Upload
nhs-kirklees
View
216
Download
0
Tags:
Embed Size (px)
DESCRIPTION
http://www.kirklees.nhs.uk/fileadmin/documents/meetings/8_May_2012/CKWCB.12.116e__Cluster_Board_Assurance_Framework.pdf
Citation preview
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
1
MAY 2012
1 Strategic Objective Board Reports
Continuously improve the quality of commissioned health services (Effectiveness, Safety and Experience) Executive Director Lead; Sue Cannon Executive Director for Quality and Governance
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
1.1) Implementation of cost improvement programmes has an adverse impact on the quality of services and patient safety. Risk Owner: Sue Cannon Risk Manager (s) Julie Lawreniuk Carol McKenna Gill Galdins
Amber All Cost Improvement Schemes to be reviewed for quality impact by Medical Directors and Directors of Nursing. Scrutiny and review of service specifications, delegated responsibility through terms of reference to CCEs. Scrutiny and review through Clinical Quality / Contract Management Boards Scrutiny and review through Transformation / QIPP governance
Transition report to Board Quality reports to CCEs and Quality Boards Audit and Governance Group report through CCE Governance Committee oversight of quality reporting CCGs initial SHA rating Internal audit of governance arrangements CCG authorisation process Participation in Board to Board reviews.
Significant (GIC)
Key controls are not fully embedded across all CCGs
(GIA)
Reasonable
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
2
1 Strategic Objective Board Reports
Continuously improve the quality of commissioned health services (Effectiveness, Safety and Experience) Executive Director Lead; Sue Cannon Executive Director for Quality and Governance
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
1.2) Patients are not receiving the expected standards of care through providers not adhering to the standards set by commissioners. Risk Owner: Sue Cannon Risk Manager (s) Julie Lawreniuk Carol McKenna Gill Galdins
Amber
Triangulation of Quality information from a range of services such as
- Incidents - PALS - Complaints - CQC QRPs - Patient feedback - National / regional
reviews/ audit - CQUINS
Policies & procedures to support such as risk management, whistle-blowing and safeguarding Quality governance arrangements in place
- Board - Governance committee - CCEs/Quality Groups - Contract Quality Boards
Quality Dashboard report and exceptions to Quality Group and CCE’s Board Quality reports Governance Committee scrutiny Internal audit review of governance arrangements
Significant (GIC) Key controls are not fully embedded across all CCGs (GIA) Internal audit not yet undertaken.
CQC Inspection reports Safeguarding reports
CQC – Quarterly risk profiles
Reasonable
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
3
1 Strategic Objective Board Reports
Continuously improve the quality of commissioned health services (Effectiveness, Safety and Experience) Executive Director Lead; Sue Cannon Executive Director for Quality and Governance
Principal Risks Risk Owner
RRisk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
1. 3) Constituent PCT controls become ineffective during a transition period e.g. safeguarding, performance management of serious incidents, handling patient complaints, disseminating safety alerts, etc. Risk Owner: Sue Cannon Risk Manager (s) Julie Lawreniuk Carol McKenna Gill Galdins
Amber Incident management system in place. Safety alert process. Documented policies and procedures in place to support such as safeguarding, serious incidents, risk management and triangulation. Continue to review and monitor these. Quality governance arrangements in place
- Board - Governance committee - CCEs/Quality Groups - Contract Quality Boards - LSCB & LSAB
CCG Leadership in place Annual work plan for key safety priorities
Quality reports to CCE & CQBs on key performance indicators and escalation Board Quality reports Annual review and self assessment of governance arrangements
Significant (GIC) Key controls are not fully embedded across all CCGs (GIA)
CQC Inspection reports
Reasonable
Internal audit and risk management report - Calderdale
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
4
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
5
1 Strategic Objective Board Reports
Continuously improve the quality of commissioned health services (Effectiveness, Safety and Experience) Executive Director Lead; Sue Cannon Executive Director for Quality and Governance
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
1.4) Clinical Commissioning Groups are not prepared and supported to take on their future roles with respect to quality Risk Owner: Sue Cannon Risk Manager (s) Julie Lawreniuk Carol McKenna Gill Galdins
Amber
Quality CCG leadership identified OD plan in place for each CCG ; which incorporates three domains of Quality Delegation for responsibility for Quality CCG (PCT) via CCE Terms of Reference Quality Group established for each CCG GP leadership on Quality Boards
Regular reports to CCE on implementation of OD plan including Quality developments CCG Self assessment completed and participation in Board to Board reviews Transition report to Board
Significant (GIC) Quality Groups are not yet fully embedded in the governance structure (GIA) Internal audit not yet undertaken.
Internal audit plan includes Quality Plan
Reasonable
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
6
1 Strategic Objective Board Reports
Continuously improve the quality of commissioned health services (Effectiveness, Safety and Experience) Executive Director Lead; Sue Cannon Executive Director for Quality and Governance
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
1.5) During transition there is a deterioration in the patient experience of health services Risk Owner: Sue Cannon Risk Manager (s) Julie Lawreniuk Carol McKenna Gill Galdins
Amber
There is a variety of information received by the CCGs regarding patient experience this includes:-
- National patient survey - Real time feedback - Complaints - Feedback from Links - CQUINS
Delegation through terms of reference to CCE’s, including the establishment of the Quality Group. Scrutiny review through Clinical Quality Boards
Quality reporting to CCEs including key performance indicators and escalation Board Quality report Internal audit review of governance arrangements Dr Foster reports
Significant (GIC) Key control are not yet fully embedded across CCGs (GIA) Internal audit best practice guidance is not yet fully implemented.
Reasonable
Limited
Internal audit report Calderdale & Kirklees
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
7
2 Strategic Objective Board Reports
Sustain the Integrated Finance, Operations and Delivery System Executive Director Lead; Jonathan Molyneux Interim Executive Director of Finance and Efficiency
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
2.1) Fail to maintain financial control and service performance with constituent PCTs. Risk Owner: Jonathan Molyneux Risk Manager (s) PCT COO’s Julie Lawreniuk Carol Mckenna Gill Galdins PCT Finance leads Julie Lawreniuk Steve Brennan Kay Hughes
Red
Financial budgets, QIPP, activity and other key targets agreed for each PCT by the Board for 2012/13. Financial and performance reporting is included in the terms of reference of the Board, CCE’s and Finance and Performance Groups. Responsibility and accountability for financial and other performance targets is set out in individual directors Objectives. Annual Internal Audit Plan has been agreed by the Audit Committee to ensure an independent check that key controls and systems are in place. The financial results for the year are subject to review and by the External Auditors who report back to the Audit Committee.
Monthly reporting on the financial position, including QIPP, by PCT. These reports are reported to and reviewed at 1 Finance and Performance Groups 2 CCE’s 3 Executive Team meetings 4 Public Board Meetings (Bi monthly) 5 SHA level on behalf of the DH Annual audit of accounts
Significant GIC MYHT is reporting a deficit after taking into account Cluster support of £10M for 2012.13 including their internal savings programme of £24M of which only 60% identified to date (April 12). MYHT financial position may have a significant impact on the plans of both MYHT and the PCT for 2012/13. MYHT is not achieving a number of the key operational targets. Financial control not maintained at constituent PCT level GIA
The Cluster Chief Executive and Director of Finance are working closely with the Trust and the SHA to clarify the size of the challenge and develop plans to address the significant financial gap. These outline options should be available for internal review at the end of the first quarter 2012/13 The Board will continue to be kept informed on a regular basis. It is recognised that there will be a challenge for the relevant CCG’s managing this situation as the new Commissioning arrangements come into place.
Cluster DoF
End Q1 2012.13
Reasonable
Cluster Boards and CCG’s receive regular financial reports on MYHT
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
8
2 Strategic Objective Board Reports
Sustain the Integrated Finance, Operations and Delivery System Executive Director Lead; Jonathan Molyneux Interim Executive Director of Finance and Efficiency
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
2.2) Lack of effective systems in place to manage devolved budgets. Risk Owner: Jonathan Molyneux Risk Manager (s) Risk Owner: Jonathan Molyneux Risk Manager (s) PCT COO’s Julie Lawreniuk Carol McKenna Jo Webster PCT Finance leads Julie Lawreniuk Steve Brennan Kay Hughes
Amber
Scheme of delegation to CCG’s agreed at October and December 2011 Cluster Board meetings Budgets have been allocated to and reported on, at CCG level, in 2011/12 and specific budgets will allocated and formally agreed for 2012/13. Monitoring of financial performance by CCG’s will be part of the formal governance arrangements, including Finance and Performance groups and the CCE’s. The Cluster Director of Finance retains overall accountability for financial management during the transition period. The CCG structure includes an Accountable Officer and a Senior Financial Officer who will be accountable for the financial performance of the CCG including ensuring that all the financial targets are met. CCG OD plans include financial management and financial Governance
Finance report to the Board Performance against CCG budgets will be monitored by the Finance and Performance Groups on a monthly basis. The Cluster Director of Finance will ensure robust performance management processes are in place at CCG level and will retain an overview of performance across the cluster. Internal Audit reviews will be reported to the Audit Committee/s CCG authorisation process Self Assessment Board to Boards The annual internal audit plan will include the formal review of CCG financial management.
Significant Not fully implemented. GIC No chief finance officer for Wakefield Wakefield seen as a high level risk in terms of meeting its financial targets due to the gap and potential risk as the CCG has the lowest margin of financial flexibility and the most exposure to MYHT
There are revised management and governance arrangements in place that have been approved by the Cluster Board for managing financial and operational performance and ensuring that systems and processes are robust. These arrangements include monthly CCE’s and Finance and Performance groups where performance detailed reports are reviewed, under performance
identified and then followed up. Accountable Officers have been assigned in three of the four proposed CCGs Calderdale, Greater Huddersfield and Wakefield, the gap being in North Kirklees which is being addressed. Finance leads have been assigned, one person covering both Calderdale and Greater Huddersfield and one person covering North Kirklees. This leaves a gap in Wakefield.
End July 12
Reasonable
Monthly CCE’s and Finance and Performance groups
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
9
2 Strategic Objective Board Reports
Sustain the Integrated Finance, Operations and Delivery System Executive Director Lead; Jonathan Molyneux Interim Executive Director of Finance and Efficiency
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
2.3 QIPP challenge not met due to the lack of realistic QIPP plans from PCT / CCGs and /or poor monitoring and delivery of the agreed plan. Risk Owner: Jonathan Molyneux Risk Manager (s) PCT COO’s Julie Lawreniuk Carol McKenna Gill Galdins
Amber
3 Year QIPP plan has been submitted to SHA. Annual Operating Plans for 2012/13 included the QIPP plans – these were reviewed and agreed by the PCT Boards QIPP plans relating to healthcare contracts are built into annual SLA’s. Under the new Governance arrangements QIPP proposals and performance against approved schemes are reviewed monthly by the relevant CCE Finance and Performance Group. Contracts have been agreed within tight margins reducing the acute QIPP risk for 2012/13. If these are not achieved in 2012/13 then this will present a financial risk for the starting contract value for the following year
PCT QIPP Plans in place to 2014/15 Monthly finance reports detail main schemes and performance against these. Monthly SMT and Finance and Performance Group Monitoring of QIPP schemes. Quarterly DH/SHA monitoring. Board reporting CCE reporting
Significant (GIC) (GIA) Some shortfall in achievement of schemes during 2011/12. QIPP plans are being reviewed and developed for 2012/13 as part of the Business Planning process.
Performance has been reviewed Underachievement has been offset by allocation of contingency funding. Original plans for 2012/13 need to be refreshed in light of experience during 2011/12
CFO’s End of May 12
Reasonable
reported Monthly to and reviewed by the CCE’s and Finance and
Performance Groups
Cluster Senior Finance team for Financial and QIPP made up of
members from the 3 PCT’s that meet on a regular basis which gives a view
across the cluster
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
10
3 Strategic Objective Board Reports
Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls
Key Positive Assurance
(**External / Independent)
Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
3.1) Major transformational programmes are not delivered across the commissioning economy. Risk Owner: Mike Potts Risk Manager (s) Carol McKenna Matt Walsh Risk Owner: Mike Potts Risk Manager(s): Jo Webster
Amber
CHFT Programme Office being established with key performance indicator agreed and monitored for elements of the programme for Calderdale and Huddersfield Whole system Transformation Board. Clinical leadership at CCG fully committed MYHT Programme Office in place with key performance indicator agreed and monitored for elements of the programme .
QIPP tracker and oversight Mid Yorks HEFT Programme set up overseen by Programme Management Office, lead by Programme Director MY HEFT PMO review of relevant 12/13 QIPP schemes. MY HEFT PMO survey of CCGs’ potential commissioning intentions Review of MYHT CIPs by Ernst Young Analysis of outputs from above two activities by PMO
CHFT Supported By National Team for LTCS MYHT Reports to Cluster Board and Exec team MY HEFT update reports to MY HEFT Board and Cluster Board, regularly. Updates to MYHT Board QIPP outcome report sent to HEFT Executive group, Cluster CE, Cluster DoF, Wakefield District and Kirklees COOs, MYHT DoF and Dir Strategy Dec 2011 for action. Report on CCGs’ commissioning intentions provided to MYHT and Cluster senior team. Whole System Transformation event and report on priorities widely circulated for action Regular meetings between CCG GPs and MYHT clinicians to work through Clinical Service Strategy options.
Significant (GIC) Stakeholder engagement. Lack of cluster agreement on the scale of transformation (GIA) reliance on National evidence. Detail on major reconfiguration across the whole health economy still at early stages . Scope for major reconfiguration may be limited (GIC) (GIA) MYHEFT high level risk register No CHFT RR
Ongoing Transformation workshops across whole health economy to agree shared vision. Ongoing Clinical commissioning Groups priorities aligned with whole health economy strategy. Priorities agreed with Health and Well Being Boards x 3 High level risk register required for CHFT
End of July 12
Garland review of MYHT Tri partite Formal Agreement MYHT
Reasonable
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
11
3 Strategic Objective Board Reports
Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
3.2) Safe and secure transfer of responsibilities from PCTs to new organisations does not occur Risk Owner: Sue Cannon Risk Manager (s) Julie Lawreniuk Carol McKenna Gill Galdins
Amber
Stock take conducted in July 2011 Legacy reports from constituent PCTs – submitted to SHA September 2011 Quality Group development meeting Legacy documents reviewed January 2012 and planned quarterly thereafter Standing agenda item on Board committees regarding items for inclusion in legacy documents.
Scrutiny & oversight by Governance Committee Audit Committee
Management oversight by executive team Performance management quarterly by North of Englnad SHA Audit Committee Scrutiny & oversight re close down of board committees.
Significant (GIC) (GIA) Quarterly quality reviews at an early stage
Reasonable
Internal review of legacy reports from SHA - satisfactory
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
12
3 Strategic Objective Board Reports
Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
3.3) Effective transition and delivery of Public Health functions to new commissioning landscapes may not be achieved Risk Owner: Ann Ballarini Risk Manager (s) Directors of Public Health AndrewFurber Judith Hooper Graham Wardman
Amber
Existing transition plans for the approach to the transfer of Public health functions to the Local Authority Have been agreed with cluster board and local authorities and submitted to the SHA and agreed. Directors of Public Health (3) joint transition groups with each Local Authority (Calderdale, Kirklees and Wakefield district) continue to oversee the transition. Shadow working arrangements in local authority by no later than 31st October 2012.
Board and Cluster Executive Team (CET) updates on progress with the development of the plans Board report re implementation of plan
Significant GIA Some elements of national guidance still awaited.
Setting up a series of planning meetings to implement the transition Plans to be updated on receipt of complete information.
DPHs 31st October 2012
Letter from SHA agreeing each PCT’s individual plan APL 12
Reasonable
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
13
3 Strategic Objective Board Reports
Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
3.4 ) Lack of robust clinical workforce, training, planning and performance data across the commissioning economy may lead to insufficient clinical skills and failure to deliver expected outcomes. Risk Owner: June Goodson-Moore Risk Manager (s) Laura Smith
Amber
Health Economy Risk Assessment Process annually Programme of workforce assurance meetings in place with key Providers Training Needs analysis undertaken. Turnover monitored in cluster via workforce scorecards. Business Continuity Plans in place to prioritise work Assignment to CCG and CSO roles (letter dated January 2012). Provision of career development and resilience support to staff. Shared working across Cluster within functions. PDR process and time management support. Escalate workforce planning issues with providers as appropriate.
LDA Schedule 3 documents. Workforce integration of Board performance reports bi-monthly. Board Performance reports includes Staff in Post against trajectory plus turnover plus sickness absence. National staff survey results and actions plans report to Board and CCE Training Plan including mandatory training approved at Cluster Leadership Team (Aug 2011)
Significant (GIC) People transition policies to be adopted. (GIA) Training plan to be approved
SHA reviews of Schedule 3 Implementation of OLM to ensure Cluster Mandatory Training take-up. CQC registration.
Reasonable
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
14
3 Strategic Objective Board Reports
Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
3.5) The Cluster workforce in transition is not supported and managed effectively, allowing business critical staff to leave and failing to delivery key priorities and not developing the new commissioning landscapes. Risk Owner: June Goodson-Moore Risk Manager (s) Laura Smith Susan Maloney
Amber
Sickness absence, staff in post and turnover is monitored monthly in each PCT. Positive employee relations and staff partnerships arrangements in place. Introduction of new Transition Sub Group across CKW and ABL as sub group of existing partnership arrangements Staff health and resilience initiatives in place. Monitor internal staff sickness levels and manage, in keeping with policy. Actions from industrial action been implemented Business critical roles identified.
Cluster workforce scorecard reports. Board Performance Reports. Staff survey results and action plans to Board and CCE. Staff Forum in place – Calderdale. IIP Group, Kirklees. Employee relations and staff participation forums in place (Staff side meeting) Workforce reports to individual SMTs as well as to Board
Significant (GIC) Public health/CCG/CSO transition plans predicated on DH guidance (GIA)
Feedback timetable via Regional Social Partnership Forum
June Goodson-Moore
Staff Survey Agreed CKW People Transition Policy Jan 2012 Regional Social Partnership Forum
Reasonable
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
15
3 Strategic Objective Board Reports
Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
3.6) Cluster Governance arrangements are not fully embedded therefore decisions may be made without due authority. Risk Owner: Sue Cannon Julie Lawreniuk Carol McKenna Gill Galdins
Amber Shared operating for CKW PCT Clusters model implemented (September 2011 Boards) SOS/SFIs reviewed and approved for the Cluster (March 2012 Board) Scheme of Delegation approved (November 2011Board) Terms of Reference in place for Committees and Sub Groups. All CKW staff communications on SOS/SFIs CCG OD plan includes Governance External and internal Audit completed training on governance for CCGs.
Board to CCG Board CCG Authorisation process Internal Audit review of governance arrangements (February 2012) Governance report to Board Committee minutes to Board Policy on policies approved by Governance Committee (December 2011) Communication Plan fully implemented
Significant GIC Not all CCGs have fully implemented Governance arrangements GIA
SHA – CCG Risk Ratings Internal Audit review of governance
significant assurance
Reasonable
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
16
3 Strategic Objective Board Reports
Provide Strong Health System Management Executive Lead; Mike Potts Chief Executive Officer
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
3.7) Unauthorised access, loss or damage to data occurs due to inadequate information governance arrangements Risk Owner: Peter Flynn Risk Managers: Vicky Pickles, Terry Service, Michael Goodson
Amber
IG Toolkit submissions. Previously PCT based, Cluster based for 11/12 Governance Committee and local Audit and Governance groups. Local Audit & Governance groups have information governance in their Terms of Reference. Cluster IG team in place Port control and encryption implemented
Baseline and improvement plan considered by CET and to be on Governance agenda Governance Committee report February 2012 External: Annual review by Internal Audit Calderdale – Emergency Planning business continuity test included information governance Cluster IG toolkit score
Significant GIA Recommendations from Internal Audit regarding records management. Expected by end of Q1 12/13 GIC Imminent departure of 2 Risk Managers
Implement records management audit action plan across the cluster. Share Risk Manager with ABL and/or acquire additional capacity via THIS contract
Risk Owner: Q2 12/13 Risk Owner: Q1 12/13
Reasonable
Limited
Internal Audit Report re records management received December 2011
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
17
4 Strategic Objective Board Reports
Deliver the New Commissioning System Infrastructure Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
4.1) Clinical Commissioning Groups fail to achieve authorisation due to ineffective support from PCTs. Risk Owner: Ann Ballarini Risk Manager (s) Danny Alba
Amber
Each eCCG has PCT staff working with them to support their application for authorisation this includes an aligned shadow accountable officer OD lead and finance support. Clear Programme Office structure in place which describes the areas of transition, timescales and leads with a designated coordinator for a portfolio that includes eCCG development and authorisation. Development and OD Plan in place Compliance with the 6 domains required for authorisation
Board to Board Reviews
Delivery against the key milestones for eCCG authorisation is monitored through the Commissioning Development Assurance Framework with the SHA
CCG Authorisation process. Monthly and quarterly monitoring return to SHA Review of progress through the Programme Office and clear reporting to the Cluster Board as a regular exception report. Collation of evidence demonstrating compliance with 6 domains
Significant 2 practices currently not allocated to an eCCG. Discussion ongoing to finalise arrangements With existing eCCG. Delay in the alignment of staff to eCCGs Potential weak areas in the assessment against the 6 areas for authorisation
Support provided through COO to reach a conclusion to this and offered from the Cluster leads Delivery of a plan to address areas of underachievement will be developed when the national assessment criteria is issued.
eCCGs when appropriate
Reasonable
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
18
4 Strategic Objective Board Reports
Deliver the New Commissioning System Infrastructure Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
4.2) New commissioning support offer does not deliver requirements of eCCGs Risk Owner: Ann Ballarini Risk Manager (s) Rachel Spilsbury
Amber
Delivery against the key milestones of the Commissioning Development Assurance Framework for SHA which covers requirements of delivering the West Yorkshire CSO Support through National and Regional team, membership of Regional DCD group and input to national workshops WY Footprint Project Group in place CCG partnership in developing offer Recruitment of a shadow ‘Managing Director’ for the West Yorkshire CSO in early January 2012. Monthly CSO Programme Board meetings with supporting task and finish groups Business Plan submitted and discussed with SHA Consultation underway on high level structure for CSS
Monthly and quarterly reports to SHA Board reports on progress and providing assurances against the key milestones for the development of the Prospectus, business plan and service level agreements
Significant Programme Board
April 2013
Reasonable
SHA monitoring
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
19
4 Strategic Objective Board Reports
Deliver the New Commissioning System Infrastructure Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
4.3) Development of an ineffective model for direct commissioning function of NHS Commissioning Board Risk Owner: Ann Ballarini Risk Manager (s) Louise Auger and Danny Alba
Amber Delivery against the key milestones of the Commissioning Development Assurance Framework which covers requirements of preparing for the hand over to the NHSCB Clear Programme Office structure in place which describes the areas of transition, timescales and designated coordinator for each portfolio. System in place to performance review against the key milestones and to identify areas of risk and mitigating actions. Clear leads for areas of work identified across the Cluster contributing to the 6 portfolios. Sharing of information and intelligence across the Programme Office . Director of Commissioning link to SHA meetings providing clarity on requirements and timescales. Gateway for documents relating to this area provided by the SHA so that all relevant transition communications go directly to the DCD.
Monthly and quarterly returns Clear reporting to the Cluster Board as a regular exception report. Agenda of monthly DCD meeting with SHA
Significant GIC Lack of national guidance on how NCB functions will be discharged.
Reasonable
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
20
5. Strategic Objective Board Reports
Maintain the capacity to carry out Emergency Planning and Resilience during transition. Executive Director Lead; Judith Hooper Executive Director of Public Health Kirklees
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
5.1a) Reduced capacity in PCT emergency preparedness teams leads to lack of preparedness for emergencies. Risk Owner: Judith Hooper 5.1b) Reduced director-level capacity reduces ability of NHS to coordinate the healthcare response to an incident Risk Owner: Judith Hooper 5.1c) Reducing public health capacity reduces on call cover and ability to activate Scientific and Technical Advice Cell. Risk Owner: Judith Hooper (Ben Fryer)
Amber Emergency planning teams are in place in each of the three PCTs, who work collaboratively across the cluster and across west Yorkshire to manage their workload effectively. In each PCT, a work plan is in place to ensure that essential preparedness work is completed. The director on call rotas have been merged across the cluster. The fully staffed rota is supported by an updated on call pack and staff call in lists. Up to date incident control rooms are maintained in all three PCT HQs Local Emergency Planning meetings The cluster has a fully staffed Public Health on call rota. All rota members have received training in activating the STAC. The HPA operates a 2nd on call rota
Plans, Rotas and training records are maintained for all relevant systems. Approved Major Incident Plans and a STAC plan are in place. Debrief records from previous incidents, events and exercises. Monthly communications tests and annual exercises, e.g Exercise Vespa (November 2011), Exercise Agora (July 2011)
Significant No current gaps in assurance.- risks on RR Wakefield score 12 Kirklees and Calderdale score 6
N/A N/A
Reasonable
Successful coordination of planning for and response to industrial action in November 2011
Limited
Exercise Vespa Exercise Agora
SHA assurance December 2011 return
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
21
5. Strategic Objective Board Reports
Maintain the capacity to carry out Emergency Planning and Resilience during transition. Executive Director Lead; Judith Hooper Executive Director of Public Health Kirklees
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
5.2). Lack of clarity regarding future delivery model for Emergency Planning and Resilience in the NHS within Calderdale, Kirklees and Wakefield District Risk Owner: Judith Hooper (Ben Fryer)
Amber Maintenance of existing local and West Yorkshire NHS planning for major incidents Maintenance of Lead PCT role to represent the NHS at West Yorkshire Resilience Forum activities Winter planning system and winter plan Active engagement with discussions on future health protection arrangements across the region Development of Commissioning Support Unit specification for Emergency Preparedness Series of workshops on Health protection and Emergency Planning West Yorkshire Health Protection memorandum of understanding West Yorkshire Emergency Preparedness CSO specification
Bimonthly West Yorkshire Resilience Forum Health Subgroup meetings Continued regular attendance at all meetings PCT emergency preparedness committees Updates provided for NHS partners at LRF meetings
Significant GIA - Lack of clarity on roles and responsibilities from DH .- risks on RR Wakefield score 12 Kirklees and Calderdale score 6
Awaiting guidance from DH
Reasonable
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
22
6. Strategic Objective Board Reports
Maintain full engagement in the provider development agenda to ensure effective partnership with current and future Foundation Trusts Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development Trusts
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on
Controls Key Positive Assurance
(**External / Independent) Gaps in Control (GIC) and/or
Gaps in Assurance (GIA) Corrective Action
Responsibility Target Date
6.1) Local trusts fail to achieve foundation trust status due to lack of sufficient support from commissioners Risk Owner: Ann Ballarini Risk Manager (s) Rachel Carter Chris Dowse
RED Mid Yorkshire Hospitals NHS Trust (MYHT) MYHEFT programme set up with a plan and 4 key work streams. Structures are in place to support the transactional aspects of the FT application process. Governance is provided through the MYHEFT Board which meets every two months and the smaller executive group which meets every fortnight, led by a Programme Director. Regular high level meetings between MYHT, CKW Cluster and SHA to agree financial recovery plan. Regular meetings between CCG GPs and MYHT clinicians to work through Clinical Service Strategy options. Ambulance Service Reports to Board. YAS Integrated Business Plan to support milestones for YAS FT application process Monitor assessment process
Commences: July 2012
Minutes of meetings Board papers QIPP outcome report sent to HEFT Executive group, Cluster CE, Cluster DoF, Wakefield District and Kirklees COOs, MYHT DoF and Dir Strategy Dec 2011 for action. Report on CCGs’ commissioning intentions provided to MYHT and Cluster senior team. Whole System Transformation event held Nov 11. Report on priorities widely circulated for action Board updates through PO papers
Significant Financial balance MYHT HEFT high level risk register
System wide review to create opportunities to improve financial resilience Regular updates on financial plans on aspirant FT Risk register in circulation Continued discussion between MYHT, CKW cluster and SHA
HEFT/PMO Ongoing
Reasonable
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
23
6. Strategic Objective Board Reports
Maintain full engagement in the provider development agenda to ensure effective partnership with current and future Foundation Trusts Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development Trusts
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control or Assurance
(GIA) or (GIC) Corrective Action
Responsibility Target Date
6.2) Fail to deliver effective implementation of Any Qualified Provider (AQP) as set out in the guidance on 19 July 2011. Risk Owner: Ann Ballarini Risk Manager (s) Rachel Carter and Danny Alba
Amber
1. Delivery against the key milestones of the Commissioning Development Assurance Framework, i.e. 3b.4.1 Clusters to have signed off priority AQP services with SHAs and 3b.4.2 Clusters to have started delivery of at least 3 AQP community and mental health services, working in partnership with CCGs; 2. Project delivery trajectories for Phase 1 AQP implementation and Phase 2 AQP implementation; 3. Stakeholder (includes key providers) engagement and consultation process and activities;
4. DH guidance / directive on a future selection of services suitable for AQP, and dissemination of standardised AQP service specifications for use in AQP procurements. 5. Communication and engagement strategy with key stakeholders (includes key providers) to determine services suitable for AQP; 6. AQP within eCCGs' commissioning intentions / operating plans;
1. Commissioning Development Portfolio is coordinated by the NHSCKW Programme Management Office (PMO) with the DCD as senior responsible owner; Regular report to Cluster Board and CCEs
Significant GIA) None identified (GIC) DH policy changes / directives that may influence phase 2 list of services suitable for AQP procurement not yet available.
GIC) Further central guidance expected imminently and being scanned for. Engagement in Y&H planning (11th January) and North of England event (25th January). Project delivery trajectory for Phases 1 and 2 AQP implementation are amenable to adjustment in light of anticipated DH policy guidance, including expected standardised AQP service specifications.
Local eCCGs supported by NHSCKW heads of contracting.
Reasonable
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
24
6. Strategic Objective Board Reports
Maintain full engagement in the provider development agenda to ensure effective partnership with current and future Foundation Trusts Executive Lead; Ann Ballarini Executive Director of Commissioning and Service Development Trusts
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control or Assurance
(GIA) or (GIC) Corrective Action
Responsibility Target Date
6.3) Insufficient oversight of the ‘NHS organisation failure regime’ within the cluster geographical area of responsibility. Risk Owner: Peter Flynn Risk Manager (s): Louise Auger
Amber
Accountability framework implemented for all KPIs at Cluster & PCT catchment level. Contract Management Groups, Quality Groups and Executive Contract Boards for each main contract with key providers review performance , activity, finance and quality monthly.
Monthly Performance Report containing 11/12 Operating Framework KPIs with underperformance exception reporting for Provider and PCT Catchment presented to F and P Committees and CCEs Cluster Board report (Bimonthly) Report with recovery plans for underperformance to CCGs and through CCE DH/SHA monitoring of data and feedback to Cluster on areas of under performance Performance reporting to Cluster Board at Cluster level and from CCEs Key Staff assigned to senior CCG roles
Significant GIC Level of knowledge of eCCGs during transition as future leads for this area
Development of dialogue at CCE level CCG level reporting to CCEs and to Cluster Board Support through CSS Part of OD Plan and CSS Development
Risk Owner: Q1 2012/13 CCG Accountable Officers When launched
Reasonable
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
25
7. Strategic Objective Board Reports
Deliver high quality Communications and Engagement Executive Lead; Mike Potts Chief Executive Officer
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control or Assurance
(GIA) or (GIC) Corrective Action
Responsibility Target Date
7.1) Staff are not fully engaged in the reforms in line with the NHS Constitution Risk Owner: June Goodson-Moore Risk Manager (s) Eleanor Nossiter
Amber
Comms and engagement strategy and action group. Monthly internal staff briefing. Consistent weekly bulletin across Cluster. Staff survey uptake and action plans. Communication and engagement staff in place in all PCTs. Creation of Cluster Intranet Communication and engagement plan 2011-2012 in place Cluster forum being established, which will incorporate Calderdale staff forum and Kirklees IIP Group.
Workforce report to Board Staff survey results report to Board
Significant (GIA) (GIC) No staff forum arrangement in Wakefield
Will be covered by joint Cluster forum being established
Staff survey - cluster response 74%.
Reasonable
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
26
7. Strategic Objective Board Reports
Deliver high quality Communications and Engagement Executive Lead; Mike Potts Chief Executive Officer
Principal Risks Risk Owner
Risk Status RAG
Key Controls Assurances on Controls Key Positive Assurance
(**External / Independent) Gaps in Control or Assurance
(GIA) or (GIC) Corrective Action
Responsibility Target Date
7.2) Fail to ensure constituent PCTs continue to meet their statutory responsibilities for communication and engagement Risk Owner: June Goodson-Moore Risk Manager (s) Eleanor Nossiter
Amber
Comms and engagement steering groups for MY and C&H transformation programmes Regular engagement with local MPs Daily monitoring of media coverage. Communication and Engagement Strategies developed for CCGs Communications and Engagement development sessions for CCGs Work Plan Governance Committee Terms of Reference PPI Engagement annual reports sign off by Board and CCE.
Weekly monitoring conference calls with Mid
Yorkshire & SHA Communications and Engagement is standing item on agenda of the two transformation boards
Significant (GIA) Potential capacity issues in comms and engagement staffing the system (GIC)
Ongoing discussions and resilience assessment across CKW cluster, Mid Yorkshire and CHFT
Eleanor Nossiter July 2012
PPI and engagement reports to SHA
Reasonable
Limited
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
27
Principal Risks: are what could prevent key objectives from being achieved. Key risks should be true risks (rather than consequences), and so cannot just be the converse of the objective.
Risk Status: (green, amber or red). This shows the ‘traffic lighting’ applied to each risk, and seeks to help the Board ‘weight’ the amount of attention that it directs in reviewing entries on the Assurance Framework.
The risk status is updated quarterly using the risk matrix
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls. Key Controls: are factors, systems or processes that are in place to mitigate the principal risk(s) and assist in securing delivery of the relevant key objective. Key controls should be robust and specific, and properly
match the associated key objective(s). For example; a sub committee or committee of the Board which is tasked with monitoring the specific risk.
Assurance on Controls: are sources of evidence that the key controls are effective. Assurances should be matched with specific key control(s) wherever possible.
Key Positive Assurance: assessment seeks to measure the level of assurance with which it can be determined that the key controls are mitigating the principal risks identified. The assessment also specifies
how/where the organisation has evidence showing that principal risks are being managed reasonably. Descriptions should provide sufficient details to identify specific documentary evidence, e.g. dates of meetings, publications, reviews etc. External or Independent assurances are generally given more weight than internal sources.
Gaps in Control: indicates where the organisation has failed to put key controls in place, or has failed to make key controls effective.
Gaps in Assurance: indicates where the organisation is failing to gain evidence that key controls are effective.
Corrective Action: shows what will or is being done to address the gap(s) in control or assurance.
Responsibility / Target Date: shows the Director (or senior manager) responsible for appropriate and timely implementation of corrective action(s) and the expected date by which actions should be completed.
Progress reports provide a quarterly update on achievement of action plans and identify where gaps in control or assurance have been addressed. They should also indicate where the risk grading has changed for any
risks associated with that objective.
Generally, Assurance Frameworks should map key objectives to principal risks, key controls and assurances explicitly. Assurance frameworks should be embedded and dynamic, providing regular Board information
and not viewed as year-end exercises.
NHS CALDERDALE, KIRKLEES AND WAKEFIELD: BOARD ASSURANCE FRAMEWORK 2012/13
Green – the risk is being appropriately managed, all controls are in place and appropriate assurances being received. Amber – the risk is increasing either through gaps in control or as a result of actions, not being fully embedded and / or insufficient assurance on controls. Red – the risk has increased with significant gaps in control and / or insufficient assurance on controls.
28
Assurance
Examples of what constitutes differing levels of assurance:
Key Positive assurance (** External/Independent) EXAMPLES OF TYPES OF ASSURANCE
**SHA Audit of data quality indicating no significant concerns, reported to Trust Board January 2011, Clinical Commissioning Executive Committee February 2011. (significant assurance)
**CQC indicators met for relevant targets as reported in periodic review, October 2011 (significant assurance)
Performance Report received by the Trust Board, most recent September 2011, showing performance within tolerance for overall achievement of target for Q1 (reasonable assurance)
Contract monitoring report to Clinical Commissioning Executive Committee in September 2011 showing performance within tolerance for overall achievement of target for Q1 (reasonable assurance)
Performance report to Trust Board, most recent September 2011, indicating current position against key targets (limited assurance)
Key Positive assurance EXAMPLE OF LAYOUT Significant Assurance
2011/2012 prospectus published March 2011, included for information in Board papers May 2011
Uptake report on attendance at Health & Safety courses at Health & Safety working group November 2011 shows 60% of staff have attended relevant courses, compared with 40% last year
Reasonable Assurance
Update report to audit and governance committee September 2011 demonstrating 80% of required courses now established
Limited Assurance
Performance report to Trust Board, most recent September 2011, indicating current position against key targets
Beginners Guide to Board Assurance\BAF Sources of Assurance.doc
Note. The risk status does not necessarily mirror the positive assurance assessment. For example, it is possible that work may be well on track (or ahead of plan) to develop controls or address a risk, and hence management may determine that the risk status be assessed as ‘green’. However, because that work is not complete, the positive assurance assessment may be ‘limited assurance’, with actions identified to complete the relevant work