NLG(16)133

DATE 29 March 2016

REPORT FOR Trust Board of Directors – Public

REPORT FROM Wendy Booth, Director of Performance Assurance

CONTACT OFFICER Jeremy Daws, Head of Quality Assurance

SUBJECT Board Assurance Framework (BAF)

BACKGROUND DOCUMENT (IF ANY) Redeveloping the Board Assurance Framework – NLAG R eview (October 2015)

REPORT PREVIOUSLY CONSIDERED BY & DATE(S) TGAC Meeting – 17 March 2016

EXECUTIVE COMMENT (INCLUDING KEY ISSUES OF NOTE OR, WHERE RELEVANT, CONCERN AND / OR NED CHALLENGE THAT THE BOARD NEED TO BE MADE AWARE OF)

This report is the first summary of the newly revis ed Board Assurance Framework (BAF). The BAF process is still in develo pment and so future reports will provide more complete information, how ever this quarters report provides a greater illustration of the BAF process in understanding the Trust’s Strategic Objectives and the assurance mech anisms in place for contributory key drivers

HAVE THE STAFF SIDE BEEN CONSULTED ON THE PROPOSALS?

N/A

HAVE THE RELEVANT SERVICE USERS/CARERS BEEN CONSULTED ON THE PROPOSALS?

N/A

ARE THERE ANY FINANCIAL CONSEQUENCES ARISING FROM THE RECOMMENDATIONS?

N/A

IF YES, HAVE THESE BEEN AGREED WITH THE RELEVANT BUDGET HOLDER AND DIRECTOR OF FINANCE, AND HAVE ANY FUNDING ISSUES BEEN RESOLVED?

N/A

ARE THERE ANY LEGAL IMPLICATIONS ARISING FROM THIS PAPER THAT THE BOARD NEED TO BE MADE AWARE OF?

N/A

WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO THE NHS CONSTITUTION IN ANY DECISIONS OR ACTIONS PROPOSED?

N/A

WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO SUSTAINABILITY IMPLICATIONS (QUALITY & FINANCIAL) & CLIMATE CHANGE?

N/A

THE PROPOPSAL OR ARRANGEMENTS OUTLINED IN THIS PAPER SUPPORT THE ACHIEVEMENT OF THE TRUST OBJECTIVE(S) AND COMPLIANCE WITH THE REGULATORY STANDARDS LISTED

N/A

ACTION REQUIRED BY THE BOARD The Board is asked to note the contents of the Boar d Assurance Framework (BAF)

Directorate of Performance Assurance

BOARD ASSURANCE

FRAMEWORK (BAF)

March 2016

Introduction to the Board Assurance Framework (BAF)

The Board Assurance Framework (BAF) is designed to provide a structured process to enable the organisation to focus on proactively identifying those risks that might compromise achieving its most important annual (strategic) objectives and to map out the key controls in place to manage these risks, thereby guiding the Trust Board as to the assurance value and enabling proactive escalation if necessary. The benefits of a working BAF is that it encourages individuals and groups within the organisation to think about and plan for the achievement of their objectives in a proactive manner with board agendas focussed on the strategic and reputational risks rather than operational issues.

The BAF should assure that potential risks to the achievement of the Trust’s objectives are identified and managed. As a result there is a clear cross-over between the risk register, containing the Trust’s strategic risks, and the Board Assurance Framework.

NLAG Strategic objectives 2016/17:

As the BAF is designed to aid proactive identification of the risks to delivery of the Trust’s strategic objectives, for clarity, these objectives are listed as follows:

1. To deliver services efficiently without impacting a dversely on the quality of care.

This will deliver optimum efficiency across the whole of the Trust cost base, and support the redesign process.

2. Working together across the health and care spectru m provides the greatest opportunity to control demand, alleviating the cost pressures arising from demand growth. Integration improves the quality of care provided by removing organisational boundaries, enabling clinical teams to work seamlessly across the patient journey.

3. Radical transformation where needed. The Trust is prepared to act to improve

patient care or to deliver more efficient and effective services.

To support delivery of these strategic objectives, the following enablers have been strengthened by the Trust:

• Continued development of a true patient first workforce whose services are

delivered through a single, engaged and empowered team that has a voice and strives for uniqueness, innovation, quality and safety.

• The IM&T strategy harnesses the strengthening reputation and developing skills base. The strategic goal is to develop a local IM&T solution which meets the service needs enabling sharing of information across the patient journey, removing organisational boundaries.

• Delivery of truly integrated service provision is reliant upon the workforce of the Trust being able to work as a multi-disciplinary team regardless of where the patient is. With prime clinical space at a premium, maximum utilisation of the estate is key to deliver value.

References:

• Five Year Strategic Plan 2014-19 • Trust response to CQC, September 2015

Progress to date: BAF Redesign Components Included in March 2016 Quarterly Report • The following diagram pictorially represents the Trust’s 3 strategic objectives and their linkage to the CQC Fundamental Standards. Beneath each

objective, is the list of key drivers that contribute to delivery:

• The Head of Quality Assurance is still in the process of meeting with each of the above named ‘owners’ to work through, together, the completion of the ‘BAF Foundations’ Assurance Framework. As a result, some areas are not yet complete and the detail therefore is unable to be reported here. KEY:

Meeting held with ‘owner’ – BAF entry completed and presented within this report,

Meeting not yet held, not included within this report.

BOARD ASSURANCE FRAMEWORK ‘At a Glance’ Compliance Dashboard

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Executive Summary:

• Hygiene code is rated as RED (no assurance) due to gaps in both controls and assurances available. An action plan is in place and is being overseen by Infection Prevention and Control Committee. This is an item on the Risk Register already.

• Equality & Diversity is rated as RED (partial assurance, with improvements required) due to gaps in both controls and assurances. The delivery of the Equality & Diversity Strategy is at risk of non-delivery due to a lack of resource available to act on the information gathered; no analysis is currently performed leading to a lack of application in the Trust.

KEY to RAG (Red, Amber, Green) Ratings:

GREEN: Effective controls definitely in place and Board satisfied that appropriate assurances are available

AMBER: Effective controls thought to be in place but assurances are uncertain and/or possibly insufficient

RED: Effective controls may not be in place and/or appropriate assurances are not available to Trust Board

Not Yet Assessed: Meeting with ‘owner’ not yet taken place

…Example…**GREEN**

…Example…**AMBER**

…Example…**RED**

…Example…<Not Yet Assessed>

BOARD ASSURANCE FRAMEWORK (BAF) – Detailed Narrativ e

Strategic Objective 1: To deliver services efficiently without impacting a dversely on the quality of care.

CQC Fundamental Standard: SAFE Reporting by exception: Assurance

Level Assurance status value

Controls Gaps in controls Assurances Gaps in assurances

Risk register

entry

Risk rating

Mortality Performance (Lawrence Roberts)

AMBER Significant Assurance with Minor Improvement Opportunities

MPAC oversight,

Deputy Medical Director is mortality lead,

Case review (SJR) approved as RCP tool of choice,

Clinical leaders engagement, not top-down.

Uncertainty about the NHS strategy, in particular avoidable mortality,

Continued improvement in leadership and management skills (an action on the QDP),

Lack of clarity from DH regarding a framework for medical workforce succession planning/ capability,

Local accountability arrangements for medical staff.

Mortality report,

Workforce report,

SI/complaint themes,

MPAC meetings with clinical presence,

Mortality lead role working with clinicians.

Medical Director’s dashboard (in development) and accountability arrangements for medical staff.

1468 25, 5x5

Hygiene Code (Karen Dunderdale)

RED No assurance

Monthly task and finish group,

Action plan now in place,

New prescription chart,

Medicines safety thermometer,

Submitting data to national dataset.

Training and compliance issues for antimicrobial usage,

No data/measurement available to guide progress,

Medicines safety thermometer information and nationally submitted information not widely accessible locally for use.

None at present, action plan in place with the intention of closing gaps.

No audit information available to evaluate effectiveness of new prescription sheet,

Lack of measureable information, although audit is a section on action plan.

1734 16, 4x4

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CQC Fundamental Standard: SAFE (continued…) Reporting by exception: Assurance

Level Assurance status value

Controls Gaps in controls Assurances Gaps in assurances

Risk register

entry

Risk rating

Patient Safety Alerts (CAS Alerts System) (Wendy Booth)

AMBER Partial assurance with improvements required

CAS Alerts System (DH),

CAS Alerts tracker (modelled on NICE tracker),

Admin support oversees CAS alerts,

CAS Alerts policy,

MDA policy,

TGAC oversight,

Distribution lists.

CAS Alerts policy in need of revision and expanding to include MDA and the role of the Medical Devices Safety Officer,

Greater clarity for staff involved in acting on CAS alerts what their responsibilities are and greater help to ensure effective transmission of alerts,

Embedding of CAS Alerts tracking system,

More effective and useful highlight reports needed for TGAC and for operational use by groups.

CAS alert paper received by TGAC quarterly,

CAS Alerts system outlines Trust adherence to deadlines set, Group governance minutes,

Evidence of transmission.

That CAS alerts are being effectively communic-ated, increased quality of information and clarity on roles and responsibilities needed,

Evidence of learning lessons or process for feeding into learning lessons review group.

Not presently on Risk Register

N/A

CQC Fundamental Standard: EFFECTIVE

Reporting by exception:

No exceptions to report

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CQC Fundamental Standard: CARING Reporting by exception: Assurance

Level Assurance status value

Controls Gaps in controls Assurances Gaps in assurances

Risk register

entry

Risk rating

Equality & Diversity (Director of HR)

RED Partial assurance with improvements required

Annual reporting of the information collected which is then published on the Trust’s website.

5 year strategy in place with objectives included.

There is no resource currently available to analyse and produce an action plan outlining what the information is telling us and what action is needed to be taken. Implementation is therefore a gap.

The strategy includes to understand and act upon this, therefore there is a risk of being unable to deliver the 5 year strategy.

Data available from E&D,

Trust action plan/evidence linked into strategy and objectives contained within.

Resource issues to undertake analysis and incorporate this into the action plan, leading to implementation.

Strategy implementation to understand what the data is telling us. Risk of non-delivery of strategy.

Not presently on Risk Register

N/A

Staff Experience / Morale (Karen Dunderdale)

Amber Partial assurance with improvements required

Education and training, available,

Value based recruitment and interview process,

Staff engagement and comms,

Leadership and management.

Strategy in place but lacks detail of an implementation plan,

Response rate to staff morale barometer in the past has been poor, leading to insufficient data to act,

Escalation process for non-V&V behaviour.

Staff FFT,

National staff survey.

Low response rate to internal surveying,

Rewards and recognition policy in place, but need greater assurance that this is working

Not presently on Risk Register

N/A

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Strategic Objective 2:

Working together across the health and care spectru m…

CQC Fundamental Standard: WELL-LED Reporting by exception: Assurance

Level Assurance status value

Controls Gaps in controls Assurances Gaps in assurances

Risk register

entry

Risk rating

Staffing – Strategic (Karen Dunderdale)

Amber Significant assurance with minor improvement opportunities

Workforce report overseen by Resource committee,

NED challenge,

board paper seen monthly

Weekly controls meetings (sustainability)

Daily operational meetings, day to day overseeing of staffing numbers,

Safe Care Live used in Ops Centre,

E-roster in use

Procurement of agencies - RAG rating for agencies based on cap/framework set by Monitor.

Locum, agency or temporary clinical staff knowledge of Trust procedures,

Induction process for these temporary staff.

Wealth of workforce data,

Acuity and dependency data,

Director visits and ward reviews,

Fill rate presented against nursing dashboard, including and strips out bank and agency.

Links between data/stats and quality of care information.

None identified

1688 12, 3x4

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CQC Fundamental Standard: WELL-LED (continued…) Reporting by exception: Assurance

Level Assurance status value

Controls Gaps in controls Assurances Gaps in assurances

Risk register

entry

Risk rating

Staffing – Nursing (Tara Filby)

Amber Significant assurance with minor improvement opportunities

Weekly working meeting escalated to Sustainability,

Overseen by NMAF, to focus on professional issues,

Quarterly staffing report on agency use, bank use, recruitment, sickness rate, recruitment plans and programme (action plan),

Risk profile for the wards,

Health Roster and Safer Nursing Care Tool around acuity and whether meeting demand,

Daily ops centre reviews of staffing.

A wealth of information can make it difficult to get clarity on key issues, Operational staff may not need daily meetings (and the huge investment of time each day) if more proactive planning was possible, at minute to reactionary - plugging last minute gaps, would like to move to a more proactive approach Risk behind choice of agency to use off contract. ICU are only ward allowed to block book. Retention of staff / poor morale complicated by non-specialty outliers, medical model and patient flow complicate and make this more challenging.

Weekly meeting, (to be further strengthened in March by oversight meeting chaired by Chief Nurse), SPG stocktake oversight, Fill rates data overseen. Recruitment and retention workforce report overseen at resources committee.

Limited proactive planning – a weekly meeting is planned to be in place with support from a dedicated project manager post, Need greater guidance for site teams and out of hours management (how do we support a non-nursing manager make the decision where to go/who to use in regard to agency workforce.) Need a policy with those parameters included.

No specific Risk Register entry for nurse staffing 1921 regarding Nursing Revalidat-ion relates to this area of staffing 1688 relates to recruit-ment and retention difficulties for medical and nursing staff

N/A 12, 4x3 12, 3x4

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CQC Fundamental Standard: WELL-LED (continued…) Reporting by exception: Assurance

Level Assurance status value

Controls Gaps in controls Assurances Gaps in assurances

Risk register

entry

Risk rating

Staffing – Medical (Lawrence Roberts)

Amber Significant assurance with minor improvement opportunities

Working with Deanery, medical schools to alert them to short supply of medical staff,

Working to improve experience for medical students and trainees,

Working to ensure there is protected time in their job plans for training,

Looking to develop incentives with Deanery,

Use of agency to plug gaps with preserving patient safety,

Monthly workforce report.

Job planning for consultants (working to complete),

Accommodation issues for medical staff.

Appraisal systems have resulted in full assurance,

Reporting to TGAC and Trust Board,

GMC external reporting process,

Sustainability work stream overseeing,

Monthly workforce report.

Job planning evaluation.

No specific Risk Register entry for medical staffing 1688 relates to recruit-ment and retention difficulties for medical and nursing staff

N/A 12, 3x4

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Strategic Objective 3:

Radical transformation where needed.

CQC Fundamental Standard: RESPONSIVE Reporting by exception: No exceptions to report

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BAF drivers/objectives presently on the risk regist er:

The following BAF reported areas are currently listed on the risk register:

Existing Risk Register Reported Risks

BAF driver/objectives Risk number Rating of risk

Mortality performance 1468 25 (5x5)

Premises & Equipment (community only) 1873 16 (4x4)

Healthy Lives & Healthy Futures 1879 15 (5x3)

Staffing (main risk register entry) 1688 12 (3x4)

Sustainability Delivery Programme 1888 15 (5x3)

Hygiene Code 1734 16 (4x4)

Information Governance Toolkit 1762 8 (4x2)

Monitor’s Risk Assessment Framework 1793 10 (5x2)

Compliance with NICE Guidance 1758 10 (5x2)

Patient Safety Alerts (residual actions) 1277 16 (4x4)

1657 12 (4x3)

National Clinical Audit Programme 1863 12 (3x4)

Recommendations from BAF to be added to the risk re gister:

Recommended Amendments to the Risk Register

BAF reported area Rating of risk

Equality & Diversity 12 (4x3)

Is anything missing from the BAF?

For the Board Assurance Framework to be useful to the Board in proactively examining key drivers/objectives that relate to the attainment of the strategic objectives, it is important that the right objectives and drivers are included in the BAF framework. The following areas, some, time limited, have been identified as other potential areas for inclusion within future iterations of the BAF:

• Electronic Patient Record Development (Medical and Nursing), • NHS Information Standard,

• Is there anything else that is missing?

Trust Governance and Assurance Committee Action:

The Committee is asked to:-

• Review and approve the revised approach to the Board Assurance Framework – noting that the style of the report will likely evolve over time as will the quality of information presented,

• Approve the use of this approach going forward, enabling the remaining meetings to be conducted using the BAF foundations framework,

• Approve the additions to the Risk Register,

• Consider if any other areas are currently missing from the BAF that equally driver/contribute significantly to the Trust meeting its objectives.

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GLOSSARY

How are the dashboards RAG (Red, Amber, Green) rate d?

GREEN: Effective controls definitely in place and Board satisfied that appropriate assurances are available

AMBER: Effective controls thought to be in place but assurances are uncertain and/or possibly insufficient

RED: Effective controls may not be in place and/or appropriate assurances are not available to Trust Board

Not Yet Assessed: Meeting with ‘owner’ not yet taken place These RAG rating assessments are arrived at in collaboration with the owner’s self-assessment, following completion of the other BAF elements namely risks, controls, gaps in control, assurances and gaps in assurance. How is assurance rated within this report and withi n the BAF Framework? Assurance is rated using 4 specific categories:

• Significant assurance, • Significant assurance with minor improvement opportunities, • Partial assurance with improvements required, • No assurance

These categories are also arrived at by the owner in a self-assessment, following completion of the other BAF elements, as above. These categories are based on those used by KPMG when undertaking their internal audit on the completion of the BAF process. What framework is used currently for risk rating ar eas for recording within the risk register? The 5x5 risk management matrix is used for this purpose, this is available within the Trust’s Risk Management Policy. How does the BAF and the Trust’s Risk Register inte rface? The BAF and the risk register contain many similarities, both report risk. The BAF however works top down from the Trust’s strategic objectives determining, proactively, what controls and assurances of controls are in place. If any gaps are found from this proactive approach with ‘owners’ it enables them to be better informed of risks perhaps they were not fully aware of. As a result, but not always, an owner may choose to add something not already on the risk register. This decision may also be taken by the Trust Governance & Assurance Committee on review of the BAF. For those risks already known to the Trust and listed on the risk register, the BAF process can help ensure these risks are reviewed and updated on a regular basis, a key element of good governance. For BAF scrutinised driver/objectives with low assurance levels, it is likely the ‘owners’ of these areas will want to oversee the proactive work to close any gaps in control or gaps in assurance on a more frequent basis than quarterly. The BAF therefore is more than a quarterly report, it needs to be an ongoing assurance system supporting colleagues within the Trust proactively identify all risks to deliver of key drivers/objectives that could impact on the Trusts ability to deliver its strategic objectives.

…Example…**GREEN**

…Example…**AMBER**

…Example…**RED**

…Example…<Not Yet Assessed>

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