Objective 1 - Safe Deliver safe, high quality care and ...€¦ · Objective 1 - Safe – Deliver...

Objective 1 - Safe – Deliver safe, high quality care and improving services which pursue perfection and be in the top 25% of our peers

Strategic Theme / Annual priority Reduce Avoidable Harm Director responsible Chief Nurse

Medical Director

Key Action for 2018-19 objectives and description of any potential significant risk to this priority

1.1 There is a risk that the Trust will

not be in the top quartile for safety and

continue to improve beyond this

benchmark if opportunities to innovate

and learn from benchmarked outcome

data/peer review are not adopted and

implemented.

Initial Risk S4 x L3 = 12

Current rating S4 x L2 = 8

Target risk score S4 x L1 = 4

Target Date 2 yrs

Linked to Risk 1514, 1798, 1903, 1936

Controls in place Gaps in Control

1) Regular review of patient safety data including incidents, HSMR, the Safety Thermometer at ward, divisional, executive and board level

2) Nursing staffing levels benchmarked nationally monitored (care hours per patient day) and related issues managed daily

3) National patient safety alerts NICE guidance and other safety related guidance reviewed, audited and implemented where relevant and appropriate

4) Serious incident review group in place to monitor and evaluate investigation progress and demonstrate progress against agreed actions

5) IPCAS Team and Group in place, monthly taskforce meetings in place 6) Assurance process in place for C. diff / MRSA blood stream infection. 7) Variety of national audits contributed to and reviewed 8) Member of AHSN 9) STP member 10) GIRFT and model hospital work within hospital 11) 7 day services audit benchmarked with STP 12) Falls and pressure damage targeted work in place 13) Innovative patient safety work on “key words” within SI reports to facilitate,

direct and embed learning 14) Mortality governance review and reports to Board, Medical Examiners,

Structured Judgment review for LD death 15) Director of Outcomes in post and reviewing Board to ward information and

novel ways to interrogate and report data.

1) Developing systems to support safety benchmarking 2) Electronic EWS with alert system likely to be more effective in ensuring clinical

response to deteriorating patient / sepsis 3) Data quality and lag for use in improvement programmes 4) Absence of electronic prescribing 5) No audits of integrated care record use by hospital

Potential Sources of Assurance (documented evidence of controls effectiveness)

Actual Assurances: Positive (+) or Negative (-)

1) External reports and visits to clinical areas both scheduled and unscheduled (e.g. genba walks / CQC /audit)

2) Divisional and Trust level dashboards 3) SASH + Program 4) Benchmark reporting 5) Compliance with NICE guidance audits 6) Improving data regarding new harm in safety thermometer at trust level 7) Model hospital reports 8) GIRFT reports 9) CQC inspection 10) Director of Outcomes work on linking process and outcome measures 11) Right Care data/variation vs peers 12) Respect tool for advance care plans audit 13) De-prescribing work in frail and elderly within the polypharmacy AHSN work

Positive

(+) CQC Chief Inspector of Hospitals Report

(+) RAG rated Green by NHS Resolution (former CNST Level 2)

(+) EWS audit, action plan in place including development of electronic systems

(+) Datix incident reporting and analysis including increase in reporting

(+) Datix linkages to audit and strengthening legal affairs systems

(+) Monthly trust wide reporting using national benchmarking

(+) Reduction in falls and reduction in upper control limit of falls SPC charts

(+) Strong evidence of improved SI investigation management and closures

(+) Improved reporting of patient falls has enabled the Trust to understand fall profile

and revised strategy and action plan in development

(+) Initiation of ‘Stop, Access, Send’ initiative for the management of loose stool

(+) Management of diarrhoea ‘SASH+ Value Streams’ Trust wide implementation in

progress

(+) Antimicrobial prescribing audit compliance

(+) Feedback from CQC (periodic rather than formal report)

(+)SHMI Mortality is lower than expected for our patient group when benchmarked

against national comparators. Ambition to be best in class for HSMR and SHMI

(+) Safety Thermometer

(+) Band 6 ready programme publishes innovation on the I2I factory site

Negative

(-) Never events incidence

(-) Recent increase in moderate safety incidents, reduction in no harm reporting

(-) Incidence of pressure ulcers overall rate is increasing

(-) falls with harm, however overall falls with harm reducing

Gaps in assurance Assurance Level gained: RAG

Ability to benchmark in real time and data quality of elements of reporting

Actions Progress (including dates, notes on slippage or controls/ assurance failing.

1) VMI/SASH plus development program 2) Actions described in the IPCAS strategy 3) Focused support regarding falls and pressure damage from Deputy Chief Nurse for Innovation &

Improvement 4) Embed Structured Judgment review of death for people with LD and establish plans to use this

methodology to review all death

1) Sepsis and Discharge identified as new High level value streams and commenced May/ August 2018 respectively

2)NEWS2 launched on 10th September, Abbey score for pain

management for dementia in new nursing documentation, Compliance with DOC monitored at Patient Safety and Improved shared learning from incidents being promoted by

5) Identified learning from incidents to be embedded into CEO led monthly Team Talk 6) Chief Nurse monthly newsletter being circulated with weekly safety message as standing item 7) Learning from Never Event session being led by chief nurse and medical director 8) SIRG agenda altered to focus on shared learning and monitoring of actions from previous SI’s 9) Review of moderate incidents undertaken within each Division and analysed by Director of

outcomes. Paper, conclusions and any required actions to be discussed at ECQR February 10) Quality Strategy being drafted and consulted on.

inclusion in Team talk, monthly chief nurse letter, consistent attendance at SIRG

3) Pilot complete, learning being rolled out to all remaining wards, Falls rate per 1000 bed stay days is 3.9 ( below national average) falls with harm 1.16 per 1000 bed stay days.

4) All LD deaths reviewed by clinical chiefs utilising SJR 5) Commenced in September 2018 6) Commenced October 2018 7) Delivered in PGD and well attended on 28

th September 2018

8) Implemented February 2019 9) Tabled for ECQR 17/2/19 10) Final draft due end March

Update by EC 18/02/19 JD 21/02/19

Date discussed at board February 2019

Objective 2 - Effective – As a teaching hospital, deliver effective and sustainable clinical care, which focus on outcomes, innovation and technology

Strategic Theme / Annual priority

Research, Development and

Innovation

Co-design with patients and

partners for better outcomes

Director

responsible

Medical Director


2.1 There is a risk that the Trust will not develop the right models of care for chronic conditions management and frail elderly care if it does not embed processes promoting co-design, relevant research and education programmes and an increased focus on outcomes.

Initial Risk L3 x S3 = 9

Current rating L3 x S3 = 9

Target risk

score

L2 x S3 = 6

Target Date 2yrs

Linked to Risk 1895


1) Agreed Education strategy and Board reports 2) Regular Education and Research and Development reports to SQC / Board 3) Monitoring a range of outcome data

1) Metrics relating to co-design / PROMs (outcome measures) / PREMs (experience measures)

2) League tables for CRN KSS do not measure adoption of research outcomes



1) Regulator and commissioner statements of value (e.g. NIHR?CRN, HEEKSS, BSMS, University of Surrey

2) Bespoke patient surveys 3) Director of Outcomes work on triangulating metrics around outcomes

Positive (+) GMC Survey Results (+) R+D regional reports on studies and recruitment (+) Case studies of co-design


Metrics and strategy milestones to be developed to support assurance


1) Agree strategies, metrics and milestones at Exec and Board 1) March 2019

Update by EC 18/02/19 Date discussed at board February 2019

Objective 2 - Effective – As a teaching hospital, deliver effective and sustainable clinical care, which focus on outcomes, innovation and technology

Strategic Theme / Annual priority Prevention



Directors

responsible

Medical Director

Director of Corporate Affairs


2.2 There is a risk the Trust will not

maximise its potential to contribute to

the public health agenda if it does not

coordinate its focus on prevention and

healthy living with the wider health and

social care system.



Target risk

score

L2 x S3 = 6

Target Date (2yrs+) 2018/20

Linked to Risk None identified


1) Monitoring outcomes for patients –

Dr Foster data utilising Co-morbidity risk stratification

Patient demographics including deprivation

Local Clinical Audit Programme 2) National programme outputs (GIRFT, national audits, PROMs) 3) CQUIN for patients focusing on reducing risky behaviour 4) Patient & Public Engagement Strategy which identified seldom heard groups including those with protected characteristics as identified by the Equality Act 2010 (Age, Disability, Gender reassignment, Marriage and civil partnership, Pregnancy and maternity, Race, Religion or belief, Sex / Gender, Sexual orientation)

5) Agreed smoke free SASH strategy

1) Evidence of co-design for improved outcomes therefore new metrics needed. 2) Strategy for health and wellbeing offering to patients and general public still in

development 3) Mental Health strategy and metrics in development with system partners



1) Strategy for improvement in health for patients and staff 2) Vaccination strategy for staff 3) Alignment with JSNA and STP population health priorities

Positive (+) CQUIN delivery for health and wellbeing (+) PPE and co-design activity taking place e.g. patient support groups, feedback sessions (+) Governor engagement and involvement in working groups and key areas across the Trust including the Big Health & Social Care conversation (+) Endoscopy patient engagement event (+) Mapping of patient engagement and co-design activities taking place (+) Guidance and support for patients and the public approved (+) Election of four new governors


1) Strategy and metrics not yet agreed in relation to ambition for health of non-patient / non staff “foot fall”

2) Development of an engagement and partnerships strategy 3) Trust-wide roll-out and adoption of PPE and co-design tools, techniques and ways of working


1) Agree strategies, metrics and milestones at Exec and Board 1) March 2019

Update by EC 18/02/19 GFM 18/02/19


Objective 3 - Caring – Develop the compassionate care we provide in partnership with patients, staff, families, carers and community services

Strategic Theme / Annual priority Create best environment for

patients

Director

responsible

Chief Nurse



not meet its commitment to learning

from patient feedback to create the

best possible environment if it does

not seek to shape patient centered

clinical services and learn from all

sources of patient feedback.



Target risk

score

S3 x L2 = 6

Target Date (1-2yrs)

Linked to Risk 1506,1775


1) Patient experience committee reviews performance and escalates areas of work and concerns to Executive Committee for Quality & Risk (ECQR) and Board

2) ECQR receives reports and provides feedback regarding patient experience 3) Engagement with the voluntary sector including dementia groups 4) Carers support network, involvement in John’s campaign 5) Open visiting introduced in general ward areas in addition to existing areas 6) High level indicators agreed at Value stream for Discharge including patient

feedback 7) New system procured and in place for YCM 8) Cerner solution for Accessible Information Standard in place 9) Review of patient information at new patient Information review Group

chaired by Director of Corporate Affairs 10) Hospital @night group aiming to reduce noise and aid sleep

Groups and patients which are “seldom heard”

Outpatient FFT not yet able to be analysed by clinic/ service



1) Your Care Matters (YCM) results (including free text comments) 2) FFT scores and free text responses 3) Staff survey 4) National patient surveys 5) Complaints 6) PALS concerns 7) Duty of Candour 8) Engagement with representatives from shadow Council of Governors

(including patient experience committee) 9) Patient feedback with SASH plus improvement work

Positive

(+) CQC Inspector report rated Trust outstanding for Caring

(+) Carers passport

(+) Standards of behaviour and feedback from staff

(+) National cancer survey

(+) National paediatric survey

(+) Patient feedback

(+) Place audit

10) Feedback from open visiting 11) PROMS rolling out to show we care about patients 12) Ward improvement linked to access and signage 13) Involvement of governors and patients in SASH + work, visits to clinical

areas, members of patient experience subcommittee , inclusion group and patient information review group

(+) Improving performance in the number of complaints received

Negative

(-) No clear improvement in YCM or national results relating to discharge or

communication around medication and danger signals

(-) Outpatient YCM comments

(-) Work to achieve full compliance with Accessible Information Standard

(-) Outpatient and Paediatric feedback via YCM

(-) FFT score below target in particular areas , most notably Out patients

(-) Feedback via complaints highlights areas that require improvement


Trust position known - no identified gaps in assurance


1) Implement actions identified in Hospital @ night group to reduce noise and activity at night

2) All Outpatient FFT feedback to be structured to enable this to be analysed by clinic so targeted actions can be taken

3) Each Division to identify the clinic that information already available indicates needs improvement and agree and implement actions designed to improve patient satisfaction

4) Complaints Review Group to identify themed learning from complaints review and share this across divisions in all relevant forums, including patient experience committee. TOR agreed.

5) Local Resolution meetings in place and learning from these must be shared across divisions, at ECQR and Patient Safety Briefings.

6) Patient Experience Committee to focus on key actions initially identified as safe keeping of patient property and available recreational activities. Patient Focus group to be arranged.

1) Actions implemented. Evaluation to be undertaken in two months. Against KPIs to be agreed due January 2) Restructuring of data complete. Preliminary data available end September 2018. Outstanding action. Change in personnel and technical difficulties. Approach agreed at PEC in February 2019 3) Complete. Cardiology and fracture clinic identified, Actions underway 4)Ongoing 5)Ongoing 6) Commenced and ongoing. Documentation in place in ED. Pilot of safe storage boxes for valuables being commenced December 2018.

Update by JD 21/02/19 Date discussed at board February 2019

Objective 4 - Responsive – To continue to be the secondary care provider of choice for the people of our community

Strategic Theme / Annual priority Timely access to services Director

responsible

Chief Operating Officer


4.1 There is a risk that elective

demand will decrease if we do not

offer timely access to elective

services, which will have an adverse

impact on quality outcomes, staff

satisfaction, income and expenditure.



Target risk

score

S4 x L2 = 8

Target Date (2yrs)

Linked to Risk 1491, 1724, 1757, 1838, 1850, 1856/8, 1905/07, 1918,


1) North System Improvement Board and key workstreams

Reduction of Super Stranded Patients

Reducing ED attendances

Reducing non elective admissions 2) SASH System A&E Delivery Board workplan

Urgent and Emergency Care System Wide Escalation Plan Reduction of admissions from Care Homes Initiative

3) Theatre Productivity Project

4) GIRFT reviews and Action Plans

5) Model Hospital Action Plans 6) Ambulatory Pathways 7) Outpatient Board and associated action plans 8) Specialty Plans to ensure first outpatient times less than 12 weeks 9) RTT Recovery Plan

1. Financial position across the health system has potential to undermine efforts

to deliver RTT

2. Limited prospective cover for specialist elective work



1) Integrated Performance Report 2) Benchmarking Report 3) Activity Report 4) Productivity Report 5) Winter Plan 6) SASH Escalation Plan 7) SASH System Escalation Plan

Positive (+) Evidence of increase in elective work through Q3 (+) Delivered surplus in 17/18 and plan in Q1 18/19 (+) Strong elective performance in 17/18 (+) Paper switch off delivered August 2018 (+) Opening of 2 temporary theatres (+) Successful bids for additional funding to support Surrey Social Services (+) Agreed ongoing funding of CHS until March 2019 (+) Review of barriers to flow with NHSI and ECIST Negative (-) Increase in super stranded patients (-) Community capacity does not meet demand (in volume or type) (-) Temporary closure of 2 laminar flow theatres (-) Increase in volume and LOS of patients with complex discharge needs


1) CCG commitment to increase capacity or to agree use of a winter resilience fund 2) Suspension and review of the NSIB through Q3 and Q4


1) Delivery of all actions both at SASH and system wide 1) Ongoing

Update by AS 20/02/19


Objective 5 - Well Led – To be a high quality employer of choice and deliver financial and clinical sustainability around a patient centered, clinically led leadership model

Strategic Theme / Annual priority Integrated health and social care Director

responsible

Chief Executive Officer


5.1 There is a risk that the

Sustainability and Transformation

Partnership does not meet its

requirements to develop an Integrated

Care System which outlines a model

of care that can be sustainably

delivered by the Trust.



Target risk

score

S3 x L3 = 9

Target Date ( 2yrs) Milestone: January 2019 Target date: January 2020



1) STP structure and leadership [Exec Board, Operational Delivery Group, Finance Group and Clinical Board. Plus others];

2) STP also has an Oversight Group 3) National consultation rules, national publication and national leadership of

STPs; 4) Reporting to Board, including Board seminar discussions every other month; 5) Trust strategy plans agreed by Board (part of existing Trust process); 6) New commissioning structure established (Central Sussex Alliance now in

place with new senior staffing – the Alliance was expanded to include East Sussex in September 2018)

7) BSUH Management Contract in place with WSHFT

1) Financial position across the health system 2) Commissioning reshape in progress but strategic direction remains separate from

STP governance 3) Infrastructure resourcing below benchmarked levels of other STPs and difficulties

committing to longer term structures to support STP [but improving] 4) Potential for conflict with organisational objectives and strategic and conditional

behaviours 5) Lack of national formality around STP operations, authority and accountability 6) Interpretation of 2019/20 planning guidance 7) Unclear what changes to the STP structure will happen in April 2019 (flowing from

Regulator joining together and planning guidance)



1) STP meetings, reporting and outputs 2) SASH involvement in STP work streams 3) Board understanding and input into STP solutions 4) Place based plans 5) Output from North System Improvement Board 6) Agreed implementation plans across the STP footprint 7) Engagement and communication plan in place with stakeholders 8) Engagement of relevant stakeholders 9) Feedback from NHSE/NHSI , NAO and others 10) IA report into STP/Trust interaction & governance (completed – to go to next

AAC)

Positive (+) Full Time STP Executive Chair and Programme Director appointed (+) Meeting structure embedded and functioning after review and changes in 2018 (+) Successfully responds to regulator submission requests (+) STP Estate strategy is clearly described (+) CCG consolidation largely complete [CEO position affirmed in January] (+) Improvements in special measures trusts [BSUH rated CQC good in January] (+). (+) Resourcing expectation (from organisations) agreed [Sept 2018] (+) Mental health case for change report provided a clear situation report (+) Board states it is adequately briefed on STP (+) Appointments to STP posts now in train – HRD now appointed.

(+) Draft Case for Change being considered by Trust Boards/Governing Bodies with key themes & priorities

(+) Previous style North System Improvement Board disbanded – to be relaunched in March 2019

Negative (-) STP itself may not be the driver of some of the positive assurances listed (e.g.: CCG consolidation and BSUH improvement) (-) Output from STP workstreams is limited and Place plans remain underdeveloped (affirmed at Operational Delivery Group meeting) (-) Issues over the presentation of clinical strategies and the “case for change” [population health check]. (-) Progress on MH case for change perhaps not as strong as it might be


Several areas listed under sources of assurance (e.g.: agreed implementation plans) do not yet have a clear output – assurance therefore rated as amber.


1) Continue working positively with the STP, including Director engagement in workstreams (ongoing)

2) Deliver North System Improvement Board workstreams (ongoing) 3) Influence the STP Executive through engagement (ongoing) 4) Adapt reporting to Board as work progresses (ongoing) 5) STP Case for Change (on service issues) taken to November Private Board – waiting for

response from STP to comments

Actions proceeding to plan.

Update by PS 19/02/19 Date discussed at board February 2019



responsible

Chief Finance Officer


5.2 There is a risk to the Trust’s short

term financial stability if the annual

income plan is not achieved and/or if

divisional spending exceeds budget.



Target risk

score S3 x L2 = 6

Target Date (2yrs+)

Linked to Risk 1663, 1688, 1689


1) Business Plans & budgets (activity/ financial) waste reduction & productivity plans.

2) Agreed contracts in place – Contracts signed January 2017 for 2 years…agreed indicative activity plan (IAP) and draft expected annual contract value (EACV) for 2018/19 for main CCG contract…but no Contract Variation signed

3) Contract management process in place with CCGs. 4) Financial reporting, including periodic forecast scenarios, is in place and

effective – the first detail forecast went to Board in July (Q1), the next will be October (Q2).

5) A&E Delivery Board and System improvement Board operating 6) NHSi/NHS England Performance Meetings: 7) COO has established “boards” to oversee productivity delivery, emergency

care management & CQUIN 8) Divisional cases to support correction for overspending areas in past year and

agree activity investment in 2018/19

1) No Contract Variation signed to formalize agreed indicative activity plan (IAP) and draft expected annual contract value (EACV) for main CCG contract;

2) No agreement yet over Marginal Rate Emergency Tariff (MRET) review outcome – but escalated negotiation now in progress

3) Linked to #2, strategic management of activity (contract meetings, A&E Delivery & System Improvement Boards) not fully effective

4) Activity demand continues to be a significant issue 5) There is continued overspending at M10 in all clinical Divisions 6) Workforce pressures manifest as agency cost 7) There are activity shortfalls in outpatients and other areas (although better through

Q3 and into M10).



1) Financial performance and contractual reporting to Exec Committee, Finance & Workforce Committee and Trust Board (including CQUIN reporting process).

2) Performance Review and Exec Quality and Risk process with Divisions, monthly contract cycle with CCGs. Service line reporting process

3) Outputs and reporting from contract and information teams 4) Output and reporting from health system management (e.g.: A&E Delivery

Positive (+) Trust delivered an overall (and recurrent) surplus in 2017/18 and settled all historic past year issues with CCGs (+) 2018/19 Q3 plan delivered - PSF will be paid for Q3 (+) Bank increase agreed and pilot implemented. Negative

Board/System Improvement Board) 5) Output of Contract Management Process. 6) Agency and roster PMOs.

(-) The M10 position is adverse to Plan and there are additional pressures from rent and rates rises notified in 2019. (-) Emergency activity pressures continued through the summer, into the Autumn and all clinical divisions are overspending as a result. Post Xmas demand is severe – Trust not functioning optimally, overspending continues (-) Workforce pressures are manifested in additional ADH and agency costs (-) Commissioners around the Trust have significant financial risk – deficits in 2017/18 were substantial (although they are on plan at M09) (-) Too much non elective activity, not enough elective – risk remains over emergency demand


Amber recognizing pressures visible at M10 and data describing income adverse to Plan


1) Operational teams acting to increase outpatient capacity with prospective capacity reporting in place as well as weekly overall activity monitoring - being reported to Execs (weekly – ongoing, including through winter pressures, but obviously that restricts action)

2) Continue performance management of Divisions to deal with activity backlog and meet demand (ongoing – now more frequent than normal monthly cycle – ongoing)

3) Robust contractual process operated and robust response to CCG challenge (ongoing – process has monthly cycle)

4) MRET escalated negotiation now started.

Actions proceeding to timetable.




responsible



5.3 There is a risk to the Trust’s longer

term financial stability if it is unable to

deliver its medium term financial plan.



Target risk

score S4 x L2 = 8

Target Date (2yrs)

Linked to Risk 1603


1) Items referred to in 5.2 above 2) NHSi Plan submitted in April 2018 and accepted 3) Waste reduction plan process in place (including QIA structure) 4) Contracts agreed with commissioners in 2017/18 5) 2018/19 planning shows recurrent surplus with gain from HRG4+ (tariff pricing

change) – but risk in delivering control totals specified. 6) Broader strategic and business planning process being strengthened ahead of

next planning round (for 2019/20 and beyond)

1) Items listed above (5.2) are applicable here 2) Reliance on centrally determined rules for tariff & wider NHS finance regime. 3) Risk over capacity from other operational pressures 4) Overall health system financial view describes significant financial pressures,

some with a structural basis 5) 2019/20 financial regime and NTPS may mean changes – partial information is

available, but not yet finalised. 6) Central actions over NHS spend may have an adverse impact on Trust because

of manner of application (e.g. withholding capital and cash). 7) STP process identifies significant “do nothing” deficit [noting impact of actions

reduces that considerably] – action required to correct, and not yet fully scoped. 8) The error in 2019/20 control totals has not been corrected by regulators –

currently the Trust cannot sign up to the stated figure...



1) Production of 2018/19 budget, financial model, business plan

documentation, and delivery against them 2) Agreed contracts with commissioners describing realistic demand and

acceptable financial values 3) Sign off of 2018/19 Plan, provider sustainability funding with NHS

Improvement in 2018/19

Positive (+)Trust delivered a surplus in 2016/17 and in 2017/18 had a recurrent surplus. The Trust ended 2017/18 with a surplus of £13.6m. (+) Trust’s liquidity position has moved to a [on balance] positive ratio – this and the recurrent surplus are “firsts” for SASH in its history. (+) 2017/19 (i.e.: 2 year) contract signed and although not formalised within a Contract variation an IAP and EACV (see #5.2 above) are agreed with CCGs. Also, all historic CCG disputes were resolved in 2017/18. (+) HRG4+ provided a significant, and recurrent, benefit to the trust in 2017/18

Negative (-) overall health system loss of resource through structural reasons (see “Gaps In Control #4)…health system and wider STP footprint in overall deficit. (-) Announced control totals for 2019/20 remain challenging and an error in that announced for SaSH means the trust cannot sign up to it This runs the risk of losing sustainability funding and MRET repayment).


Amber recognising risks to set against good starting position for 2018/19. To be revised once detail

of 2019/20 changes to financial regime clear.


1) Please see mitigating actions listed for #5.2, but in addition: 2) Refreshed financial model provided and Plan submission made on 12 February – further action

will follow national planning timetable until final submission in April.

Actions proceeding to timetable




responsible

Director of IT and Facilities



5.4 There is a risk of impact on

patients from the delivery of the

Trust’s capital programme caused by

national / local availability and priority

of capital resources if it does not

effectively prioritise and manage its

resources.



Target risk

score

S4 x L1 = 4

Target Date (2yrs)

Linked to Risk 1976


1) Business Plans, Capital Plan (including 5 year plan) & capital budgets. 2) Capital allocation process in place and embedded with monthly Capital

Group 3) Chiefs involved in decision making process for capital budget

prioritisation (through weekly Chief’s meeting); 4) Capital and financial reporting to Execs, FWC and Board (at least

monthly) 5) NHSi notification of capital resource and cash limits, and NHSi

reporting 6) Patient safety and quality reporting and risk registers 7) Clinical informatics Board and EPR programme management 8) Individual capital scheme project groups

1) Agreement of capital loans effectively suspended by NHSi and DHSC 2) An alternative approach delivering the same clinical benefits as the

electronic patient record digitise project would be difficult to create and there is a clinical opportunity cost from not having EPR digitise (safety for sepsis, drug administration, AKI and other areas would be improved by the programme)

3) Additional capital is being made available mainly through various centrally run competitions [the Trust has secured all the capital it asked for through the various routes here, but the control gap remains].

4) Press interest may misinterpret the contents of Board reporting about capital funding availability



1) Capital and financial performance reporting to Exec Committee, Finance & Workforce Committee and Trust Board

2) NHSi notification of capital resource limit 3) Safety and Quality reporting to Exec Committee, Safety & Quality

Committee and trust Board. 4) Clinical informatics Board and EPR programme management reporting 5) Individual capital scheme project group reporting

Positive (+)Trust has delivered its capital resource limit every year, and did so again in 2017/18 (+) Trust’s liquidity position has moved to a positive ratio, and it is making surpluses that provide additional cash (+) robust prioritization process (+) £2.5m of additional CRL was awarded to the Trust as incentive from financial performance in 2017/18 (+) Alternative routes for capital funding are now becoming clearer – that includes

EPMA and STP digital funding. (+) Trust successful in its request for £3.2m of additional CRL funded from cash reserves…and also for the Decant ward (£3.9m)…and also additional funding (£710k) from STP Digitisation fund available for EPR hardware. Negative (-) None currently.


Rated green – capital secured, on track to meet CRL


1) CEO and CFO contact with NHSi and DHSC (including at senior level) about the lack of any decision on the EPR loan (intermittent but ongoing);

2) Participate in EPMA bid in January (completed) 3) Re-profile 2019/20 indicative capital budget (now complete). 4) Strict monitoring on spend (we must deliver the budget now we have secured additional

funding) (ongoing, and with CEO review).

Actions proceeding to timetable



Strategic Theme / Annual priority Integrated health and social care

Recruitment & Retention

Director

responsible

Director of Organisational Development & People



not meet its objectives if it does not

implement the workforce strategy that

drives the recruitment and retention of

talent across all staff groups that

meets patient needs.



Target risk

score

L2 x S3 = 6

Target Date 5 year strategy

Linked to Risk 1633, 1748, 1895, 1938


1) Trust’s five year ‘People & Organisational Development Strategy: 2018 – 2023’ approved by the Trust Board in July 2018

2) The Strategy covers six key themes: Recruitment & Retention Leadership Staff Health Training & Professional Development Staff Engagement & Involvement Workforce Planning

3) Over-arching strategy links to other workforce related strategies, (e.g. Multi-disciplinary Education & Training Strategy; One Team Inclusion Strategy; Retention Strategy) 4) SASH Leadership framework being developed which will support formal leadership development, succession planning and talent management

1) Acknowledged national and regional shortage of key groups of staff (e.g. nurses, doctors, Allied Health Professionals)

2) Recruitment and retention issues contributing to high temporary staffing spend 3) Operational activity levels in the Trust stated as reason by line managers for non-

compliance with Corporate targets 4) External issues outside of SASH control (e.g. Brexit)



1) Progress towards Trust’s Workforce Strategy objectives is reported monthly to the Trust Board; Finance & Workforce Committee; Workforce Committee 2) The quarterly Annual Plan report to the Board also includes People & OD Strategy updates 3) Workforce planning confirmed with NHSi as part of the 2019/20 Operating Plan 4) Key Workforce Indicators (e.g. recruitment, establishment, sickness, turnover, AR compliance, etc.), reported on a monthly basis to the Trust Board; Finance & Workforce Committee; Workforce Committee

Positive

(+) Turnover and vacancy rates have increased for all staff groups (by 0.47%) and for nursing staff (by 0.3%) (+) However vacancy rates for all staff groups (by 0.55%) and nursing staff (by 0.38%) have reduced (+)The Trust had 70 new starters in January across all professional groups (+)There are 237 candidates currently being processed of these 45 are bank and 21 international nurses, due to commence shortly

4) 2018 National Staff Survey results were published, (under embargo), on 8th

February. National publication of full results is due on 26th February

5) CQC Inspection – CQC Outstanding rating for Use of Resources 6) CQC Inspection – CQC Outstanding rating for Well-led

(+) There was a successful graduate nurse recruitment event that resulted in 14 offers (+)The Trust made 184 offers to international nurses during a recruitment event in Kerala, of which 107 are IELTS passed and rest are awaiting their results (+)The Trust received the highest intake of international nurses so far in the recruitment programme when we had 23 nurses commence in January 2019 (+)12 band 5/6 registered nurse or midwives are currently being screened to join the temporary bank. Workers from 25 other professions are also currently completing recruitment checks to join the bank (+) The Trust is re-promoting the EU Settled Status scheme when this reopens in March (+) Medical and nursing staff excluded from Tier 2 restrictions (+) We have been undertaking the initial scoping work with Clever Together in relation to the ‘Best at Work’ programme to support retention (+) Work has been on-going with staff in ED and the Security team to support the reduction of abuse from patients / visitors towards staff (+) The next phase of the SASH Leadership Framework pilot is being developed – will support succession planning and robust talent management (+) Work has been on-going nationally and locally with regard to the removal of Band 1 as part of the new AfC terms & conditions of service Negative (-) SASH was in the lowest 20% nationally in the 2017 National Staff Survey for staff experiencing physical violence from patients, relatives or the public and staff experiencing bullying and harassment from patients, relatives or the public (-) Nursing recruitment challenging with negative effect on Bank and Agency usage (-) Consequences for workforce due to Brexit still to be determined


Ongoing work to improve staff experience of physical violence and bullying and provide assurance of improvement, described in assurances above.


1) Implementing actions agreed in 5 year action plans in the People & OD strategy for the six key themes 2) Action planning from the 2017 National Staff Survey on-going 3) 2018 Achievement Review cascade process completed – KPI target met (i.e. 90% of staff with completed AR) 4) Pro-active recruitment planning in place including international campaigns 5) SASH Leadership Framework being developed and pilot groups identified 6) 2018 National Staff Survey – 64% response rate

1) Trust Board approved People & OD Strategy 2) SLaM staff sessions held to address and support staff resilience – SLaM report issued to Trust for review and implementation 3) Chief Nurse and Director of OD & People meeting with ED colleagues to review incidents of abuse from patients to staff 4) SASH Leadership framework pilot groups identified for next phase of pilot

Update by MP 14/02/19 Date discussed at board February 2019


Strategic Theme / Annual priority Technology as an enabler

Director

responsible

Director of IT and Facilities Medical Director



not fully maximise the opportunities to

use technology in innovation and as

an enabler either due to capability

and/or investment.



Target risk

score

L2 x S3 = 6

Target Date (2yrs)

Linked to Risk 1656, 1798, 1820


1) Nice TA / CG compliance statements 2) Digital Maturity Index 3) EPR Digitise FBC approved by The Board

4) NHS innovation accelerator and innovation and technology tariff program run nationally to promote uptake new technical solutions with evidence to support adoption

1) League tables for uptake of innovation (e.g. uptake of NHS innovation accelerator and innovation technology payment) to be developed

2) Peer comparison 3) Digital strategy as opposed to IT Strategy



1) ‘Patient Knows Best’ in inflammatory bowel disease 2) Skype and secure video conference for relatives on ward rounds 3) Internal report on TTP and NIA uptake (un-bench marked)

Positive (+) Development of plans to implement EPR (+) Procurement output related to technology procurement (+) Effectiveness committee new procedure approval (+) EPR pilot work including monitoring of vital signs (+) Paperless systems implanted in ED and Kingsfold Unit (+) Stroke telemedicine service supporting ‘out of hours’ care


1) New risk against medium term strategy demand vs. capacity and workforce need therefore many gaps that need to be understood and reduced.

2) Some technologies require EPR.


1) Work with STP and AHSN to develop league tables of tech adoption 2) Digital strategy to be developed by February 2019 3) Progress pilot work with NHSI for virtual outpatient clinics (five clinics initially)

1) Ongoing 2) February 2019 3) December 2019

Update by EC 18/02/19 IM 07/01/19




Well-being and rehabilitation

Director

responsible

Director of IT and Facilities



not capitalise on the opportunity to

develop its estate and sites if it does

not seek to ensure the developments

meet the growing and changing needs

of the local population.

Initial Risk L3 x L3 = 9

Current rating L3 x L3 = 9

Target risk

score

L3 x L2 = 6

Target Date (2yrs)



1) Establishment of the East Surrey Hospital Site Development Working Group with clear ToR

2) Monthly reports to the Trust Board in private 3) Revised Estates Strategy being developed

1) None identified at present



1) Compatibility with the wider health and social care system estates strategy 2) Work within relevant legal frameworks 3) Amend governance arrangements for the ESH as plans develop

Positive (+) Clear strategic direction and its supporting data, analysis and reasoning (+) Translation of the strategic direction into a set of development options/opportunities for the ESH site (+) Trust actively engaged with RBBC Local Plan Development


1) Development of an ESH Site Master plan


1) Executive’s exploration of these development opportunities 2) Proposals in relation to the ESH site before recommending to the Board for discussion and

decisions 3) Alignment with JSNA, population health, needs and future workforce pre; STP health and social

care themes & priorities

Working group in early stages of development and implementation of actions

Update by IM 07/01/19 Date discussed at board February 2019





Director

responsible

Medical Director

Chief Operating Officer


5.8 There is a risk the Trust will not

maximise its potential to support

peoples mental health needs if it does

not coordinate its resources and

pathways with local mental health

providers.



Target risk

score

L2 x S2 = 4

Target Date (2yrs)

Linked to Risk 1732


1) Commissioning standards from CCGs 2) Templates for staffing vs population size 3) SASH System AEDB 4) NSIB Mental Health Workstream

1) Gap analysis is not routinely performed 2) Strategy for improvement is not finalised 3) Inadequate mental health practitioner cover out of hours 4) Trusted assessor model not in place 5) No agreed system strategy 6) Capacity for emergency care does not meet demand 7) Pathways for 136 patients not robust 8) CAMHS capacity does not meet demand and there is no out of hours support 9) No escalation process for inpatient emergencies 10) Inpatient psychiatric care 11) No Trust level or divisional level metrics



1) Assurance statements on outcomes from local mental health providers and commissioners

2) Audit information for patients with mental health 3) Patient stories 4) Mental Health strategy published in draft for input from public, staff and

partners

Positive

(+) Escalation Process agreed with MH partners (+) Peer review complete- key issues identified (+) CSESCA board to board in Sept 2018 with SASH identified MH as a joint priority (+) Mental Health Data collection exercise commenced on 7

th January

(+) ‘Core 24’ funding agreed from April 2019


1) Board not sighted on controls and assurances


1) Finalise strategy with commissioners and MHPT to satisfy controls and therefore provide assurance

2) Develop Mental Health dashboard

1) Draft mental health strategy reviewed at Board Seminar Oct 2018 Draft Mental Health Strategy our for consultation Jan/Feb 2019

2) April 2019

Update by AS 20/02/19 EC 18/02/19


Risk Appetite 2018-19

The Board of Directors has developed and agreed the principles of risk that the Trust is prepared to accept, seek and tolerate whilst in the pursuit of its objectives. The Board actively encourages well-managed and defined risk management, acknowledging that service development, innovation and improvements in quality requires risk taking. This position is based on the expectation that there is a demonstrated capability to anticipate and manage the associated risks as well. The key following principles further define this stance with an opinion from the Board:

Quality: The quality of our services, measured by clinical effectiveness, safety, experience and responsiveness is our core business. We will only put the quality of our services at risk if, upon consideration, the benefits of the risk to improve quality are justifiable and the management controls in place are well defined and practicable. Target: Green

Well Led: The Board acknowledges that healthcare and the NHS operates within a highly regulated environment, and that it has to meet high levels of compliance expectations from a large number of regulatory sources. It will meet those expectations within a framework of prudent controls, balancing the prospect of risk reduction and elimination against pragmatic operational imperatives. The Board will seek to innovate and take risks where there is potential to develop inspirational leadership as it recognises that this is key to both becoming the local employer of choice and developing strategic partnerships with new bodies. Target: Green Well Led services /

Amber Leadership development

Financial: The Trust is prepared to invest for return and minimise the possibility of financial loss by managing risk to a tolerable level. The Board will take decisions that may result in an adverse financial performance rating in the face of opportunities that balance safety and quality and are of compelling value and benefit to the organisation. The Board acknowledges that financial challenges throughout 2018/19 will be significant and there will be an expectation of aggressive risk reduction strategies and increased scrutiny of mitigating actions. Target: Amber

Reputation: The Board is prepared to take decisions that have the potential to bring scrutiny of the organisation, provided that potential benefits outweigh the risks and by prospectively managing any reputational consequences. Target: Amber

Workforce: The good will of our staff is important to the Trust. Any decision that places at risk staff morale and has the potential to adversely affect any aspect of the working life of our employees will be balanced very carefully against any potential consequent benefits and will only be considered if the inherent risk is low. The Board recognises the complications attached to recruitment and retention that are caused by geographical and national position and takes this into account when reviewing workforce related risks. Target: Amber

Innovation: The Trust is highly supportive of service development and innovation and will seek to encourage and support it at all levels with a high degree of earned autonomy. We recognise that innovation is essential and drives challenge to current practice both internally and across the wider health economy. Target: Amber

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