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Royal National Orthopaedic Hospital Trust (RNOH) BGM Submission Document [Insert date of BGM submission] [Insert planned date to enter DH process as per TFA]

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Contents

Page Board context 45 Summary results 47

1. Board composition & commitment 50 2. Board evaluation, development & learning 54

3. Board insight and foresight 59

4. Board engagement and involvement 64 5. Board impact case studies 69

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Board context

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Board context

This section should set the overall context for the Trust and should include a brief overview of the Trust, together with a summary of the Board’s key strategic objectives and how the Trust is performing against them. This overview links into section 3.3 of the Board Memorandum under good practice point 5 which covers the Board’s strategic focus. It provides the Board with an opportunity to summarise what is important to the organisation, how it performs against KPIs and what patients think of the services provided. In this section please provide a brief overview of:

1. Your organisation in terms of income, staff and key services provided; 2. Your organisation’s key strategic objectives; 3. Summary of the KPIs the Board uses to track performance against these objectives and how it is currently performing; 4. Summary of the Trust position with regards patient feedback

The Trust has 1200 staff with a £110m turnover. £1m surplus achieved in 2011/12 and has agreed a target of £2.3m at the end of 2012/13. RNOH is the largest specialist orthopaedic hospital in the UK and is regarded as a leader in the field of orthopaedics. The Trust provides a comprehensive and unique range of neuro-musculoskeletal healthcare, ranging from acute spinal injuries to orthopaedic medicine and specialist rehabilitation for chronic back pain sufferers. Patient Feedback at the RNOH includes; Patient ‘Real-time’ feedback, RNOH Patient Group visits to the patient areas, patient involvement in the Trust’s PFI project through user groups

RNOH 2012/13 Corporate Objectives: Principal Objective One - Licence to Operate (A)Maintain clinical excellence; Improve patient care by reducing avoidable infections and providing a clean, safe environment; Provide efficient, safe and effective care, improving patient experience and clinical productivity; B) Consistently achieve patient access national standards; C) Achieve financial targets and deliver transformation programme; D) Improve workforce effectiveness and engagement – fit for purpose. Principal Objective Two – Organisational Capability A) Improve the quality of our buildings and facilities B) Provide timely, accurate and comprehensive clinical management information; C) Improve the planning process to better integrate service provision, research and education.

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RNOH 2012/13 Corporate Objectives: Principal Objective Three – Strategic Development A) Deliver planned in-year service developments and transformation programme targets; B) Maintain and update an Integrated Business Plan including 10 year clinical service, finance and estates plan securing the redevelopment of the Stanmore site; C) Further develop the academic track record by delivering research and education developments in line with the Joint Academic Plan agreed with UCL; D) Further develop relationships and partnerships. E) Meeting Foundation Trust milestones for the year

The Trust’s 2012/2013 Key Performance Indicators (K PIs): Zero MRSA – green status Zero pressure ulcers – green status Zero clostridium difficile – red status Zero inpatient surgical site infections – green status Drug errors – red status VTE assessments (>=95%) – red status, Zero DVTs and PEs – red status Never events – green status Dementia screening in over 75s – monitoring this target has not started as waiting for guidance from DoH regarding the national screening questions. 95th percentile admitted < 18 weeks – red status 95th percentile non-admitted <18.3 weeks – green status Incomplete pathways – no more than 92% waiting more than 18 weeks – green status Cancer two week wait (93%) – greens status Cancer 31 day first treatment (96%) – red status Cancer 31 day subsequent treatment (94%) – red status Cancer 62 day standard treatment (85%) – green status Cancer staging (90% new patients with stage of tumour at time of diagnosis accurately recorded) - The collection of the data has been delayed whilst the details concerning collection are agreed with commissioners. Financial surplus target (£2.3m) – red status Appraisal rates (90%) – red status Cancelled operations (reduction in number for clinical or non-clinical reasons) – red status

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Summary results

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Summary results Overview of BGM sections 1 to 3 inclusive

1. Board composition and commitment

Ref Area Self-Assessment rating Any additional notes 1.1 Board positions and size Green

1.2 Balance and calibre of Board members Green

1.3 Board member commitment Green

2. Board evaluation, development and learning

2.1 Effective Board-level evaluation Amber - Red Independent evaluation of effectiveness undertaken in 2008. Plans for independent evaluation in 2012/13.

2.2 Whole Board development programme Amber - Green Board development programme in place. Partially aligned to FT.

2.3 Board induction, succession and contingency planning

Amber - Green Succession plans in development. Documented induction process under development.

2.4 Board member appraisal and personal development

Amber - Red Appraisal process recently refreshed to align with FT requirements. Board contribution review underway.

3. Board insight and foresight

3.1 Board performance reporting Amber - Green

3.2 Efficiency and Productivity Amber - Green Robust process for MD, DoN, DoO to sign off CIP/Transformation savings do

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not compromise patient safety recently developed. Need to include post-risk assessment.

3.3 Environmental and strategic focus Amber - Green IBP SWOT/PESTELI needs to be completed.

3.4 Quality of Board papers and timeliness of information

Amber - Red Data Quality requirement needs to be actioned

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Summary results Overview of BGM sections 4 to 5 inclusive

4. Board engagement and involvement Ref Area Self-Assessment rating Any additional notes 4.1 External stakeholders Amber - Red

All sections in 4.1 need to be addressed

4.2 Internal stakeholders Amber - Green

Revised values to be embedded in organisation. Strategic direction needs to be communicated to organisation.

4.3 Board profile and visibility Amber - Green

Attendance at high profile needed.

4.4 Future engagement with FT Governors Red

Membership Strategy in place. No membership engagement strategy.

5. Board impact case studies Key points to highlight 5.1 Performance issues in the areas of quality

5.2 Performance issues in the areas of finance

5.3 Organisational culture change

5.4 Organisational strategy

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1. Board composition and commitment

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1. Board composition and commitment 1.1 Board positions and size

Evidence of compliance with good practice (Please reference any supporting documentation below and attach with your submission)

Action Plans to achieve good practice (Please reference Actions Plans below and attach with your submission)

Explanation if not complying with good practice

Grant Thornton review (2009) Board minutes SID job description Board minutes Letters of Authority from relevant NEDs Board members’ biographies Board Structure Register of Interests

Foundation Trust Secretary FT Secretary to be in place 6 to 9 months prior to Authorisation.

Red Flags Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)

Notes/ comments

Section RAG rating: Green

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1. Board composition and commitment 1.2 Balance and calibre of Board members

Evidence of compliance with good practice (Please reference any supporting documentation below and attach with your submission)

Action Plans to achieve good practice (Please reference Actions Plans below and attach with your submission)

Explanation if not complying with good practice

NEDs’ Biographies Board members’ biographies Board structure NED role description Board members’ self assessment questionnaire North London Cancer Network Annual Report

Succession plan required CEO and Lead FT Director to develop succession plan

Red Flags Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)

Notes/ comments

Section RAG rating: Green

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1. Board composition and commitment 1.3 Board member commitment

Evidence of compliance with good practice (Please reference any supporting documentation below and attach with your submission)

Action Plans to achieve good practice (Please reference Actions Plans below and attach with your submission)

Explanation if not complying with good practice

Attendance record for Board meetings and sub-committee meetings NED representation at sub-Committee meetings Board Development session content table Code of Conduct for all Board members Board members’ induction programme RNOH Annual Report 2010-11, 2011-12

Red Flags Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)

Notes/ comments

Section RAG rating: Green

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2. Board evaluation, development and learning

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Board evaluation, development and learning 2.1 Effective Board level evaluation

Evidence of compliance with good practice (Please reference any supporting documentation below and attach with your submission)

Action Plans to achieve good practice (Please reference Actions Plans below and attach with your submission)

Explanation if not complying with good practice

Trust Board and sub-committee effectiveness The Board Scheme of Delegation/Reservation of Powers 2012

Trust Board and sub-committee effectiveness In progress and will conclude October 2012

Red Flags Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)

Notes/ comments

Independent evaluation of the Trust Board Independent evaluation, various evaluation methods Independent evaluation, hard and soft dimensions of effectiveness

Independent evaluation of the Trust Board to be arr anged during mid-2012/13. Specification for the evaluati on will be comprehensive and will address sections 2.1 and 2.2 requirements

Section RAG rating: Amber-Red

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Board evaluation, development and learning 2.2 Whole Board Development Programme

Evidence of compliance with good practice (Please reference any supporting documentation below and attach with your submission)

Action Plans to achieve good practice (Please reference Actions Plans below and attach with your submission)

Explanation if not complying with good practice

Board Development session work plan Board Development session topics plan Board Development session notes

Red Flags Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)

Notes/ comments

Board Development plan to be refreshed to include developmental needs identified through Board members’ self assessment

Section RAG rating: Amber-Green

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Board evaluation, development and learning 2.3 Board induction, succession and contingency planning

Evidence of compliance with good practice (Please reference any supporting documentation below and attach with your submission)

Action Plans to achieve good practice (Please reference Actions Plans below and attach with your submission)

Explanation if not complying with good practice

Trust Board meeting minutes Letter of Authority from relevant NEDs re: staggered appointment/resignation

Red Flags Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)

Notes/ comments

Induction for Executive and Non-Executive Directors Timeliness of Induction Succession plans

Induction undertaken but a robust document process required and include evidence of timeliness. EDs to work with NED partner to confirm/sign off induction proc ess completed CEO and Lead FT Director to develop succession plan

Section RAG rating: Amber-Green

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Board composition and commitment 2.4 Board member appraisal and personal development

Evidence of compliance with good practice (Please reference any supporting documentation below and attach with your submission)

Action Plans to achieve good practice (Please reference Actions Plans below and attach with your submission)

Explanation if not complying with good practice

Board members’ appraisal Trust Board meeting minutes

Robust performance appraisal process recently put in place

Red Flags Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)

Notes/ comments

Board members’ appraisal Consider involvement of Governors in the Chair and NED appraisal process once Trust becomes an FT

Robust performance appraisal process recently put in place SID to appraise Chair Development of Executive Directors as Corporate Directors Documented record of attendance at training events and conferences required

Section RAG rating: Amber-Red

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3. Board insight and foresight

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Board insight and foresight 3.1 Board Performance Reporting

Evidence of compliance with good practice (Please reference any supporting documentation below and attach with your submission)

Action Plans to achieve good practice (Please reference Actions Plans below and attach with your submission)

Explanation if not complying with good practice

2012-13 Key Performance Indicators agreed by Trust Board Update from the Performance Committee - integrated Performance Report/Executive Summary Trust Board meeting agendas Trust Board meeting minutes Reports from the formal sub-committees of the Trust Board Trust Board meeting matters arising report Update from the Performance Committee Update from the Service Transformation Committee Executive Summary Trust Board formal sub-committee structure

Red Flags Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)

Notes/ comments

Section RAG rating: Amber - Green

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Board insight and foresight 3.2 Efficiency and Productivity

Evidence of compliance with good practice (Please reference any supporting documentation below and attach with your submission)

Action Plans to achieve good practice (Please reference Actions Plans below and attach with your submission)

Explanation if not complying with good practice

Trust Board meeting minutes Update from the Performance Committee – Integrated Performance Report/Executive Summary Update from the Service Transformation Committee CIP/Transformation assessment of risks to care quality Trust Board formal sub-committee structure Transformation Project and CIP Governance Form

Red Flags Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)

Notes/ comments

CIP/Transformation assessment of risks to care quality – monitoring the ongoing risks

Process for monitoring and post implementation revi ew of transformation projects/CIPs in term of quality ass urance in progress

Section RAG rating: Amber-Green

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Board insight and foresight 3.3 Environmental and strategic focus

Evidence of compliance with good practice (Please reference any supporting documentation below and attach with your submission)

Action Plans to achieve good practice (Please refe rence Actions Plans below and attach with your submission)

Explanation if not complying with good practice

Chief Executive’s report to the Trust Board Trust Board meeting minutes Board Development session topic schedule Trust Strategic Objectives 2012-13 Key Performance Indicators 2012/13 Update from the Performance Committee – Integrated Performance Report/Executive Summary Airedale report to the Trust Board Ombudsman Six Lives report to the Trust Board Mid-Staffordshire report to the Trust Board Calendar of Trust Board agenda items Trust Board formal sub-committee structure

Red Flags Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)

Notes/ comments

SWOT/PESTELI External stakeholder mapping exercise Strategic risks actively monitored through Board Assurance Framework

SWOT/PESTELI required

Section RAG rating: Amber - Green

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Board insight and foresight 3.4 Quality of Boards papers and timeliness of information

Evidence of compliance with good practice (Please reference any supporting documentation below and attach with your submission)

Action Plans to achieve good practice (Please reference Actions Plans below and attach with your submission)

Explanation if not complying with good practice

Timetable for sending out Trust Board meeting papers Executive Summary Business Case template INSIGHT

Red Flags Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)

Notes/ comments

Regular Data Quality updates Exploration of underlying data quality of performance metrics that have been rag rated green In month flash reports not available to NEDs

Process whereby regular data quality updates are presented to the Trust Board Access to in month flash reports to be developed fo r NEDs

Section RAG rating: Amber - Red

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4. Board engagement and involvement

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Board engagement and involvement 4.1 External Stakeholders

Evidence of compliance with good practice(Please reference any supporting documentation below and attach with your submission)

Action Plans to achieve good practice (Please reference Actions Plans below and attach with your submission)

Explanation if not complying with good practice

Patient survey report Letter of support from North Central London re: OBC Addendum Organisation structures Trust Board meeting minutes

Red Flags Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)

Notes/ comments

External Stakeholder Engagement Plan Clinical Commissioning Group Strategy Involvement in development of IBP and LTFM

Section RAG rating: Amber - Red

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Board engagement and involvement 4.2 Internal Stakeholders

Evidence of compliance with good practice (Please reference any supporting documentation below and attach with your submission)

Action Plans to achieve good practice (Please reference Actions Plans below and attach with your submission)

Explanation if not complying with good practice

Team Brief 2011 Staff Survey results Timetable of Directors’ Open Forum Timetable of Chief Executive lunches Say So scheme EDs patient safety walk about Senior Manager meetings EDs back to the floor NED night visits Annual Staff Achievement Awards Clinical Excellence Awards Articulate Executive Director meetings Clinically led business planning Redevelopment Programme Board meeting minutes Clinical Working Group meeting notes Communications Strategy Organisational values Dignity at Work Policy

Section RAG rating: Amber - Green

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Red Flags Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)

Notes/ comments

Major risks cascaded to staff Staff engagement in 5 year strategy/IBP Staff understand key priorities

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Board engagement and involvement 4.3 Board profile and visibility

Evidence of compliance with good practice (Please reference any supporting documentation below and attach with your submission)

Action Plans to achieve good practice (Please reference Actions Plans below and attach with your submission)

Explanation if not complying with good practice

Trust Board meeting minutes RNOH website – Board papers publically accessible

Red Flags Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)

Notes/ comments

Structured programme of events/meetings that enable NEDs to engage with staff, patients, external stakeholders Summary reports from private part of the Trust Board meetings

Board members’ to notify Lead FT Director of attend ance at events/meetings for documentation

Section RAG rating: Amber - Green

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Board composition and commitment 4.4 Future engagement with FT Governors

Evidence of compliance with good practice (Please reference any supporting documentation below and attach with your submission)

Action Plans to achieve good practice (Please reference Actions Plans below and attach with your submission)

Explanation if not complyin g with good practice

Constitution (June 2012) Membership Strategy (June 2012) Governor Election process (June 2012)

Red Flags Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)

Notes/ comments

Council of Governors Development Plan Membership Engagement Strategy Statement on the roles and responsibilities of the Council of Governors

Section RAG rating: Red

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5. Board impact case studies

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5. Board impact case studies 5.1 Case Study 1

Performance Issues in the area of quality

Title: Pathology bone infection development

Brief description of issue

Outline Board’s understanding of the issue and how it arrived at this

Outline the challenge / scrutiny process involved

Outline how the issue was resolved

Summarise the key learning points

Summarise the key improvements made to the Trust’s governance arrangements directly as a result of the above

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5. Board impact case studies 5.2 Case Study 2 Performance issues in the area of finance

Title: Billing Error 2011/12

Brief description of issue

Outline Board’s understanding of the issue and how it arrived at this

Outline the challenge / scrutiny process involved

Outline how the issue was resolved

Summarise the key learning points

Summarise the key improvements made to the Trust’s governance arrangements directly as a result of the above

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5. Board impact case studies 5.3 Case Study 3

Organisational culture change Title: Pharmacy Department

Brief description of area of focus

Outline reasons / rationale for why the Board wanted to focus on this area

Outline the Board was assured that the plan/(s) in place were robust and realistic

Outline the assurances received by the Board that the plan/(s) were implemented and delivered the desired changes in culture

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5. Board impact case studies 5.4 Case Study 4 Organisational strategy Title: Private Patient partnership working and/or PFI affo rdability

Brief description of area of focus

Outline reasons / rationale for why the Board wanted to focus on this area

Outline the Board was assured that the plan/(s) in place were robust and realistic

Outline the assurances received by the Board that the plan/(s) were implemented and delivered the desired changes in culture

Specifically explain how the NEDs were involved

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