformation programme

responding external world

sufficiently

01/03/2012

089

Mark Hindle




Limited robust formalised partnership &

contracting arrangements particularly in

changing of clinical commissioning groups

Failure to realise benefits of new

organisation to drive through

commercial and transformational

opportunities

Stakeholder management

analysis undertaken Links at

executive level made with

emerging consortia Contract

mgt and business planning

Comms Service reviews

identoified and underweay and

reporting back Lancashire and

locality for a esatblished with

CCG reperesenation

Team to team events

Stakeholder mapping

Rethink open to new

ways Appreciative

leadership programme

Change/inconsistent

approach to

contracting/service delivery.

Development of Roles

required, linked top formal

governance procedure

Unknown key stakeholders

at moment particularly

around clinical



Implication of Any Qualified

Provider Much

organisational

transformation aimed at

productivity not supported

by service user needs and

outcomes 01/03/2012

90

Mark Hindle




Discontinuity amongst commissioners and

stakeholders

Loss of income, residual services

higher risk lower profitability

49 35

Agreed transition Plan, Locality

and Lancashire Transformation

Groups in place Contracting

process in place underpinned by

service specifiactions


Programme

Reputation

management board

Capital project board

Conversations with key

stakeholders LTCC quip

planAppreciative


Determining flexible offer

within context of contract

Knowing what we don’t

know horizon scanning

dedicated resource to

manage this complexity We

don’t have variable

stakeholder engagement.

Roles not fully worked

through linked top formal

governance procedure

Unknown key stakeholders

at ,moment particularly

around clinical



analysis of key

organisational risk

01/03/2012

14


091

Mark Hindle

Improve outcomes for service users by

providing a wide range of community

services

Systematic Patient feedback on

services/outcomes that effectively

influence service delivery

services are not tailored based on

service user input to needs

56 49

Council of Governors

performance management

framework quality accounts

patient surveys Links with

patients representatives e.g.

Links service users attend board

reporting Patient survey

Network survey care planning

and care clustering External

assessment e.g. CQC Quality

accounts

Quality accounts

Clarity about Monitor

outcomes

measurement

framework

Consistent representation,

variable relationship with

links some inflexibility in the

organisation to respond to

patient needs and wants

Systematic evidence of how

this changes service delivery

True engagement acrss all

sectors with service users

and carers. Monitor

outcome measures still

under consultation forums

within LCFT to assess

outcome importance Role of

trust professional leads in

this area Minimal outcome

measure mnet in place.

Business plannning

Completting care clustering

and care pathwayanalysis

and using the care oathway

analysis to link to outcomes

agreeing intenal outcomes

for measurement

appointment of

transformations= director

092

Mark Hindle




Developing services to meet market needLoss of income, residual services

higher risk lower profitability

64 36

Director of Transition in post,

Transition Plan, Transitional

plan EAM Programme,


Programme

Reputation

management board

Capital project board

Director of Transition

plan implementation

and approval forum

EAM Appreciative


Determining flexible offer

within context of contract

Knowing what we don’t

know horizon scanning

dedicated resource to

manage this complexity.

Implications of Any Qualified

Provider. Roles not fully

worked through linked top

formal governance

procedure Unknown key

stakeholders at ,moment

particularly around clinical



01/03/2012

15

1

Risk Ref

AF B

usi

nes

s A

ctiv

ity

Principal Risk

Vulnerability Consequence Gross

cxl

Net

cxl

P

roxi

mit

y Controls

Co

ntr

ol

Ow

ner

Assurance Actions to close gaps and completion date

Priority 1 Strengthen organisational delivery and assurance systems to improve compliance, performance and quality against a comprehensive Trust scorecard

001

O

pera

tions

Executive capacity and capability to improve organisational deliver y, compliance and quality through large scale organisational and system change

Executive Capacity and capability to focus on the key issues to deliver transformational change due to the scope and pace of change

Workforce – overworked, stressed Executives; Regulatory – standards not maintained

6

7

6

6

ST

Organisational Planning System Workforce Plans Transformation Director Additional capacity provided by Finnemores , Performance Reviews, and appraisals Deputies in place Board review of its effectiveness

DT JM MH DT All

Board performance reports Quality of Board papers and robust Action Tracking through Board and Sub- Committees Chief Execs challenge

Scheme of Delegation Ability of Executive to delegate effectively Delegate to relevant skilled individuals /succession planning Revised Performance Reporting. Board Away days, Business Planning and objective setting, and appraisal. Appreciative Leadership programme and organisational change management restructures. Identify early wins to increase confidence Regular Monitoring – March 2012

Risk Ref

AF

Bu

sin

ess

Ac

tivi

ty

Principal Risk Vulnerability

C

on

seq

ue

nce

Gross

cxl

Net

cxl

P

roxi

mit

y Controls

Co

ntr

ol

Ow

ner

Assurance Actions to close gaps and completion date

2


002

G

over

nanc

e

Management and organisational capability to develop robust effective processes

The right skill mix of people - Senior management with responsibility do not have all of the necessary skills at this point to design effective systems and structures

Financial – inefficient delivery of objectives

8

8

6

6

ST

Robust assessment process including Psychometric assessment of senior managers Objective setting linked to priorities. Performance Management systems Chief Exec review of Management Structure Chief Execs challenge EAM rolled out through business planning

JM

All

All

HTM

HTM

All

Performance Dashboard, quarterly workforce reports Gateway review process 1:1’s and PDP’s Chief Exec annual report to the Remuneration Committee

Variability of IT systems, Standardised information counting, use of statistical analysis. numeracy skills , Board review of management structure on a regular basis On-going

3

003

Str

ateg

y Resource and enabling strategies not designed for and aligned to priorities Variable alignment of enabling strategies to improve quality, regulatory standards

Implementation of IMT Strategy does not provide supporting systems to ensure robust data capture

Financial – abortive costs, data not available, development of balanced scorecard delayed

9

6

5

6

ST

Business Change Forum and Gateway process Business planning process Board sign off of Business Cases

MH

Board approval of IMT Strategy and progress reports on Implementation Plan Post project evaluation to Board

Board approval of all relevant strategies in line with commissioned areas of work

4

Risk Ref AF

Bu

sin

ess

Act

ivit

y

Principal Risk

Vulnerability

C

on

seq

ue

nce

Gross

cxl

Net

cxl

Pro

xim

ity

Controls

Co

ntr

ol

Ow

ner

Assurance Action to close gaps and completion date


004

Ope

ratio

ns

Resources not aligned to Strategy in order to deliver quality and improved performance

Workforce Plans through transition do not deliver the required workforce at required cost Capital Programme is not affordable in line with resource available

Financial – increase spend on bank and agency

Abortive costs and wasted effort

9

6

5

6

ST

Workforce Plans in place Transformation plan; IMT and Estates Strategies.

JM

DT

Performance reports to the

Board

IMT Board review of implementation

plan.

Capital Programme

Board review of

Incomplete medium term business plans, high reference costs, Lack of PDSA tools Appointed Transformation Director, High reference costs prioritised in Transformation programme March 2012

5

R

isk

Re

f

Bu

sin

ess

Act

ivit

y Principal

Risk Vulnerability Consequence Gross

cxl Netcxl

Pro

xim

ity

Co

ntr

ols

C

on

tro

l O

wn

er Assurance

Gaps/ Action Plans and completion

date

Priority 1 - Strengthen organisational delivery and assurance systems to improve compliance, performance and quality against a comprehensive Trust scorecard

005

Ope

ratio

ns

Variability of robust data to enable evidence based forecasting and decision making

Poor data capture and lack of understanding of data requirements Non compliance

Poor non evidenced

decision making, leading to poor service quality

and/or not focussing on the

areas that will deliver the

biggest cost, quality and

activity benefits

8

10

6

6

ST

Clinical Record keeping Group

review of current

practice and performance

Activity

reporting and Quality

reporting. Financial Reporting

HR

Reporting

Estate monitoring system =

ERIC

Service Line Management

; AQUA benchmarkin

g data Networks

Work Programmes

MM

DT

JM

DT

MM

Monitor reporting

Reference cost data, reported to Board, CIP sub

group discussions : Network meetings to discuss variance and subsequent planning

Statistical process management skills, numerate evidenbased decisions making Procurement data not available. Development of the Intelligence Unit End of January 2012

6

Ris

k R

ef

Bu

sin

ess

Act

ivit

y Principal Risk Vulnerability Consequence

Gross cxl

Net cxl

Pro

xim

ity

Co

ntr

ols

Co

ntr

ol

Ow

ner

Assurance Gaps/ Action Plans

and completion date

007

S

trat

egy

Transformation plans are not aligned to resource utilisation over short, medium and long term planning e

Organisational capacity to ensure correct alignment of resources Availability of benchmarked data to inform plans Current business planning is short term focussed Current plans not aligned to priorities and not fully reflecting transitional issues

Financial – unforeseen costs in recruiting/ staff Efficiencies not delivered

6

7

6

6

MT

Appointment of Transformation Director, Business Change Forum; Management capacity aligned to priorities. Network Directors in post. .

MH

Transition Plan 100 days completed and agreed by Board. Business Transformation Agreement. Monitor Risk Rating.

ESR merge still outstanding.

Development of

Master System and Business Planning

process; realignment of service

transformation resource to support

delivery of key priorities

March 2012

7

Risk Ref

Bu

sin

ess

Act

ivit

y

Principal Risk

Vulnerability Consequence Gross cxl

Net cxl

Pro

xim

ity

Controls

Co

ntr

ol

Ow

ner

s Assurance Gaps/Action Plans and completion

date

Priority 2 - Deliver efficiency savings of 20% across the whole Trust income base over 5 years, achieving 5% in 2011/12.

008

O

pera

tions

Management capacity and capability to deliver the Transformation Programme

Transformation programme increases pressure on managers Availability of appropriate skills base and capacity to co-ordinate skills to deliver priorities

Financial – efficiency savings not achieved Priorities with programme not delivered

8

8

6

6

ST

Transition Plan

in place and approved by Networks.

MH

1:1s and objective

setting/measurement

Progress against agreed priorities,

Delivery of CIP plans

Priorities within

Transition Plan to inform Master Control

plan,

March 2012

009

G

over

nanc

e

Unforeseen or unmanageable cost pressures

Overall performance above reference costs for services

Target Financial

risk rating not achieved

8

9

8

5

ST

Early warning identification of potential issues to Board through Financial Management Systems.

DT

Oversight of CIP plans and variances by CIP Subgroup Monitor Financial Risk Rating

None identified

8

Risk Ref

Bu

sin

ess

Act

ivit

y

Principal Risk


Net cxl

Pro

xim

ity

Controls

Co

ntr

ol

Ow

ner

s Assurance Gaps, Actions and Completion date

Priority 3 Deliver the benefits of the integration of community services as set out in the business case

010

E

nviro

nmen

tal

Discontinuity of Commissioners

Changes in Commissioners with shifting commissioning intentions

Loss of income, commissioner dissatisfaction

10

8

10

4

MT

Relationship Management, Contract negotiation

DT

Financial Monitoring

Assurance Contract Monitoring System March 2012

011

Env

ironm

enta

l

Changes in policy effect income flows and continued integration of care pathways

Patient Choice and Any Qualified provider

Loss of income to

alternative providers

10

7

10

4

MT

Analysis of response to 8 AQP priorities. Contract discussion and risk assessment of 8AQP priorities.

MH

Financial

Monitoring

Assurance Contract Monitoring System March 2012

012

Ope

ratio

ns

Variability of robust benchmarked data to enable evidence based forecasting and decision making

Poor data capture and lack of understanding of requirements

Resources not aligned to delivery, efficiencies not delivered

9

5

9

3

ST

Data Improvement Plan. KPI’s audited.

DT

Data Quality Group

review of Data Improvement plan. PBR Focus group.

Monitor Risk Rating, CQC QRP

Capacity and demand analysis, benchmarking informally with similar organisations, June 2012

Risk Ref

Bu

sin

ess

Act

ivit

y

Principal Risk

Vulnerability Consequence Gross Net

Pro

xim

it

Controls

Co

ntr

ol

Ow

ner

s Assurance Gaps, Actions and Completion date

9

Priority 3 – Deliver the benefits of the integration of community services as set out in the business case

013

O

pera

tions

Inability to sustain a culture supporting organisational change,

Personal, professional resistance to aligned change through fear

Workforce – disengaged, delivery of priorities delayed

8

6

4

6

MT

Appreciative Leadership Programme, Modern Manager Programme, Engage Events, Team Brief, Objective setting process. Accountability CE Challenge

JM

HTM

Performance Management, Staff Surveys

Organisational span of

leadership programmes, over reliance on electronic communication, variable

systems to assess engagement,

Economic climate affecting morale

On-going leadership

Strategy and revised PDR linked value process.

Further work to embed values.

Post project initiative

evaluation on a systematic basis

March 2012

10

Bu

sin

ess

Ac

tivi

ty

Principal Risk


cxl

Net

cxl Pro

xim

ity

Controls

Co

ntr

ol

Ow

ner

Assurance Gaps, Actions and Completion date

Priority 4 Deliver service transformation and the associated capital programme as agreed with commissioners and within budget

014

O

pera

tions

Capabilities of Senior Management to implement the transformation programme

The right skill mix of people - Senior management with responsibility do not have all of the necessary skills at this point to design effective systems and structures

Transformation programme not

delivered; efficiencies not

delivered

8

8

6

6

ST

Transformation

Director, Business Gateway

Control process, Transition Plan

agreed,

Business Change Forum overseeing Gateway control

Identification of Transformation

Priorities Management skills development plans,

Full overarching Master Control Plan

not in place Transformation

Director in post to develop overarching

plans, Robust objective setting,

sound performance management.

On-going Monitoring

March 2012

11

Risk Ref

Bu

sin

ess

Act

ivit

y

Principal Risk


cxl

Net

cxl pro

xim

ity

Controls

Co

ntr

ol

Ow

ner

Assurance Gaps/ Actions and Completion date


015

O

pera

tions

Workforce plans not aligned to Commissioner intentions

Financial – additional

workforce spend required to meet service delivery

7

8

7

5

MT

Agreed workforce plan for In patient build

JM

Board sign off of In-patient build business case

Wider alignment not in place,

understanding of capacity and demand

at service level, to enable workforce planning to deliver services, Inflexible

highly paid workforce (n’s terms and

conditions)

Inability to move to more flexible

mechanisms such as social enterprise

Ability to evaluate

transformation programmes such as

shift system whilst delivering services.

Business Planning process underway,

Capacity and demand analysis in line with business

plans.

March 2012

12

Risk Ref

Bu

sin

ess

Act

ivit

y

Principal Risk


cxl

Net cxl

pro

xim

ity

Controls

Co

ntr

ol

Ow

ner

Assurance Gaps/ Actions and Completion date


016

O

pera

tions

Ability to design and deliver services to meet demand and deliver the contractual service specification

Block contract requires delivery of services despite activity levels

Loss of business, disruption patient pathways Reputational damage

9

9

4

9

MT

Relationship management

with Commissioner

Contract

negotiations process.

Business and service planning

effective partnerships to deliver services e.g. Sections 75

agreements

Innovation Strategy and

R&D Programme

MH

DT

MM

Gateway Process overseen by

Business change forum, Innovation Group reports to

Network

Solid relationships with OSC, GP

Commissioning Groups, Lancashire and Locality level,

Service Line Management

User engagement

and influence

Appoint Clinical Directors and GP

advisors

March 2012

017

O

pera

tions

Organisational structures and systems not aligned to implications of activity based costing systems (PBR)

Lack of effective engagement of clinicians in clustering of patients

Financial – loss of business

7

5

7

3

LT

PBR clustering tool and policy,

Service Line Management/Re

porting Reference Costs and

limited benchmarking

DT

MM

MH

Progress reports

reporting progress against standard (100% by Dec)

Reference costs overseen by CIP

Subgroup and Board

All services on block contract, high reference costs, lack of sophisticated, HR Group type information, PBR clustering, Care Pathways, Managing Service against reference cost and delivery, business planning process March 2012

13

Risk Ref

Bu

sin

ess

Ac

tivi

ty

Principal Risk


Net cxl

pro

xim

ity

Controls

Co

ntr

ol

Ow

ner

Assurance

Gaps/ Actions and Completion

date

Priority 5 - Engage positively and effectively with patients, service users, carers, staff, partners and commissioners.

018

R

eput

atio

n

Variable implementation of engagement strategies in a complex, changing environment

Inconsistent communication by managers. Engagement is not consistent with patients/services users and carers across all services. Clinical Commission groups in transition

Reputational – loss of stakeholder confidence,

9

7

8

5

Engage events Team brief Community Service reviews identified and underway Stakeholder management analysis undertaken. Execs Links with emerging consortia. Contract mgt and business planning process.

JM

MH

JM

DT

Appreciative leadership programme

Board to Board/Team to

Team events. Stakeholder mapping

Reporting from

Lancashire and locality clinical Commissioning

Groups

Board to boards with associated improvement plans Determine key partnerships and provide focus of execs around this

15

Risk Ref

Bu

sin

ess

Ac

tivi

ty

Principal Risk


cxl

Net

cxl

Pro

xim

ity Controls

Co

ntr

ol

Ow

ner

Assurance


date


020

Organisational capacity to deliver effective engagement across all stakeholders

Executive and senior managers capacity aligned to Stakeholder Engagement Strategy

Strategy not deliverable; reputational damage

8

8

6

6

ST

GP Charter and related Network Action plans Stakeholder Map and Engagement Strategy

MM JM

Oversight by Reputation Management Board of implementation of GP Charter and Stakeholder Engagement Strategy

Consultations on some

services e.g. Dementia, multiple scrutiny

committees with conflicting views. Cultural change linked to Community

Provider

Clinical Service Lines,

Refocus of Governance Committees on gaps in assurance

June 2012

16

Risk Ref

Bu

sin

ess

Act

ivit

y

Principal Risk


cxl

Net

cxl P

roxi

mit

y

Controls

Co

ntr

ol

Ow

ner


date


021

Shifts in external environment dictate changes in key stakeholders

Multiple locally based commissioners Loss of business due to fragmentation of care pathways

Loss of business; reputational damage

Stakeholder Map, GP Charter and related Network Action plans

JM MM MH

Oversight by Reputation Management Board of implementation of GP Charter and Stakeholder Engagement Strategy

GP consortia for Lancashire

not agreed, Transition to Lancashire cluster is

challenging, Potential

variability of care pathways with multiple

clinical consortia,

implications of changes to social care and formal.

Informal partnerships

Regular

monitoring and response

plans

March 2012

17

Risk Ref

Bu

sin

ess

Act

ivit

y

Principal Risk


cxl

Net cxl

Controls

Assurance


date


022

Limited robust formalised partnership and contracting arrangements particularly in changing commissioning groups

Financial – changes

in commissioning requirements require

further spend

9

7

4

7

Contract Negotiation Team, and

meetings, GP Charter,

Same controls as

commissioner risk

Financial Report Systems

Contract

management

End of March 2012

18

Risk Ref

Bu

sin

ess

Act

ivit

y

Principal Risk


Netcxl

Pro

xim

ity

Controls

Co

ntr

ol

Ow

ner

Assurance Gaps/Actions

and Completion

date

023

C

linic

al C

are

Systematic patient feedback on services and outcomes that effectively influence service delivery

Feedback is not currently consistent across all services

Patient Experience – service improvements not established, services not developed on service user needs

8

7

7

7

MT

Community

Service reviews,

Patient

Expérience Programme,

Expert Patient Groups,

MH

PS

Complaints/

Compliments quarterly reports to the Board,

National Patient Survey,

Consultations

on some services e.g. Dementia, multiple scrutiny

committees with conflicting views. Cultural change linked to Community Provider vs.

Mental Health Provider

Increased

involvement in recruitment, Involvement

across all step models,

June 2012

agenda item: tb 195/11 subject: assurance framework report board/trust board documents... · agenda...

Documents