Trust Board papers November 2012 - Barking Havering and ...

TRUST BOARD MEETING
Wednesday, 7 November 2012 at 1.00 pm
Board Room, Trust Headquarters
Queen’s Hospital
A G E N D A
1. Apologies for Absence
2. Minutes of the meeting held on 5 September 2012 (Attachment A)
3. Matters Arising and Actions
4. GOVERNANCE:
4.1 Update on Trust-wide CQC action plan (MG) (Attachment B)
4.2 Information Governance (IG) Strategy 2012/13 (NM) (Attachment C)
4.3 Board Assurance Framework 2012 – Quarter 2 (MG) (Attachment D)
4.4 Risk Management Strategy and Policy (MG) (Attachment E)
5. QUALITY AND PATIENT STANDARDS
5.1 Quality & Patient Standards Performance Report – (Attachment F)
September 2012
5.2 Emergency Care Report (DH) (Attachment G)
5.3 Maternity Services Update (DH) (Attachment H)
5.4 Complaints Annual Report 2011/12 (FP-C) (Attachment I)
6. FINANCE, WORKFORCE AND ACTIVITY
6.1 Single Operating Model - Self certification template (NM) (Attachment J)
6.2 Finance Report – Month 6 (September) 2012/13 (DG) (To Follow - Attachment K)
6.3 Workforce Key Performance Indicators (DH) (Attachment L)
6.4 Cost Improvement Update (DH) (Attachment M)
7. INFORMATION
Matters for Noting:
7.1 Chairman and Chief Executive’s Report (Attachment N)
7.2 Minutes of the Quality & Safety Committee meeting held on (Attachment O)
14 August 2012
8. Any Other Business
Date of Next Meeting: The next public meeting will be held on Wednesday,
9 January 2013 at 1.00 p.m. in the Board Room, Trust Headquarters, Queen’s Hospital
9. Questions from the Public
10. Exclusion of the Public and Press In accordance with the Public Bodies Admission to Meetings
Act), to resolve to exclude members of the public and press from the remainder of the meeting.
Trust Board Agenda – 7 November 2012 1

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BARKING, HAVERING AND REDBRIDGE UNIVERSITY
HOSPITALS NHS TRUST
Minutes of the Part I Trust Board Meeting held on the 5 September 2012
in the Board Room, Trust Headquarters, Queen’s Hospital
Present: Mr George Wood Interim Chairman
Mrs Averil Dongworth Chief Executive
Mr Stephen Burgess Director of Clinical Strategy & Deputy Medical Director
Dr Maureen Dalziel Associate Non-Executive Director
Mr William Langley Non-Executive Director
Mr Keith Mahoney Non-Executive Director
Mr Neill Moloney
Director of Planning & Performance
Prof Anthony Warrens Non-Executive Director
Ms Judith Douglas Acting Director of Nursing
Mr David Gilburt
Interim Director of Finance
Mrs Dorothy Hosein Director of Transformation
Ms Caroline Wright Non-Executive Director
Mr Michael White
Non-Executive Director
In Attendance: Mr Nick Hulme Project Director, Integration
Ms Imogen Shillito
Director of Communications
Mrs Sue Williams
Executive Assistant/Trust Board Secretary
Ms Heather Wright Team Leader for Palliative Care
Dr Andrew Gage
Palliative Care Consultant
Dr Derek Hicks
Clinical Director, Emergency Care
2012/042 APOLOGIES FOR ABSENCE
Mrs Cathy Geddes, Chief Operating Officer, Dr Mike Gill, Medical Director and Mrs Marie Gabriel, Chair of
NELC.
2012/043 MINUTES OF THE PART I MEETING HELD ON 4 JULY 2012
The minutes of the Part I meeting held on the 4 July 2012 were noted as a true record and signed by the
Interim Chairman.
2012/044 MATTERS ARISING
2012/011: Quality & Safety Committee continuing to review the Patient Stories paper and would make their
recommendations to the Trust Board at a future meeting.
2012/045 BOARD ASSURANCE FRAMEWORK
Mr Burgess presented the Board Assurance Framework (BAF) for the first quarter of 2012. He confirmed
that following discussions at previous Trust Board meetings and at the Trust Executive Committee, there
had been a progressive journey of improvement to the BAF and the comments at these meetings had been
incorporated into the latest version.
Mr Wood questioned when there would be a coordinated output from the Learning Lessons Group
identified against Risk No 339. The Board was informed that this Group had been established by the
previous Director of Nursing and responsibility for this area had now been moved to one of the Deputy
Directors of Nursing, Gary Etheridge. Ms Douglas confirmed that one meeting had taken place to date and
another was scheduled for mid-September. The Group were amalgamating information/intelligence from
different sources in the organisation, including clinical and non-clinical, complaints, compliments, claims
and safeguarding and would be preparing an action plan to go out to the Directorates and the Corporate
areas for them to prioritise the main areas for resolution and to learn from the issues identified. It was
agreed that the action plan would feed into the Quality & Safety Committee.
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Following Mr White’s concerns raised around the ownership of risk management and the sequence of
presenting papers to different Trust Committees, the Chief Executive confirmed that this was an area that
would be picked up by the new appointment of a Director of Governance and Special Projects who would
be starting with the Trust on the 10 September. The Board noted that the overall Board Assurance would
report through the Trust Executive Committee and on to the Trust Board. The Clinical Governance Team
was meeting with each Directorate and going through a rigorous training programme, in order to ensure
that everyone understood the process. The Trust, through this new appointment, would be working
towards Integrated Governance throughout the organisation.
Dr Dalziel was concerned that the ‘Corporate Risks by Year’ chart did not provide a good comparison
between 2011 and 2012 and she could not get a sense of whether the Trust had made improvements in
going from quite a few risks, to less risks. The performance in 2011 looked to have doubled from the
analysis in 2009 and 2010. It was agreed by the Board that when presenting this type of information, the
report should include some narrative, in order to explain the trends. It was agreed that Mr Moloney,
through the Performance/Information Department, would look at the quality control of information being
presented to the Board to ensure it was meaningful for the members and complied with Information
Governance. Dr Dalziel also felt that it was important to link these analyses to staffing and vacancy levels,
as this information could not sit outside of this and needed to be linked to it in some way to ensure
correlation of data.
The Trust Board noted the changes to the Board Assurance Framework.
Action: Neill Moloney 7.11.12
2012/046 QUALITY & PATIENT STANDARDS PERFORMANCE REPORT – JULY 2012
Mr Moloney informed the Board that there had been three MRSA bacteraemias reported during the month,
bringing the Trust’s total up to five. Unfortunately since the report had been finalised, another case had
been reported, bringing the total to six, against a yearly target of seven. It was felt that the target would be
breached by the end of the year.
He also reported that the complaints performance had returned to ‘green’ and the Trust had achieved 87%
for its response times during the month of July. Another area to note was that length of stay had improved
on non-elective, but worryingly DTOCs had not reduced; increased from 4.39% in June to 4.69% in July.
Mr Mahoney raised the performance for MRSA Screening and the Trust’s position compared with other
Trusts. The Board noted that this area had been discussed in detail with the Directorates, both for elective
and non-elective and there had been a considerable amount of work ongoing since August to ensure an
improvement in performance over the next two to three months. The Emergency Department was also
looking at the Emergency Medicine Decision Unit (EMDU) to capture all the patients going through there as
well, so this would contribute to the improvement in performance. Mr Moloney informed the Board that it
had been made very clear at the Directorate Performance Review meetings recently that the performance
against this target had to improve. The Interim Deputy Director of Nursing, Gary Etheridge had taken on
responsibility for patient experience and he was currently taking a different approach to the implementation
of the hand held devices, in order to encourage both patients and their relatives to complete the
questionnaires. The Board agreed that this had to be part of the discharge process, so the Trust had some
good quality data to refer to.
The Interim Chairman raised his concerns regarding the drop in performance for appraisals (72.69%, a
drop of 3.71% on last month’s position) and whether this meant that the Trust had a large number of staff in
the organisation who did not have their objectives set for the next year. The Board agreed that it was very
important for staff to have their objectives set, in order to performance manage people appropriately. It had
been agreed at a previous Board meeting that Clinical Directors would ensure appraisals and objectives
were aligned and cascaded down through their Directorates. The Chief Executive would take this up with
the two Executive Directors currently covering the Chief Operating Officer’s responsibilities, namely Mrs
Hosein and Mr Hulme, to ensure that the Associate Directors and other senior management had their
objectives. The Chief Executive would provide the appropriate evidence for the Board.
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Following Dr Dalziel’s comments regarding staff turnover and sickness absence, Mr Moloney confirmed
that the Trust’s position was lower than the National average and it was the organisation’s ambition to
reduce sickness absence down to the London average of 3.6%. The Trust had looked at other Trusts
where they had been successful in addressing sickness absence and a Sickness Absence Plan paper had
been prepared for the private Trust Board meeting later in the day. It was also agreed that Mrs Hosein
and Mr Moloney would arrange for the staff turnover figure to be validated, as the trend indicated that this
was going up.
The Trust Board noted the content of the report and supported the actions to bring the performance back in
line with trajectory/target.
Action: Averil Dongworth 7.11.12
Dorothy Hosein/Neill Moloney 7.11.12
2012/047 EMERGENCY CARE/RESET PROGRAMME UPDATE
Dr Derek Hicks, Clinical Director for Emergency Care, attended the meeting to answer questions on the
update report. He confirmed that the recent changes in the Department should allow the Trust to sustain
and remain on the current trajectory. The Interim Chairman raised his concerns regarding patients being
left to the last five minutes of the 4 hours, even when beds were available, leaving little room for
unexpected events. It was agreed a cultural change was required by everyone, as there had in the past
been no pressure to move patients as soon as a decision was made. This was happening in some areas
more than others and the Trust was looking at Consultants and Senior Nurses performances to see if there
were any patterns of behaviour that could be addressed, in order to make people accountable for these
delays. Following a point raised by the Interim Chairman, it was noted that although it was not within the
Trust’s remit to amend Health Needs Assessment Forms, it was pushing to have them changed/modified to
reduce the time it took to complete them. The Trust was also undertaking a lot of work with the Wards, in
order to alleviate what was an onerous task with the double entry of data. This was an area that would be
rectified with the implementation of the new PAS, but in the meantime the Board asked the IT Department
to look into a short term solution that would minimise the time involved.
Mr Langley raised the issue of inappropriate admissions and if there was a periodic Audit to check these.
Dr Hicks confirmed that there was an increase in senior presence in the Department now and patients
would be filtered more effectively. He also informed the Board that there were better controls for
managing patients in the Emergency Department and the Medical Assessment Unit and the recruitment
programme was quite well advanced, which would enable the organisation to take out more bank and
agency staff. Mr White commented on the low number of discharges pre-11.00 a.m. and was concerned
that the Trust had the right processes in place to deal with these. As the discharges remained low, Mr
White questioned whether the Discharge Lounge was working as well as the Trust expected it to. Dr Hicks
informed the Board that the organisation was trying to get flow throughout the day and there were a lot of
initiatives around discharging patients pre-11.00 a.m. and for using the Discharge Lounge. Discharges
were coming up late in the day, so the Trust would be looking at how many discharges were required by
11.00 a.m. and would be holding people to account for this. The Board noted that the new Medical
Director, Dr Mike Gill, would be undertaking two sessions in the Emergency Department around Care of
the Elderly, in order to assist in turning these patients around much quicker and ensuring appropriate
admissions were being made. From next week there would be a Care of the Elderly Consultant in the
Emergency Department everyday. The Trust had undertaken an Audit last year, in conjunction with the
local GPs, to look at the quality of admissions and this exercise was going to be repeated again this year.
This would provide a healthy clinical challenge with GPs and the Trust’s clinicians looking at BHRUT’s
practice and would provide the evidence that the Trust was not inappropriately admitting patients.
Mr White referred to the next steps for the improvement in the emergency pathway; ‘create joint team with
community and social care to completely redesign and manage complex frail patients’ and questioned the
Trust’s confidence in having this process in place to prevent some of the problems experienced last Winter.
It was confirmed that this was an ongoing process and there were daily Jonah meetings, monthly Cross
Buffer Group meetings and the Trust was just about to commence weekly meetings with the Cluster to
strengthen processes, in order to get the patients discharged as soon as possible. The Board noted that
last week the Trust had eleven/twelve patients waiting for community beds and the problem was going to
get significantly worse. The Board therefore asked for a document to be prepared that showed the Trust’s
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forecast in terms of community bed requirements, including the plans the Cluster was going to put in place
to bridge the gap in available community beds. It was noted that the Trust was developing its own Winter
Plan and it was agreed that the Director of Transformation would bring back the composite plan, based on
credible data, to the next meeting, in order to provide the Board with the evidence it required. Executive
Directors of BHRUT would be meeting with the Cluster for a Clinical Strategy Day on the 21 September, in
order to share the work on their different Workstreams and use it as a good opportunity to highlight the
issues; admission criteria into nursing homes and lack of community beds. This engagement would assist
in bringing all of this to a conclusion before Winter arrived.
Dr Dalziel raised the issue of how the organisation presented performance information and whether targets
were right, as with the Trust’s previous experience, it should have more of a feel around realistic targets
and should not be over estimating what is considered to be an achievable target/performance level. She
felt that the Trust should be transparent about what was reasonable and how it presented this externally,
otherwise it would always look like it had failed.
The Chief Executive informed the Board that she would be attending a meeting tomorrow with the
Consultant Physicians regarding seven day working. There was also a Surgery ‘Awayday’ planned for
tomorrow where they would be looking at how the Surgeons would provide 7/7 working. The Board noted
that by the end of the financial year, the Consultants should be working twelve hour shifts and have 7/7
working in place.
The Outline Business Case (OBC), which included the closure of the Emergency Department at King
George Hospital, had not yet been completed, but Ernst & Young was working with the Trust to put
together a plan for Queen’s and King George Hospitals, which would include the cost of moving A&E
across from KGH to Queen’s. The OBC should be completed by the end of October/beginning of
November and would be made available for the public to review.
The Trust Board noted the update.
Action: Averil Dongworth 7.11.12
Dorothy Hosein 7.11.12
2012/048 MATERNITY SERVICES UPDATE
The Trust Board noted the content of the Maternity Services Monthly Performance Report covering the
period 1 July to 31 July 2012. At previous Board meetings Ms Wright had raised the issue of data
recorded for the ‘Out of Hours’ Obstetric Assessment Unit (OAU) not being robust and wanted to know
when this would be addressed, as there did not appear to be any explanation for her to know that this was
being handled appropriately and the Board had reliable information to monitor performance against. In the
current format it was difficult to assess whether there had been any improvement, or not.
The timing of Caesarean Section (C/S) Deliveries according to acuity were discussed and it was noted by
the Board that delays attributed to clinicians/anaesthetists required elsewhere, due to a busy Labour Ward
and Theatres, was stated as being in the top three reasons for delays. The Board agreed that it would be
helpful for them to understand the proportion of these delays by Grade 1, Grade 2 and Grades 3 & 4 and
what took precedence over these C/S’s. The Chief Executive agreed to look into this and to report back to
the Trust Board. Mrs Dongworth would also seek assurance from the Directorate that the clinical fellow
pathway had been implemented on the 30 July 2012.
The transfer of some of the Trust’s midwives, due to the changes in boundaries, was discussed and the
Chief Executive informed the Board that there would be further discussions regarding this later this week.
Mr Mahoney highlighted to the Board that he had concerns around the TUPE across of midwives to other
Trusts in the Cluster, when the births at BHRUT had increased for the second month and the organisation
was still delivering over 9k, although the Trust had been assured by the Commissioners that this would not
be the case by the end of the financial year.
The Board agreed that it was important to have agreement on the Workforce Plan for the future, in order to
ensure a safe service was operating, but the Directorate was not over resourced and left with stranded
costs. The Board noted that the Clinical Director for Maternity and the Director of Midwifery had been
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working with the Cluster over the last few months to ensure the Trust was confident that it would be
operating a safe service by the time it opened the Midwifery Led Unit and closed Maternity Services on the
King George Hospital site. A shift in the practice of women being referred from GPs to the different
catchment areas was already evident, but it was agreed that it would be useful for members of the Board to
receive a much more detailed briefing paper/visual schematic outlining all of this, in order that it could be
explicitly understood and risk managed, as it was a very complex plan.
The Commissioners had been informed that BHRUT felt that it was really important to get everything right
before signing up to any plan that would put its patients at risk.
The Trust Board noted the content of the report.
Action: Averil Dongworth 7.11.12
2012/049 BARKING & DAGENHAM SAFEGUARDING CHILDREN BOARD (BDSCB) ANNUAL
REPORT 2011/12
Ms Douglas presented the Barking & Dagenham Safeguarding Children Board Annual Report for 2011/12.
Several questions from the report were raised by members of the Board, including the Interim Chairman’s
reference to the Child Death Overview Panel looking at trends and patterns and making recommendations,
but it was not evident from the report what these recommendations, or trends, actually were. The Board
agreed it was important for the Trust to follow through on any actions required and to support the Local
Authority in the identification of any trends.
Mr White commented that this report only referred to one Safeguarding Board and he wanted assurance
that the Trust was represented on the Boards of other Boroughs. He also referred to the Trust’s
attendance on the Training Programme, as the report was indicating zero for BHRUT. Ms Douglas
confirmed that the Trust had a very robust in-house Training Programme for Safeguarding Children and
Safeguarding Adults and reassured the Board members that BHRUT did have representation at each
Borough’s Safeguarding Board meetings. The Director of Nursing was a member of each Board and Ms
Douglas would ensure, when the new Director of Nursing arrived, that appropriate representation was
timetabled for Executive Director attendance across all Boroughs. The Trust was committed to delivering
its role in the Safeguarding agenda and apart from one meeting when Ms Wheeler was not available, the
Trust now had much better representation at these meetings, and would be more of an active partner in the
future.
The Board agreed that once all the Local Borough reports had been received the Nursing Directorate
would identify someone to sit down and cross reference them all to make sure the Trust was meeting its
commitments in a timely way. It was also agreed that there would be a more comprehensive discussion
around this subject at a future Board meeting, in order to pro-actively comment on these reports. The
Board asked for a list of forthcoming reports to be prepared, so the Board was aware of the publication
dates, prior to them being issued.
The Trust Board noted the Annual Report.
Action: Judith Douglas 7.11.12
2012/050 BHRUT TFA COMPOSITE PLAN
Mr Moloney presented the revised TFA Composite Plan, which had now been signed off by the Cluster and
NHS London. The content was similar to what had been included in the Performance Report and what had
been presented previously to the Board, although there were a number of key milestones that required a
due date for delivery to be inserted in the plan. The Trust would now be reporting to NHS London on a
monthly basis.
Some milestones had been removed, as they had already been delivered and to a large extent the Trust
was now rated ‘amber’ or ‘green’. The Trust would be closely monitoring the timeframes for delivery
through to the end of the financial year. Following a comment from Dr Dalziel, Mr Moloney would arrange
for the TFA to indicate the trends on the key milestones, in order to make the current position much clearer.
Mr Gilburt would ensure that the summary progress in the Financial Viability section was aligned to the
Finance Report, as there was a discrepancy on the figure relating to the Cost Improvement Programme.
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The Trust Board noted the Plan for the period ending August 2012.
Action: Neill Moloney 30.9.12
David Gilburt 30.9.12
2012/051 FINANCE REPORT – MONTH 4 (JULY) 2012/13
Mr Gilburt highlighted the key points in the Finance Report for Month 4. The Trust was reporting a year to
date deficit of £16.9m, excluding impairments and IFRS adjustment, against the year end control total of
£40m. The deficit in month was £3.9m, which was ahead of where the Trust wanted to be and it was
therefore taking measures to bring the in month expenditure down. Further short term actions were also
being implemented to put a ‘cap’ on discretionary spending within the organisation, in order to get back on
track. The Board noted that the agreed income re-profiling had been fully reflected in the position.
Mr Gilburt reported that there was a credible plan for delivery of £17m CIPs and the Trust had identified
other schemes to address the £6m gap. At present it was not clear that these schemes would deliver this
year and it was therefore undertaking some further work on this with Ernst & Young. He also informed the
Board that the Trust was doing a lot of work with the Commissioners around payment for the over
performance in activity going through the Trust. Mr Gilburt confirmed that the Commissioners were being
very cooperative in these discussions regarding the funding of the over performance and this would play a
key part in the Trust delivering its financial target. The Trust was also talking to NHS London regarding PFI
funding, which had been previously indicated and the Trust was doing everything they were being asked to
do to get NHS London to release this funding, which could result in a lower control total at the end of the
year.
Following an issue raised by Mr Langley regarding procurement, Mr Gilburt confirmed that all purchases
had to go through the central procurement route and had to have a purchase order. Suppliers had been
informed that unless they had an official purchase order they would not be paid and there were
arrangements in place to follow this process. As previously advised, the Capital Programme had been
frozen, but there were ongoing schemes that the Trust had contractually signed up to, or were clinically
essential, that were going ahead. Mr Gilburt and Mr Moloney were taking a rigorous look at the
Programme and had arranged for a review meeting to take place next week to look at priority schemes, as
the organisation was reluctant to sign-off any additional schemes until this review had taken place.
Mr Gilburt highlighted that the Trust had recently received an injection of cash from the Commissioners and
would be monitoring cash flow carefully up to the end of the financial year.
The Trust Board noted the report.
Action: David Gilburt/Neill Moloney 7.11.12
2012/052 WORKFORCE KEY PERFORMANCE INDICATORS – JULY 2012
Mrs Hosein informed the Board that the Trust’s sickness absence rate for the month of July had increased
by 0.59% on the June position, increasing from 4% to 4.59%, but had decreased by 0.46% when compared
to the same period last year. She reported that there was a lot of work ongoing with the Wards regarding
short term sickness and the Trust was also strengthening the governance around vacancies and
scrutinising the recruitment of new staff. The Board acknowledged that there would continue to be a level
of recruitment, in order to bring down the bank/agency staff numbers.
In terms of workforce, Mrs Hosein reported that the Trust would be reviewing a lot of its policies, in
conjunction with the Joint Staff Committee, now the new Head of Workforce Transformation was in post.
The Board noted that the difference in the workforce numbers reported in this report and the Finance
Report was due to the Trust having to report staff that had transferred to Sodexo under ROE, as these
members of staff maintained their terms and conditions of employment with BHRUT.
The Trust Board noted the report.
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2012/053 TRANSFORMATION BOARD UPDATE
Mrs Hosein informed the Board that against the CIP target of £23.1m, the Trust had identified £17.6m,
following a review carried out by Ernst & Young. Further schemes were being worked on to address the
gap and the Project Management Office/Service Transformation Team was working with the Workstream
Leads to strengthen the existing schemes, in order to ensure delivery.
The Programme had delivered the target for last month and would be working towards achieving a £2m run
rate by the end of March. One Ward had been closed and the Team was currently working up a further
proposal to close another Ward. Accountability meetings with the SRO’s were continuing to ensure the
Programme was kept on track. The Board was asked to refer to a table within the Finance Report, which
set out the workstreams and the deliverables for the CIP.
Mr Langley raised the issue of improving and embedding controls in relation to bank and agency staff and
Mrs Hosein confirmed that a lot of work had been put into this with the Wards and they would now be
concentrating and drilling down on the medical spend. Each Directorate had been asked to identify their
medical staff expenditure and to come back with their short, medium and long term actions on how they
would reduce their bank and agency spend in this area, albeit there were obviously still recruitment issues
in some areas, e.g. Emergency Department.
The Trust Board noted the update report.
2012/054 ANNUAL AUDIT LETTER 2011/12
The Trust Board noted the Annual Audit Letter 2011/12 submitted to the Trust from the Audit Commission.
2012/055 END OF LIFE CARE ADVISORY BOARD – BRIEFING PAPER
Ms Heather Wright, Team Leader for Palliative Care and Dr Andrew Gage, Palliative Care Consultant
presented their end of life video. Dr Gage informed the Board that along with Dr Claire Bates, they had
developed the End of Life Care (EOLC) Advisory Board (ELCAB), which aimed to facilitate the
implementation of the EOLC Strategy (2008) and NICE End of Life Quality Standards (2011) within the
Trust. The Strategy was comprehensive and would assist the Trust in improving practices in the short term
and for the longer term change the culture of End of Life Care. Dr Gage highlighted that there were a high
number of deaths in Outer North East London (ONEL), compared with the rest of the Country and the
ONEL community palliative care services were poorly resourced, with inequity across the Boroughs. The
Board noted that there was a CQUIN for EOLC, which commenced in April this year following negotiation
with the Commissioners to ensure there was a realistic, but challenging goal agreed (c.£478k to the Trust).
It was acknowledged that the education of Doctors was important and they had developed a bespoke DVD
for the ‘Dying Matters Week’ in order to empower and support Trust clinicians to take on the responsibility
themselves. Ms Wright informed the Board that the Dying Matters Coalition wanted to put the Trust’s DVD
on their website, after addressing any copyright issues.
The Board was advised that there were Borough Facilitators who trained staff in the nursing and residential
homes, but access to specialist palliative care seven days a week, or ’out of hours’, was difficult, as the
community and the acute sector were not joined up at the moment.
The Directorate had been highlighting since 2004 the requirement for an additional nurse at the Trust. The
organisation also needed to address the under resourcing of specialist beds. The number of in hospital
deaths occurring on the Liverpool Care Pathway was raised by the Interim Chairman, as well as the
available bed base. Dr Gage confirmed that the current figure for these beds in this locality was three per
100k population, against seven in Tower Hamlets and 4.55 for the Trust, which was below the National
average. Dr Gage also informed the Board that Redbridge and Waltham Forest were under resourced for
24 hour cover. Mr Wood would take this up outside of the meeting, in order to assist in moving things
forward in this area.
It was noted that this paper had not been through the normal channels and discussions had not taken
place at Executive Director level. The Quality & Safety Committee would therefore review the issues
raised and recommend the appropriate actions to be taken.
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The Co-Chair of the Improving Patient Experience Group (IPEG) Mrs Elaine Clarke raised the point that
there was no provision for End of Life Care for patients with long term conditions, as with these patients it
was difficult to assess when they would die. The Quality & Safety Committee would also consider this
cohort of patients and provide the Board with their recommendations.
The Board noted the key achievements during 2011/12 and the work now in progress.
The Trust Board agreed that the Quality & Safety Committee should discuss and agree the named
Executive Trust Lead for End of Life Care and this individual would chair the End of Life Care Advisory
Board (previously chaired by the Director of Nursing).
Action: Caroline Wright/Anthony Warrens 7.11.12
2012/056 DEMENTIA STRATEGY – PHASE 2
Ms Douglas presented the Dementia Strategy – Phase 2, which included meeting the National CQUIN and
the roll out of the Butterfly Scheme. All the work in the Dementia Strategy would be undertaken in
conjunction with the Elderly Care Strategy.
The Dementia Strategy was launched in 2010 and following a gap analysis against the National Dementia
Strategy, 17 key objectives were agreed. Ms Douglas informed the Board that a Dementia Steering Group
had been established and an Action Plan agreed. She also confirmed that the Trust’s overall
responsibilities would be monitored through the Action Plan, in order to ensure a smooth pathway from the
community into hospital. BHRUT had worked with North East London Foundation Trust (NELFT), as they
were the leading partner for this Strategy. This Strategy was part of the operational plan requirements
from the Department of Health to improve Dementia Services for all. The Board agreed it would be useful
to see the framework of the organisations involved, in order to understand the structure.
It was noted by the Board that the Borough of Havering had the highest population numbers in this
category and this was going to increase by at least 15% over the next ten to fifteen years. The Trust
therefore needed to prepare for this and be assured that someone would be taking this on, as the Board
did not currently have confidence that the organisation was in a position to meet the challenges that would
present themselves over the coming years. The Chief Executive advised the Board that she would be
attending an Integrated Care Coalition meeting with members of the Cluster tomorrow and she would
ensure that the Board’s concerns were raised there.
Dr Dalziel referred to the earlier End of Life presentation and the requirement for both of these to be linked
in a different cultural approach towards people dying, whether they had dementia or not. A lot of patients
were at home, rather than in hospital, and it should be acknowledged that this was quite complicated and
needed to be brought together in some way.
The Interim Chairman raised the point relating to Discharge Coordination rated ‘red’ in the Action Plan and
the requirement for a Trust Lead to be agreed as part of the restructure. Ms Douglas confirmed to the
Board that there was a lot of work ongoing on the Wards regarding the discharge coordination of patients
with dementia, in order to ensure patients were being discharged appropriately. The identification of a
Trust Lead was obviously a priority, as the Action Plan stated the timescale as January 2012. Questions
were raised as to why this timescale had slipped and how this fitted into the whole Governance
Framework. The Board agreed that Ms Douglas would go back and review with the relevant clinicians if
there was a case to recruit someone for this post, or for Dr Mike Gill, the Medical Director, to be the Lead.
Mr Langley referred to a further ‘red’ rated theme on the Expected Outcome Measures in relation to
Improved patient and carer experience and the outcome noted as ‘data non specific for dementia’. He had
concerns that there was insufficient measurement criteria to provide comfort to the Board. Ms Douglas
agreed that there was some work to do on this linking to the patient pathway and the Butterfly Scheme and
she informed the Board that this would all be tied together.
The Board noted the impact of dementia and the staggering numbers involved with 700k people living with
dementia in England, with this number likely to double over the next thirty years, costing the UK economy
£17bn per year. With the expected increase in patients, the costs in the next thirty years would rise to
Trust Board Minutes Part I – 5 September 2012

9
£50bn a year. It was also noted by the Board that the number of people over the age of 65 would increase
by 15% and over age 85 would increase by 27%. With the number of older people in the population
continuing to rise, it was likely the future cost of dementia care would increase considerably.
The Board agreed that all reports of this nature should be presented to the Quality & Safety Committee,
prior to coming to the Trust Board.
The Trust Board supported the ongoing development of the work and agreed that Ms Douglas would look
into who would be the Executive Champion/Lead for Dementia/Elderly Care.
2012/057 MATTERS FOR NOTING:
INTERIM CHAIR AND CHIEF EXECUTIVE’S REPORT
The Trust Board noted the Interim Chair and Chief Executive’s Report.
2012/058 DECLARATION OF MEMBERS’ INTERESTS 2012/13 UPDATE
The Trust Board noted the Declaration of Members’ Interests 2012/13 Update.
Action: Averil Dongworth 6.9.12
Judith Douglas 7.11.12
2012/059 MINUTES OF THE QUALITY & SAFETY COMMITTEE MEETING HELD ON THE
12 JUNE 2012
The Trust Board noted the minutes of the Quality & Safety Committee meeting held on the 12 June 2012.
2012/060 MINUTES OF THE CHARITABLE FUNDS COMMITTEE MEETING HELD ON THE
29 MAY 2012
The Trust Board noted the minutes of the Charitable Funds Committee meeting held on the 29 May 2012.
2012/061 ANY OTHER BUSINESS
No further business.
Meeting closed at 3.30 p.m.
The next meeting of the Barking, Havering and Redbridge University Hospitals NHS Trust Board will take
place on Wednesday, 7 November 2012 in the Board Room, Trust Headquarters, Queen’s Hospital.
Trust Board Minutes Part I – 5 September 2012

TRUST BOARD MEETING
Actions from Minutes of Part I meeting held on 5 September 2012
in the Board Room, Trust Headquarters, Queen’s Hospital
Agenda Item Action Deadline
Date
Date
Completed/Upd
ate/
Agenda Item
2012/011
(Issues for
Escalation from
Quality & Safety
Committee)
2012/031
(Learning Disability
Progress Report)
2012/032
(Milestone
Tracker/Composite
Plan)
2012/045
(Board Assurance
Framework)
Review Patient Stories paper at
Quality & Safety Committee and
prepare proposal for Trust Board
members to review at
September Trust Board meeting.
Check mechanisms in place in
each Borough regarding health
checks for people with learning
disabilities.
Draft OBC to be presented at
August Trust Board meeting.
Review quality control of
information being presented to
the Board and ensure it
complies with Information
Governance.
CW/AW 5.9.12 Deferred
PW 5.9.12
(advise SW when
proposal ready to
present)
NH 1.8.12 Deferred to
November
NM 7.11.12 7.11.12
2012/046
(Quality & Patient
Standards
Performance
Report – July 2012)
Ensure Clinical Directors
objectives are set and they are
cascading down through their
Directorates.
Review staff turnover figure, as
trend indicated this was going
up.
AD
DH/NM
7.11.12
7.11.12
7.11.12
7.11.12
2012/047
(Emergency
Care/RESET
Programme Update
Arrange for the IT Department to
review the double entry of data
for Health Needs Assessment
Forms and look at a short term
solution that could minimise the
time involved in completing
these.
Composite Plan around Trust’s
forecast for community beds, in
AD
DH
7.11.12
7.11.12
7.11.12
Trust Board Meeting (Part I) 5 September 2012

Agenda Item Action Deadline
Date
Date
Completed/Upd
ate/
Agenda Item
2012/048
(Maternity Services
Update)
2012/049
(Barking &
Dagenham
Safeguarding
Children Board
(BDSCB) Annual
Report 2011/12)
2012/050
(BHRUT TFA
Composite Plan)
2012/051
(Finance Report –
Month 4 (July)
2012/13)
2012/055
(End of Life Care
Advisory Board –
Briefing Paper)
2012/056
(Dementia Strategy
– Phase 2)
relation to Winter Plan, including
plans the Cluster is putting in
place to bridge the gap in
available community beds, to be
presented at the November
Board meeting.
Review reasons for delays for
C/S deliveries, by Grade, and
report back to the Board at the
next meeting in November.
Ensure there is a timetable for
appropriate Executive Director
representation at Safeguarding
Board meetings, across all
Boroughs.
Prepare a list of forthcoming
reports, so the Board is aware of
the publication dates for these,
prior to them being issued.
Arrange for the TFA to indicate
the trends on the key
milestones.
Ensure the summary progress in
the Financial Viability section is
aligned to the Finance Report.
Review Capital Programme to
identify priority schemes.
Quality & Safety Committee to
consider the cohort of patients
with long term conditions in
relation to their End of Life Care
and provide the Board with their
recommendations for addressing
this.
Agree Executive Trust Lead for
End of Life Care at the next
Quality & Safety Committee
meeting and advise Board
members.
Attend Integrated Care Coalition
meeting and raise Board’s
concerns in relation to the
challenge ahead for patients
with Dementia, considering the
AD 7.11.12 7.11.12
JD
JD
NM
DG
7.11.12
7.11.12
30.9.12
30.9.12
7.11.12
7.11.12
Format of plan
has now
changed.
30.9.12
DG/NM 7.11.12 Review has
taken place and
has been
presented to
the Finance
Committee
CW/AW
CW/AW
7.11.12
7.11.12 7.11.12
AD 6.9.12 6.9.12
Trust Board Meeting (Part I) 5 September 2012

Agenda Item Action Deadline
Date
Date
Completed/Upd
ate/
Agenda Item
increasing population numbers.
Agree an Executive
Champion/Lead for
Dementia/Elderly Care and
advise Board members (as
above).
JD 7.11.12 7.11.12
Chairman …………………
Date …………………..
Trust Board Meeting (Part I) 5 September 2012

TRUST BOARD MEETING
5 September 2012
Board Room, Trust Headquarters, Queen’s Hospital
Points and Questions raised by members of the Public
at the above Trust Board meeting
Question:
In reference to the Maternity Services
Update report and the transfer of
women to other Trusts with the change
in boundaries, Mr Skillman asked if
patient choice was taken into account
when transferring women, as this had
been highlighted when the Survey was
undertaken regarding the closure of
Maternity Services at King George
Hospital (the vast majority of women
had confirmed in the Survey that they
wanted to give birth at KGH). He was
concerned that there would not be any
patient choice whatsoever if the
proposals came to fruition.
Response/Action:
The Chief Executive confirmed that
there would be a choice for women and
this would be managed by the GPs.
The Trust would want women to be
delivering their babies as close to home
as possible, but it needed to be open
and honest about its capacity issues, to
ensure it was running a safe service. It
was acknowledged that the proposal did
take away some choice for women.
Mr Skillman raised the point that the
number of deliveries at the Trust had
been discussed at the recent Overview
& Scrutiny Committee meeting with
Heather Mullin, as they differed from
the number the Trust was reporting
between Queen’s and the Midwifery
Led Unit (MLU). Mr Skillman noted that
an escalation plan was in place, but he
wanted confirmation that the Trust was
not going backwards, that it had
everything under control, it was not
going to have problems again with the
service and that the figures were not
going to change.
Mr Moloney confirmed that for this year
the Trust was expecting to deliver just
over 9k and the plan for the next
financial year was approximately 8k,
when taking into account activity from
Outer North East London PCTs and
some women from Essex.
Mr Moloney also confirmed that the
figures were not changing, as Heather
Mullin would have been referring to
KGH not running a maternity service at
all (the Trust could deliver 2,500 at
KGH).
Trust Board Meeting (Part I) 5 September 2012

Question:
Mr Skillman was pleased to read in the
Telegraph that the Department of
Health was looking to assist some
financially challenged Trusts with their
Private Finance Initiatives (PFI’s) and
wanted to know if anything had been
agreed with BHRUT for this financial
year, or would it be next year.
Mr Skillman mentioned that when
attending outpatients to see a
Consultant, if a follow-up appointment
was required, the patient had to go
back to book this at the desk and was
then informed that an appointment
letter would be sent in the post. He
questioned whether appointment cards
could not be re-introduced, which
would not only save posting costs, but
would also be more efficient for the
patient.
Response/Action:
Mr Wood confirmed that BHRUT was
one of the Trusts involved and the
Department of Health had used
BHRUT’s practices with its PFI partners
to share with other Trusts. Most of the
Soft FM contracts were non negotiable,
but some savings had been made on
initiatives led by the Trust.
The initial Bond for the PFI could not be
renegotiated, but the Trust was working
to achieve as many efficiencies as
possible outside the terms of the
contract.
Mr Wood informed Mr Skillman that it
was worth noting that the PFI had not
just been signed by BHRUT, it had
been agreed by the Strategic Health
Authority, the Department of Health and
the Treasury.
Mrs Hosein acknowledged that Mr
Skillman was absolutely right and this
was part of the outpatient improvement
project that was currently being
undertaken, but due to the Trust’s
Patient Administration System (PAS)
and how patients were booked, it was
not possible to do this. The Trust was
currently installing a new Savience
system (kiosks) for patients to book
themselves in for appointments. It was
acknowledged that the Trust currently
generated a lot of unnecessary letters
and the new Savience system would
improve this area in the future. Mrs
Hosein asked the public to bear with the
Trust in the meantime, as these
improvements involved a great deal of
process change, which would take time
to implement.
Mr Skillman noted that he was pleased
to see in the Finance Report that there
were now vacancy controls in place
and recruitment/new posts could only
be approved by the Chief Executive, or
the Director of Transformation.
Trust Board Meeting (Part I) 5 September 2012

EXECUTIVE SUMMARY
TITLE:
Update on Trust wide CQC action plan
BOARD/GROUP/COMMITTEE:
Trust Board
1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:
This report outlines the progress to date with the
completion of the Trust wide action plan following a
series of unannounced CQC inspections in 2010 and
2011.
Transformation Board ( 17/10/12)
2. DECISION REQUIRED: CATEGORY:
The Board is asked to:-
• Agree the formal closure report of the Trust
wide CQC action plan.
• Recognise the progress since June 2012
• Formally agree the ongoing work required for
the ‘part met’ recommendations with key
performance indicators.
• Agree the transition into business as usual
and monitoring process.
N.B.
Please note that live access to the
evidence files will be in place
during the Board meeting
CQC registration
Health & safety
Assurance framework
Corporate objectives
AUTHOR/PRESENTER:
Dr M. Gill - Medical Director BHRUT
Donna Kinnair- Director Governance
DATE:
25 October 2012
The PMO/STT office will have 6 PC
terminals available on the morning
of the 7 November if Board
members would like to review any
evidence with colleagues on hand
to provide navigation and
assistance.
3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:
4. DELIVERABLES
5. KEY PERFORMANCE INDICATORS
AGREED AT : CQC Trust project board. DATE: 29 October 2012
REVIEW DATE (if applicable) ___________________________

CQC Trust-wide Action Plan
Review and Closure Report
OCTOBER 2012
Version: 20121028.2
Page 1 |
26-Oct-12

EXECUTIVE SUMMARY
This paper has been developed to reassure the Trust Board of the progress made in respect
of the Trust response to the CQC Investigation report and subsequent action plan originally
produced in October and November 2011.
The paper seeks to reassure the Board of the current status of the Action Plan, and the
transition to routine business as usual, monitored via normal service reviews.
The Trust Board is asked to :
• To agree the formal closure of the Trust-wide CQC Action Plan,
• To recognise the progress made since November 2011.
• To recognise the progress made since June 2012.
• To formally recognise the need for monitoring and implementation of the plan and its
recommendations, whilst in transition to ‘Business as Usual’
Page 2 |
26-Oct-12

1.0 PURPOSE
1.1 Background
This report has been produced predominantly for information regarding progress against
agreed actions originally identified by the CQC following their formal investigation report in
October and November 2011.
The initial CQC assessment indicated that Barking, Havering and Redbridge University
Hospitals NHS Trust had a history of poor performance under the previous regulatory
framework. At the time of CQC registration, the Trust had a high number of ‘conditions’
placed on it to require improvements in care. A series of unannounced inspections in 2010/11
resulted in some of these being lifted, but also resulted in warning notices being issued to the
trust (in March, June and July 2011) on staffing levels and maternity care.
The CQC saw some evidence of improvements being made in response to these notices, but
the Trust’s overall capacity to respond to the extent and level of CQC’s concerns was in
question. Throughout this period, the CQC continued to receive information about poor quality
care from patients and the public.
This report will confirm the ‘journey’ the Trust has taken; the progress made; the current
status of the report and its associated action plans and the recommendations requiring further
work. It will also seek to outline the key ‘milestones’ which have been reached, which will
demonstrate the continuous improvement of the organisation in addressing the CQC
recommendations.
1.2 Project Closure Status
The CQC have advised the Trust that having reviewed the formal Action Plan, its evidence
and supporting documentation, and given that the formal investigation has been completed,
future monitoring of compliance would be undertaken as part of the normal routine service
reviews. Hence the formal update report published by the CQC in June 2012, the monitoring
phase has developed into continued improvement being ‘Business as Usual’.
This report is a project review and closure report. The original recommendations have either
been met, or embedded into normal business, or have been superseded by other projects
and initiatives which will deliver compliance against the CQC’s essential standards.
1.3 Summary of Actions required by the Trust Board
The Board is asked:
• To agree the formal closure of the Trust-wide CQC Action Plan,
• To recognise the progress made since November 2011.
• To recognise the progress made since June 2012.
• To formally recognise the need for monitoring and implementation of the plan and its
recommendations, whilst in transition to ‘Business as Usual’
2.0 CONTEXT AND BACKGROUND
Following the imposition of registration conditions on the Trust in 2010, the CQC’s judgement
was that continuing to tackle poor performance at the trust on a case-by-case basis was not
going to address deep-seated issues around the quality of care at the Trust. As a result, the
CQC took the decision to launch a full investigation into the quality of care provided by the
trust at Queen’s Hospital and King George Hospital.
Page 3 |
26-Oct-12

On 29 June 2011, a team of CQC inspectors and external expert advisors, including experts
in maternity, accident and emergency, and nursing care, began the investigation on 4 July
2011.
The investigation assessed the systems and procedures the Trust had in place to ensure that
people are protected against the risk of inappropriate care and treatment. The team focused
on three care pathways – maternity, elective vascular surgery, and emergency care, and
examined the trust’s governance and management systems.
http://www.cqc.org.uk/sites/default/files/media/reports/RF4_Barking_Havering_and_Redbridge_Universit
y_Hospitals_NHS_Trust_RF4QH_Queens_Hospital_20110729.pdf
At the end of October 2011, the CQC published its Investigation Report, containing a total of
75 recommendations, with which BHRUT were required to comply; a further 6
recommendations were added in late November 2011. These 81 recommendations are
spread across a number of general categories; strategy, capacity, leadership, and some more
specific outcomes, including those in relation to maternity services.
14 themes were identified against which the 81 actions were identified:
1) Respecting and involving people
2) Care and welfare of people
3) Cooperating with other providers
4) Safeguarding people from abuse
5) Cleanliness and infection control
6) Management of Medicines
7) Safety and suitability of premises
8) Safety, availability and suitability of equipment
9) Staffing and supporting workers
10) Assessing and monitoring the quality of service provision
11) Complaints
12) Records
13) Leadership
14) Capacity
Upon receipt of the full Investigation Report, the Trust developed a Trust-wide Action Plan,
detailing all 81 recommendations, and began implementing the necessary actions required to
achieve compliance with the CQC essential standards; along with an identification of officers
and clinicians responsible for delivery, and the target dates for delivery.
http://aglovale/assets/pdfs/comms/cqcactionplan11.xls
As previously reported to the Board, significant progress has been made to the point where in
June 2012, the CQC revisited the Trust and further assessed progress made against the
original action plan. Report available at http://aglovale/assets/pdfs/comms/cqcupdatereportjun12.pdf
The Trust was encouraged that the CQC had confirmed that of the original 81
recommendations identified:
27 were assessed as MET
48 were assessed as PART MET
6 were assessed as NOT MET
In August 2012, the newly appointed Medical Director commissioned the Service
Transformation Team to review, re-engage and re-evaluate progress against implementation
of the required actions allowing the Trust to update the current status of each of the ‘PART
MET’ and ‘NOT MET’ recommendations from the CQC Update of July 2012.
http://aglovale/assets/pdfs/comms/cqcstakeholderupdate250612.pdf
In addition to the review of completeness the Team was asked to:
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26-Oct-12

• Review the Senior Responsible Officers (SROs) to align with the new management
and executive structures.
• Ensure the Operational leads are appropriate and aligned with the organisational
structures.
• Where appropriate, to develop measurable objectives and incorporate into a revised
Action Plan
• Reformat the Action Plan to facilitate improved navigation for users and external
stakeholders
• Integrate the evidence inventory to the action plan, improving access to users and
stakeholders.
• Drafting of a formal response to the internal draft Audit Report.
• This assessment was presented to the Quality and Safety Committee on the 16 th October.
• This revised Action Plan was presented to the Transformation Board on the 17 th October.
This work has been undertaken in conjunction with the Internal Audit report conducted by
Park Hill in August 2012. A formal response to this report is due to be presented at the next
Audit Committee.
3.0 EXCEPTION REPORT
The Exception report below highlights that 6 of the original 81 recommendations are
assessed as PART MET. This recognises the timescales involved in completion, or the
strategic context by which it is influenced.
The current Trust assessment finds that none of the original 81 recommendations remains
‘NOT MET’
The action plan and evidence log for this are attached at Appendix 2. Where sufficient
evidence of progress has been made, continued progress continues via ‘Business as Usual’
with Clinical Directors being accountable for delivery and achievement on a routine basis.
Where appropriate this is monitored via the Trust Audit Programme, and clinical governance
structures.
4.0 THE WAY FORWARD
As a result of the work to meet the recommendations of the original action plan, there have
been significant moves to establish good practice and embed this in the routine workings of
the Trust.
The evidence and supporting documentation will be migrated as appropriate to a web based
page. Evidence is currently restricted to those individuals who can access shared secured
drives on the Trust system.
These include :
• New Senior Management Team
• New Clinical Leadership structures in place
• Revised Clinical Governance Structure
• Robust Audit Programme
• Improved Communications (Internal and External)
• Revised Performance Management arrangements.
• Use of shared drives for the archiving and sharing of evidence.
Other helpful documents can be found at :
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http://aglovale/assets/pdfs/comms/cqcrecommendationactionplansept12.pdf (Draft)
http://aglovale/assets/pdfs/comms/cqccomp5.pdf (Radiology)
http://aglovale/assets/pdfs/comms/cqccomp4.pdf (Maternity)
http://aglovale/assets/pdfs/comms/cqccomp2.pdf (EU)
http://aglovale/assets/pdfs/comms/cqccomp1.pdf (KGH)
http://www.cqc.org.uk/directory/rf4qh
Page 6 |
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APPENDIX 1 ‐ CQC ACTION PLAN – EXCEPTION REPORT
(OCTOBER 2012)
Theme/Outcome CQC Recommendation CQC Observation (June 2012) Progress Executive Lead Current Status
LEADERSHIP 21. Put a cultural change Building blocks are in place – ‘Big Conversation’ The Trust has submitted a bid to NHS Director of Nursing PART MET
programme in place across the underway with staff engagement group set up and London for some Organisational
organisation. The programme
of change needs to engage all
staff so that the trust can
clearly articulate what the
expectations are of individual
staff, what a high performing
several staff engagement meetings held.
Executive team now dedicate one day a month to
take on a front line role in order to increase
understanding of care challenges and improve
management visibility and accessibility.
Conflict resolution training is being delivered for
Development funding.
Funding has been allocated and the
Trust is currently identifying suitable
development support to take this
work forward.
The Trust is currently working with a
organisation feels like to work managers; BHRUT Code being reviewed with range of external consultants
in and be clear of the penalties significant staff input, including seeking clear including:
for staff they should not examples of acceptable and unacceptable practice. QFI who run a leadership programme
behave appropriately.
Consultants are carrying out an analysis of team
working and practice in women’s services
for CD’s, Clinical Fellows and senior
leads, supported and funded by NHS
London.
Management Information and
Development (MIAD) for Consultants
Tavistock Consulting working with
maternity
McKinsey to embed sustainable
patient flow through the Trust
Ernst and Young to support financial
sustainability and governance
Transformation Team has been
established and is working across the
Trust to develop and implement
leadership skills locally in multiprofessional
groups.
ASSESSING &
MONITORING
75. Ensure that it has
appropriate levels of staff in
place to allow its governance
systems to function effectively
and that these staff are
embedding appropriate
systems in clinical services.
Following the review of governance, suitable staff
have been identified to ensure its recommendations
are properly implemented. As above, proof of
success will be seen through delivery.
Associate Medical Director for Clinical
Governance now in post (3 P.A.)
Business case for Patient Safety
Managers covering Clinical
Directorates in progress following
approval by the Q&S Committee.
Medical Director
PART MET
CARE & WELFARE 29. Develop a culture where The appraisal process for emergency department An additional patient information Medical Director PART MET
Page 7 |
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‐ EMERGENCY
CARE
SAFETY &
SUITABILITY OF
PREMISES
everyone feels empowered to
challenge episodes of variable
or poor practice, including
regular monitoring of practice
and feedback and learning
opportunities for staff.
53. Ensure that appropriate
waiting facilities are available
for patients and relatives in
the urgent care centre.
staff has been reviewed; all staff in this area have
personal development plans. Hourly vital signs
checks are underway and monthly spot audits are
being carried out to ensure staff feel empowered to
challenge poor performance. Patient satisfaction
surveys are in place and staff are reminded of the
importance of challenging poor practice as a
standing item on A&E team meetings. Audit results
do not yet support the processes that have been put
in place.
As above, these waiting facilities are being reviewed
as part of the Health for NEL programme.
leaflet explaining the process of the
ED is being drafted which will have a
section to write who the patients
named nurse and doctor are. There
will be a feedback area on this leaflet
to enable patients to anonymously
write any feedback both positive and
negative. This will enable direct
feedback to the staff that cared for
the patient. It is hoped that this will
provide more audit results as the
feedback mechanism will be directly
accessible for patients.
Trend information on complaints is
being collated to further support
feedback to all staff.
Customer service competency
checklist is being developed to
provide staff with additional training
to support improvements in
communication skills.
Peer challenge on poor practice
remains in place.
The current waiting facilities are
deemed sufficient for the needs of
patients currently.
Investment is currently underway to
extend the Rapid Assessment &
Treatment areas within the
department. This initiative will deliver
shorter waiting times and improve
the patient experience. Work is due
to be completed before Christmas.
Patient experience will be measured
via the annual patient surveys, and in
house paper and electronic solutions.
Director of Nursing
Divisional Manager
(Estates, Facilities &
Capital)
PART MET
RECORDS 80. Improve its systems for The Trust’s Medical Records Committee has been re‐ The development of the eHandover Chief Operating PART MET
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26-Oct-12

RECORDS
records management to
ensure that notes can be
retrieved effectively and
expediently, and reduce the
risks associated with multiple
sets of temporary notes and
poor data handling.
81. Develop integrated patient
administration
and
information systems to ensure
that, where ever a patient is
being treated within the trust,
their full healthcare history
can be accessed by all staff.
established with new Terms of Reference; training
levels for healthcare professionals are discussed at
this Committee on a regular basis. Weekend
transport for transfer of notes has been
reintroduced and a nursing documentation booklet
has been piloted across several wards and will be
fully implemented by the autumn.
A procurement process is underway to introduce an
effective system to enable access to patient
histories. Funding challenges have slowed
introducing of a full electronic patient record.
system will provide a Trustwide
joined up reference database for the
use in patient care.
A new PAS is being commissioned in
2013 for implementation which will
improve the availability of Patient
records and reduce the incidence of
Temporary folders.
It is anticipated that patients will be
migrated onto one hospital number
covered by barcode scanning options
as part of the roll‐out and
implementation.
Decision on Strategic Capital Funding
for PAS Replacement by NHS London
immanent
A new PAS is being commissioned in
2013 for implementation which will
improve the availability of Patient
records and reduce the incidence of
Temporary folders.
It is anticipated that patients will be
migrated onto one hospital number
covered by barcode scanning options
as part of the roll‐out and
implementation.
Decision on Strategic Capital Funding
by NHS London immanent.
Officer
and
Director of
Performance &
Planning
Director of
Performance &
Planning
PART MET
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APPENDIX 2 ‐ CQC ACTION PLAN – OCTOBER ACTION PLAN FOR
PART MET AND NOT MET RECOMMENDATIONS.
Page 10 |
26-Oct-12

CQC Update Report
2012
Theme CQC Recommendation CQC Observation (June 2012) Further Organisational Progress Operational
Lead
LEADERSHIP 20. Ensure its board assures
Averil
itself that it has the right
Dongworth
leaders and managers in place
to develop the trust and
improve the quality of services.
LEADERSHIP 21. Put a cultural change
programme in place across the
organisation. The programme of
change needs to engage all staff
so that the trust can clearly
articulate what the expectations
are of individual staff, what a
high performing organisation
feels like to work in and be clear
of the penalties for staff they
should not behave
appropriately.
The Trust Board has completed its
review of the Executive Team,
leading to appointments of chief
operating officer and director of
transformation.
A new management structure is in
place based around clinical
directorates, led by clinical
directors and associate directors.
Recent information indicates that
there are several changes being
made to senior management at
the Trust and the impact of this
will need to be assessed.
Significant staff engagement
process is underway to consult on
wider implementation of the new
structure.
Building blocks are in place – ‘Big
Conversation’ underway with staff
engagement group set up and
several staff engagement meetings
held.
Executive team now dedicate one
day a month to take on a front line
role in order to increase
understanding of care challenges
and improve management visibility
and accessibility.
Conflict resolution training is being
delivered for managers; BHRUT
Code being reviewed with
significant staff input, including
seeking clear examples of
The following appointments have been made to the Board:
1. Director of Operations
2. Director of Transformation
3. Director of Governance
4. New Medical Director appointed
5. Director of Nursing appointed
6. New Director of Finance
Clinical Directors and Associate Directors now in post.
Consultation on going relating to the final supporting
management structure.
Management structure corporately is now in place with Associate
Medical Directors and Deputy Nurse Directors Appointed.
Consultation now ended and appointments and structure will be
put in place during June '12.
Changes at senior level in June 2012 have now posed questions
about the possibility of delivering as anticipated.
The Trust has submitted a bid to NHS London for some
Organisational Development funding.
(JM to share copy of bid)
Donna Kinnear
Julie Meddings
Trust RAG
MET
BUSINESS
AS USUAL
PART MET
BUSINESS
AS USUAL
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2012
acceptable and unacceptable
practice.
Consultants are carrying out an
analysis of team working and
practice in women’s services
LEADERSHIP
LEADERSHIP
22. Develop a culture of whole
systems working across all
divisions to reduce ‘silo’
working and the combative
nature of bed management.
24. Explore how to improve its
communications both internally
and externally so that
perceptions of poor
communication can be reduced.
Weekly operations meeting, with
directorate managers, is now in
place; multidisciplinary working
being pursued as part of RESET
project. New bed management
structures is in place, with all
divisions and specialities
attending; Matrons working
together to ensure effective
discharge process.
Internally, significant staff
engagement is underway;
externally, meetings have taken
place with LINks and Improving
Patient Experience Group (IPEG);
stakeholder briefings being
disseminated; stakeholder event
with commissioners, CQC, LINks,
IPEG and local authorities took
place in May.
Some feedback to CQC suggests
there are further improvements
that could be made, particularly in
terms of engagement with MPs.
There has been significant progress in a Trust‐wide response to
patient pathways. Initially focussing on Emergency admissions
and pathways
Daily Bed and Site team meetings held (0830;1200;1500) to
ensure patient flow and effective discharge management, Issue
Log kept daily and updated at each meeting. Performance tracker
updated daily for the current week. Senior representatives
available from all divisions, escalation protocols allow for this to
be supplemented by executive input, community and LAS
representatives
Ward sponsor programme in place to support escalation and
discharge management. Intensive support is provided by the
Service Transformation Team, and QFI.
Performance Meetings weekly with CDs and CEO, Dir. of
Transformation.
Daily multidisciplinary JONAH meetings, complex discharge
meetings, cross buffer meeting and Top 25 delays all support this.
Dorothy Hosein
MET
BUSINESS
AS USUAL
This is now monitored via normal Trust Operations. Imogen Shilito MET
BUSINESS
AS USUAL
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2012
ASSESSING &
MONITORING
70. Ensure that it has adequate
systems of governance to
promote high quality care for
patients and to deal with
concerns about performance in
an effective and timely manner.
Clinical and committee structures
have been reviewed and a new
Clinical Governance Structure has
recently been considered by the
Trust’s Board.
Expanded central data collection
for the Quality and Safety
Committee has been proposed. A
central monitoring and evidence
database has been introduced for
Serious Incidents, with Trust‐wide
audits being introduced and KPIs
introduced for reporting and
completion of investigations. A
web‐based incident reporting
system is being introduced across
the Trust after a pilot in maternity.
• All Clinical Directorates have clinical governance
meetings which feed into the Quality and Safety
Committee structure.
• Dashboards developed for Quality KPI reports.
• Rolling risk reviews in place for Q&S Committee
• Action Plan monitoring in place.
• Snapshot Audits underway
• Web‐based tracking system in place with on going
training at Induction.
Pam Strange
MET
BUSINESS
AS USUAL
ASSESSING &
MONITORING
72. Carry out a comprehensive
review of all corporate and
clinical governance systems
across the organisation to
ensure that effective and
streamlined systems and
reporting structures are in place
to provide robust assurance to
the board.
Clinical and committee structures
have been reviewed and a new
Clinical Governance Structure has
recently been considered by the
Trust’s Board.
A complete review of Trust
corporate committees has been
completed and was recently put to
the Trust Board. A complete
review of maternity clinical
governance was completed by
October 2011 to ensure full
integration with the Trust’s main
governance structures. The review
also led to Divisional managers
taking on responsibility for alerting
clinical governance teams to all
external quality and safety
recommendations (reinforced
through stringent audit and
• New Director of Governance and Special Projects in
post (September 2012)
• CDs Governance meetings supported by Facilitators.
• SI reviews embedded in performance structures
• QIPP programme supported by QIAs (Quality Impact
Assessments) within a formalised governance structure.
Averil
Dongworth
MET
BUSINESS
AS USUAL
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CQC Update Report
2012
reporting), with regular reporting
between HR and Clinical
Governance to ensure joint
management of patient safety
issues.
ASSESSING &
MONITORING
73. Ensure that it has systems in
place that allow effective
sharing and learning across the
whole organisation.
Existing guidance on learning from
serious incidents has been
reviewed and KPIs for
implementation have been
introduced. A bi‐monthly ‘Lessons
Learned’ group meets to generate
shared learning. This includes
using the content of Ombudsman
action plans to ensure learning
points are appropriately extracted
and shared. A rolling programme
of articles in the Link is supporting
learning. Directorate Boards now
review Serious Incident reports
and action plans to ensure timely
implementation.
Clinical Directors are sent details
of each relevant Serious Incident
and these are agenda items for
directorate clinical governance
meetings until they are responded
to in a suitable way.
This recommendation will only be
fully met when success can be
demonstrated over time. CQC and
other stakeholders not only expect
to see evidence that Serious
Incidents are being dealt with
internally, but also to see
commissioners and other external
organisations being informed
when relevant.
• All closed SIs are available on the Trust intranet.
• Clinical Directorate Governance leads review Sis and
other incidents for learning.
• Clinical Governance is a core topic on all monthly
meeting agendas.
Pam Strange
MET
BUSINESS
AS USUAL
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2012
ASSESSING &
MONITORING
74. Ensure that the incident
reporting system for the whole
trust is operating effectively and
all staff are learning from
incidents rather than simply
reporting incidents.
As noted above, a web‐based
incident reporting system is being
introduced across the Trust after a
pilot in maternity. If the proposed
clinical governance structure is
introduced as planned, directorate
boards will take on responsibility
for regular reviews of learning
from incidents. Learning from
incidents is now integrated into
the ward staff meeting structure,
and better structures have been
introduced to ensure learning is
shared between staff across
divisions. Again, this will need to
be demonstrated over time.
• All closed SIs are available on the Trust intranet.
• Clinical Directorate Governance leads review Sis and
other incidents for learning.
• Clinical Governance is a core topic on all monthly
meeting agendas.
Pam Strange
MET
BUSINESS
AS USUAL
ASSESSING &
MONITORING
75. Ensure that it has
appropriate levels of staff in
place to allow its governance
systems to function effectively
and that these staff are
embedding appropriate systems
in clinical services.
Following the review of
governance, suitable staff have
been identified to ensure its
recommendations are properly
implemented. As above, proof of
success will be seen through
delivery.
• Associate Medical Director for Clinical Governance now
in post (3 P.A.)
• Business case for Patient Safety Managers covering
Clinical Directorates in progress following approval by
the Q&S Committee.
Pam Strange
PART MET
STRATEGY
1. The Trust, in conjunction with
NHS London, should seek
appropriate external expertise
to support a programme of
organisational change and
service improvement.
The Trust has introduced 10
clinical fellows and four midwifery
clinical fellows as part of a clinical
leadership and engagement
programme, supported by NHS
London. Commissioners are
offering support at executive level
in the development of the Trust’s
programme management board to
coordinate the transformation
programme. Health for NEL, Skills
for Health, and the RESET
McKinsey Consultancy (RESET);
Ernst & Young (QIPP/CIP);
Averil
Dongworth
MET
BUSINESS
AS USUAL
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2012
programme in A&E are evidence of
the Trust’s willingness to engage
external support.
STRATEGY
2. The Trust, in conjunction with
its commissioners and other
partners, should identify and
implement plans to secure a
long term solution to reduce
over capacity at Queen’s
Hospital.
The Health for NEL proposals and
estates reconfiguration plan for
the Trust should see demand
reduce significantly over the next
two years to address capacity
issues. This includes seeing
demand on maternity fall by 15‐
20% (between 1,500 and 2,000
births a year) by April 2013
through effective use of
alternative maternity resources in
North East London. Success
depends on partnership working
and on going commissioner
engagement, including the role of
primary care in making sure that
people are aware of the treatment
choices open to them.
Project Teams now in place to formulate project briefs and
manage process to formal Business Case submission.
Some schemes more advanced and ready for start on site of
works ie MLU.
April '12 meetings with Estates to discuss extent of plan and
proposals, which will help inform business case.
Outline Business Case (OBC) being prepared for submission to
Trust Board beginning of August and SHA CIC Sept.
As part of the Health4Nel programme, quarterly meetings have
been held with local authority CX's for some time.
During transition to CCG's these will be wound down, and initial
forums have been held with CCG's; these may become timetabled
more regularly in due course.
Options Appraisal recommendations ‐ relating to configuration of
ED ‐ due to be submitted as part of OBC to Trust Board in Jul '12;
which will be referred to commissioners before month end.
This will be accompanied by discussions with planning providers
and PFI, due to potential impact of proposals.
Averil
Dongworth
MET
BUSINESS
AS USUAL
STRATEGY
3. Improve the flow of patients
not only in the emergency
department, but across the
whole hospital to ensure that
processes that do not add value
are removed and patients are
seen and treated in a timely
fashion.
A range of work is underway to
address this – bed mapping,
revised length of stay, reviews of
decisions to admit, care pathways
in place for emergency and
gynaecology care.
The RESET programme in A&E is
designed to ensure stronger
visibility and accountability of care
Build could take up to 18 months from decision made. This is only
an indicative timescale, which will be confirmed once option
agreed.
Length of S Work stream formed. Terms of reference agreed. 2
bed modelling papers presented and discussed at Transformation
Board.
• A&E Escalation process being developed. This will support
the timeliness of review and decision making by specialist
team, and improve patients flow.
• Further work has commenced via the Theatres work stream
to improve utilisation of Theatre capacity, which include
Gynaecology.
Dorothy Hosein
Shelagh Smith
MET
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AS USUAL
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CQC Update Report
2012
pathways throughout the hospital,
from admission to discharge.
Progress in this will be carefully
monitored both within the Trust
(including at Executive and Board
level) and by external partners.
• Patient Improvement Programme (PIP)
• Discharge Jonah rolled out in all wards.
• Top delays meetings every Tuesday and Thursday at 11h30
reviewing reasons for patient delays.
• Daily Operational Jonah meetings occurring with matrons
and senior nursing staff to review bed position and delays.
• Now linked with RESET project work stream 3: Improving
continuity of care and discharge rate in MAU.
• Now linked with RESET project work stream 5: Pre‐11am
Discharges
• Now linked with RESET project work stream 7: Effective Care
for Elderly Patients.
EQUIPMENT
CLEANLINESS
CLEANLINESS
59. Develop as part of its
cultural change programme
people’s sense of responsibility
to take positive action to ensure
that clinical areas are suitably
equipped to provide safe
patient care.
45. Ensure that all equipment
and disposable products are
stored appropriately.
47. Ensure that staff are not
posing an increased risk to
patients from cross infection.
The trust should take any
necessary steps to ensure that
staff can store personal
This will be audited by monitoring
complaints on availability of
equipment and regular equipment
audits; a business case may be
considered for a dedicated medical
devices coordinator / trainer if the
need is firmly identified. CQC’s
inspections suggest this remains a
serious issue that needs to be
addressed.
Ward managers have completed
risk assessments of equipment
management and storage facilities.
A new Trust environment /
equipment disposal policy is in
place. Weekly walkabouts with
facilities and estates have been
implemented and an action log is
in place.
The staff uniform and dress code
policy is being reviewed to ensure
standards are understood and
remedial actions are available. An
infection control annual plan is in
place and is reported against to
• Equipment deficits are monitored via the Environmental
audits utilised throughout the organisation. There has been
a re‐launch of the Medical equipment policy (hyperlink).
http://aglovale/assets/pdfs/governance/policymedicaldevices.pdf
• Equipment issues are now reported thematically via the
Complaints process. This is reported and monitored via the
Patient Experience structures.
• Environmental audits utilised throughout the organisation.
Additional near ward storage is being utilised where
appropriate. Ward stock levels are being reviewed as part of
the CIP and procurement work streams, and consideration is
being given to a ‘neutral warehouse’ solution
• The Staff Uniform and dress policy has been revised and
ratified.
Judith Douglas
Gary Etheridge
Judith Douglas
Pam Strange
MET
BUSINESS
AS USUAL
MET
BUSINESS
AS USUAL
MET
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AS USUAL
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CQC Update Report
2012
COMPLAINTS
property as necessary.
76. Continue to develop and
improve its complaints handling
systems to ensure that
complaints are responded to
fully and in a timely manner.
Infection Control Committee every
other month.
A review of outstanding
Ombudsman complaints has taken
place; a dedicated manager has
been appointed to follow up
compliance with action plans or to
report non‐compliance to the
Director of Nursing. Complaint
numbers and trends are reported
to the Quality and Safety
Committee. PALS processes have
been reviewed to try to address
patient concerns at an earlier
stage. CQC is aware that the Trust
has seen a significant increase in
complaint numbers since the
investigation was published last
year; as a result, while the
underpinning systems have been
improved, they are struggling to
cope with an unprecedented surge
in numbers.
Sept 2012 – Interim Complaints and PALS manager appointed.
Key priorities identified:
• Weekly review of open complaints and associated
timescales
• Weekly look ahead trends and priorities
• Working on resolving and clearing reactivated
complaints
• Written investigations of all complaints produced and
ratified in new complaints policy (can we attached the
policy please)
• Produced and ratified new complaints policy
• Clarified and ratified the complaint handling procedures
• Core complaint team and divisions working jointly
• Monthly briefing paper sent to commissioners
Gary Etheridge
MET
BUSINESS
AS USUAL
COMPLAINTS
77. Develop and support staff to
ensure that open
Transparent investigations take
place, that complainants are
involved as necessary and that
culturally complaints are seen
as opportunities to learn and
improve the quality
of care.
NHS London has supported the
Trust to undertake a root cause
analysis training campaign for
senior management to ensure the
importance of timely investigation
of complaints is fully understood.
A report of trends and themes
aggregated across the Trust is
reported every other month,
including identification of trends
and hotspots.
• Quarterly patient experience report, which triangulates
all patient experience issues reviewed by Trust Board
• More robust action planning process is under
development. This will enable review and trend
identification to implement changes in systems and
practice
• ‘Learning lessons’ group chaired by Asst Dir. Of Nursing
• Work in progress to review the support material that
Divisions use to investigate complains this will ensure
that we are following best practice.
• Occupational Health support available to staff in the
investigation process
Gary Etheridge
MET
BUSINESS
AS USUAL
COMPLAINTS 78. Ensure that any staff A revised policy has been drafted • The revised policy has been ratified and is now in place, Any Gary Etheridge MET
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CQC Update Report
2012
identified in a complaint are
involved in resolving the
complaint and the resulting
learning, but where there is a
complaint about an individual
there is appropriate separation
of the investigation from the
individual.
and is awaiting senior
management approval; it is
currently available to staff but will
only be considered on its way to
being met when it is implemented
and progress audited.
member of staff who is named in a complaint will be given
access to the complaint. The Trust is also developing support
mechanisms to support members of staff who have been
sighted in a complaint. This work is being implemented by
the core complaints team in collaboration with the Divisional
teams.
BUSINESS
AS USUAL
COMPLAINTS 79. Develop its reporting
mechanisms to ensure that the
board are fully informed of all
complaints, that detailed
trend analysis takes place and
that the board can assure itself
that learning is taking place, and
repetition of themes is reduced.
The Trust Executive Committee
and Board now receive a monthly
complaints
analysis; reporting is discussed at
the bimonthly Quality and Safety
Committee. The Patient
Experience report to the Quality
and Safety Committee includes a
full analysis by directorate and
highlights key issues.
Reporting began in April 2012
• Briefing report sent to commissioners and Quality Safety
committee.
• Key Non executives board members identified as Patient
champions who sit on the Quality and safety committee and
IPEG
• Monthly Complaints and patient experience to Trust Board
monthly
Gary Etheridge
MET
BUSINESS
AS USUAL
CO‐OPERATION
39. Continue to engage, and
develop effective working
relations, with external
providers and partners.
Regular stakeholder briefings have
been introduced and the Trust has
set up a regular programme of
meetings at patient representative
groups, OSCs, and briefing to
media. CQC recently attended a
stakeholder meeting at the Trust
and feedback from local authority
partners and the Improving Patient
Experience Group was that
communications with stakeholders
had significantly improved.
• Active dialogue with Local Authority; Borough Councils, MPs,
London Ambulance Service; PCTs, NHS London etc
Neill Moloney
Clare Burns
Imogen Shilito
MET
BUSINESS
AS USUAL
CO‐OPERATION 41. Work with social care
partners to develop robust
working practices to ensure
appropriate admission and
A programme director is working
at the Trust with funding from the
Cluster to liaise between the acute
Trust and borough and community
Cross Buffer meeting held weekly with Social Service partners to
facilitate timely discharge.
Discharge Partnership Boards, Cross Buffer meetings, local
escalations.
Shelagh Smith
MET
BUSINESS
AS USUAL
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CQC Update Report
2012
discharge practices
services. This post will currently
run until October 2012. There is
now a central point for escalation
and consideration is being given to
allocating a budge to the
programme director to allow them
to make spot purchases to resolve
complex discharge problems.
Work is underway to streamline
processes across all boroughs to
access community services. Gaps
in acute Trust resources are being
identified to improve discharge to
community services; early data
indicates reduced length of stay.
Development of a patient‐centred management approach,
replacing ward management approach
DISCHARGE
34. Develop its discharge and
bed management teams and
processes to ensure that they
are interlinked and that patient
flow is managed effectively
from the point of entry to the
point of discharge.
A single discharge policy is now in
place with clear roles and
responsibilities established and six
discharge specialists employed to
help with complex discharges. The
RESET project is playing a crucial
role in ensuring that discharge is
managed across all relevant
pathways and wards. The
Discharge JONAH project and
accompanying audits are in place.
Daily meetings with matrons and
senior nursing staff review the bed
position and delays. The
underpinning processes and
policies are in place here, but
CQC’s inspections and other
performance measures make clear
that delivery needs to improve to
match the Trust’s aspirations.
There is a rotational programme of ward staff onto the complex
discharge planning team. This will produce ‘skilled’ nurses back
onto the wards to enable cascade of experience and training.
Allocation of deputy nurse director for ops to oversee patient
flow within the organisation including management of both bed
and site teams and the discharge planning team.
Daily operation JONAH meetings which include ward sisters,
discharge planning team, therapies, and radiology These
meetings discuss constraints and their resolution in order to aim
for seamless patient pathways.
Twice weekly JONAH meetings to discuss and resolve delayed
transfers of care with key stakeholders i.e. Trust staff, Social
Services, Discharge planning team, ward staff, management.
Ward Sponsors programme in place throughout hospital
supported by Ward Sponsor Guidelines and Service
Transformation
Caroline Moore
Elaine Wynter
MET
BUSINESS
AS USUAL
DISCHARGE 35. Ensure that clear guidance The Trust has suitably robust Ward based documentation has been revised and relaunched. Porti Omo‐Bare MET
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CQC Update Report
2012
outlining the expectations of all
staff is produced and enforced
so that the prescribing and
dispensing of ‘to take away’
medication is managed
effectively and patient
discharges are not delayed. The
trust needs to ensure that it
monitors adherence with policy,
guidance and audit and takes
any appropriate action to
support staff to deliver a high
quality service.
guidance and policies, which is
reaffirmed at induction. Pharmacy
is meeting dispensing targets, but
better monitoring and audit needs
to be introduced to ensure that
treatment is appropriate and
supported by suitable information.
This has also been linked into the
RESET project. The Trust’s Visible
Leadership programme has
included a focus on this area of
care, with reports to the Nursing
and Midwifery Board and Quality
and Safety Committee.
Ward based Pharmacists in place to facilitate speedy discharge. Magda Smith BUSINESS
AS USUAL
DISCHARGE
EMERGENCY
UNIT
36. Review and rationalise the
discharge and bed management
information systems to ensure
that the most effective and
accurate system is fully utilised.
28. Develop its strategy and
work for improving flow of
emergency/urgent patients.
This strategy needs to have the
engagement of all clinicians and
managers as a key component.
The Discharge JONAH tool has
been rolled out as per above; this
is linked in with the RESET project.
As mentioned, the underpinning
measures are in place but
performance is yet to meet
expectations.
The ‘Discharge JONAH’ tool is
being implemented to focus on
discharge and length of stay. Daily
meetings, weekly performance
reviews, and the RESET project
mean there is frequent and indepth
scrutiny; this will be met
when outputs match the
aspirations in a sustainable way.
• Discharge Jonah continues to be operational across both
hospital sites. Daily operation meetings in place in addition
to twice weekly top delays and monthly cross buffer
meetings.
• Ward sponsors in place and supporting Jonah application
and timely escalation.
• Intensive support in place and key performance indicators
developed for on going monitoring.
• Continue to work on predicted discharges and information
flows into operational meetings and bed management.
• BedWeb in use at Ward level also
• Discharge Jonah rounds for all wards is completed daily
• RESET project continues focusing on expediting discharges
safely using various methods to ensure the whole MDT is
supported in progressing the patients care plan, e.g. orange
discharge forms at the weekend.
• Daily analysis of 4hour and black breaches when they occur
Julie Meddings
Caroline Moore
Claire Dixon
Sam Elden‐Lee
MET
BUSINESS
AS USUAL
MET
BUSINESS
AS USUAL
EMERGENCY
UNIT
29. Develop a culture where
everyone feels empowered to
The appraisal process for
emergency department staff has
• An additional patient information leaflet explaining the
process of the ED is being drafted which will have a section
Derek Hicks
Claire Dixon
PART MET
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CQC Update Report
2012
challenge episodes of variable
or poor practice, including
regular monitoring of practice
and feedback and learning
opportunities for staff.
been reviewed; all staff in this area
have personal development plans.
Hourly vital signs checks are
underway and monthly spot audits
are being carried out to ensure
staff feel empowered to challenge
poor performance. Patient
satisfaction surveys are in place
and staff are reminded of the
importance of challenging poor
practice as a standing item on A&E
team meetings. Audit results do
not yet support the processes that
have been put in place.
to write who the patients named nurse and doctor are.
There will be a feedback area on this leaflet to enable
patients to anonymously write any feedback both positive
and negative. This will enable direct feedback to the staff
that cared for the patient. It is hoped that this will provide
more audit results as the feedback mechanism will be
directly accessible for patients.
• Trend information on complaints is being collated to further
support feedback to all staff
• Customer service competency checklist is being developed
to provide staff with additional training to support
improvements in communication skills
• Peer challenge on poor practice remains in place.
EMERGENCY
UNIT
30. Ensure that all staff, both
permanent and temporary,
follow hospital policy and
procedures.
MATERNITY 4. In conjunction with its
commissioners and other
partners, identify and
implement immediate solutions
to deliver safe maternity
services at the Trust, especially
at Queen’s Hospital, while
developing plans to secure a
long‐term solution.
As noted, the appraisal process for
emergency department staff has
been reviewed; spot audits of
elective surgical consent have
indicated some issues with
consistency; not all emergency
patients receive all the information
they need about procedures; and a
new information leaflet on
anaesthesia risks is being
developed. Performance indicators
are still negative.
Work with NHS London in the
short‐term and in the longer term
via Health for NEL, has so far and
should address the highest risks to
safety for mothers. Improved audit
and reporting on c‐sections is in
place. An audit of 1:1 care in
established labour saw the Trust
achieve 100%. CQC’s inspections
have confirmed that
Some specialities consent elective patients within the outpatients
some on the day of surgery on the ward.
Emergency procedures are generally consented on the ward but
dependant on type of case and urgency can be consented in the
ED and very rarely in theatre holding bay.
All patients receive an anaesthetic review but again this can vary
due to urgency and unconscious patients receive a review but
cannot have a conversation with the anaesthetists and are
subject to a ‘Consent Form 4’ being unable to consent.
A consultant Anaesthetist will be preparing a leaflet concerning
Anaesthetic risks.
Pre Admission services are currently under review and
development.
Work continues in respect of the Health 4 NEL project.
There are regular audits to ensure 1:1 care is maintained and
these are reported monthly via the performance dashboards.
Geoff
Middleditch
Gill Perry
Wendy
Matthews
MET
BUSINESS
AS USUAL
MET
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AS USUAL
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CQC Update Report
2012
improvements have been made
and are so far being sustained
MATERNITY 9. Further improve the
maternity triage process with
the introduction of regular
monitoring and learning to
ensure that services improve for
all mothers.
MATERNITY
10. Take appropriate action to
ensure that babies are not
transferred to the neonatal care
unit unnecessarily.
New pathway implemented with
monitoring in place; performance
reported weekly to NHS London;
triage working group in place.
Performance levels need to
improve.
Policy and guidelines in place but
being reviewed; Trust audit has
recently taken place. Performance
outputs not meeting required
levels.
New pathway implemented 30th July 2012. However still issues
with middle grade doctor cover, this will be resolved when KGH
closes. Performance continues to be monitored on a monthly
basis
OAU now has appointment system and achieves the standard.
See performance report above
Target moving towards women seen by a doctor within 30
minutes.
Work has been undertaken in HDU to minimalize hypothermic
babies, e.g. skin to skin, bear‐hugger equipment, thermometers
in each bay in HDU however there are some safeguard reports of
environmental issues (cold rooms / non‐functioning thermostats)
which are impacting the temperatures of babies on postnatal
wards. Discussions underway with estates department The latest
audit of all neonatal admissions was undertaken on the 8 th
September and revealed no admission due to environmental
conditions or hypothermic neonates.
Averil Archibald
Wendy
Matthews
MET
BUSINESS
AS USUAL
MET
BUSINESS
AS USUAL
MATERNITY 13. Continue with its
recruitment plans in maternity
services to ensure that it has
suitable numbers of qualified
staff across all service delivery
departments.
Recruitment is on target to deliver
a 1:29 ratio, with higher numbers
of substantive staff in post. CQC
inspections have identified some
concerns around midwifery care
assistant staffing levels. Trust has
faced challenges in recruitment
and retention, although these are
not particular to this Trust alone.
Midwife to birth ratio 1:29 achieve with bank usage, however 26
student midwives qualifying in September to November at which
time bank will only be used for maternity leave and sickness
HDU nurses available at all times in HDU. Midwives now
undergoing training for management of critical obstetrically ill
women
all vacant MCA posts recruited. Study days for MCA's
implemented as annual mandatory training. Competency training
being rolled out.
Proposed boundary changes will ensure that this ratio is
maintained, and there are clear plans for the recruitment of
midwives on an on going basis to ensure standards are
maintained.
Richard Howard
Dele
Olorunshola
MET
BUSINESS
AS USUAL
MATERNITY
Increase the level of training on
the interpretation of CTGs, so
that all staff have undertaken
All midwives were due to have
completed training by end of
March 2012, although the
JP comments ‐ M12.1 number of SIs coming through with CTG
interpretation issues still. Discussion re management framework
for response discussed with SOM and DOM with Risk Manager ‐
Jude Piper
MET
BUSINESS
AS USUAL
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CQC Update Report
2012
MATERNITY
MATERNITY
this. maternity dashboard showed 84%
complete. Regular audits of
attendance are in place.
17. Improve the quality of
record keeping and records
management in maternity
services.
19. Ensure that maternity audit
processes are integrated with
the rest of the Trust.
Training for staff and a maternity
records tracker and audit process
are in place, but some problems
with implementation and targets
not being met to date. More that
50% of staff have now been
trained in appropriate governance.
While a clinical audit plan is in
place and infection control is being
audited, an audit midwife has only
recently been recruited. The full
set of policy and process measures
are in place but performance is not
meeting expected levels as of the
time of writing.
standard approach to be taken 1. SOM review and education is
required / template to be developed and used to show audit trail
2. second offence ‐ disciplinary process + SOM input.
For obstetric team need to liaise with tutors to determine correct
process in line with deanery programme
90% for June 2012, however due to a number of SI's with CTG
misinterpretation please see new process and comments above.
Training in place highlights ‘barn door’ competence. The revised
training package which has just been implemented will ensure
that there is a test and assess element to the training. Specific
support is available to those midwives who require additional
support.
There have been no SUI reports which have involved CTG
interpretation in September.
Tracker implemented. Audit of compliance commencing Sept
2012.
Retrospective tracking has been completed and all women are
now covered.
Old Maternity notes are subject to tracking as women attend the
unit.
Training in this is now included in Mandatory Training for all staff
and as part of Induction for all new staff.
Maternity Department has in place an annual audit plan for
2012/13 compiled by the Audit Lead Consultant and the Audit
Midwife. Audit findings are presented at monthly Audit meetings
attended by multidisciplinary representation. The action plans are
discussed at the meeting and uploaded onto the intranet by the
Clinical Audit Team .
FU comment: The crib sheet has not been shared with the Audit
midwife therefore cannot provide an update.
Wendy
Matthews
MET
BUSINESS
AS USUAL
MET
BUSINESS
AS USUAL
MEDICINES
MANAGEMENT
48. Reinforce its policy on
medication prescribing,
dispensing and administration,
ensuring that all staff are
A briefing for clinical staff
explaining the importance of this
policy and setting out
accountabilities for prescribing and
FU comment: The audit team adheres to the Trust procedures,
uses approved tools and ensures that the audits are centrally
recorded by the Trust Clinical Audit Team.
The BHRuT Medicines Care, Custody, prescribing and
Administration Policy has been finalised and ratified by the Drugs
and Therapeutics Committee, Nursing and Midwifery Board and
the Policy ratification Committee. It is available on the intranet
Ian Grant
Jane Stevens
Pam Strange
Portia Omo‐Bare
MET
BUSINESS
AS USUAL
Page 14 of 22

CQC Update Report
2012
aware of their roles and
responsibilities.
administration has been prepared;
this is due to be rolled out shortly.
A Policy Ratification Group has
been set up to ensure policies are
corporately signed off, published
on the
intranet, with summaries added to
the Link to raise awareness of
changes and expectations around
compliance. Trends and issues
relating to prescribing and
medicines are reported in the Link,
with a bimonthly prescribing
newsletter in place to ensure a
strong focus on medicines safety.
An ongoing audit programme has
looked at omitted drugs in the
MAU, pharmacist errors, and is
looking at a range of other
relevant issues.
and has been publicised for all staff in the Link and via the
Medicine Matters Bulletin. Copies have been distributed to all
wards and clinical areas in the Trust and ward matrons have been
tasked with providing a list to pharmacy of all staff who have read
the policy. A summary quick reference guide has also been
prepared and distributed for nursing and medical staff which
contains key responsibilities in the policy as applicable to these
staff groups. This is reinforced in nurse induction and mandatory
training.
MEDICINES
MANAGEMENT
49. Ensure that the results of
learning from medication errors
are widely publicised across all
services in the organisation.
PREMISES 50. Review the directional
signage at Queen’s Hospital.
The trust should ensure that it
seeks the input of patients,
relatives, visitors and staff, to
ensure that any new signage
Safe Medicines Practice Group in
place and produces a summary of
incident themes and serious
incidents to be used in directorate
meetings. Pharmacists and wards
receive monthly reports on
medicines and prescribing. Error
trends are fed back to relevant
directorates and are published on
the intranet.
Working group involving patients,
non‐execs and staff set up in
December
2011 to set signage standards;
main signage reviewed with
specialist input and new signs
Monthly meetings are taking place to review all medicines related
clinical incidents in which action plans are made to address
serious incidents and also key trends are identified and reported
back monthly to wards/directorates. Learning from these is also
shared more widely across the Trust via a range of media
including the intranet, The LINK and the pharmacy bulletin. All
medicine incidents are reported to the Trust Quality and Safety
Committee on the dashboard. The trust has recently introduced
electronic incident reporting which will improve incident
investigation timeframes and provide better data on key trends
than the previous paper reporting system.
This work has been completed. The new maps and directions are
available to visitors via the Trust website. Sodexho are currently
reviewing the signage throughout the hospital as part of the
routine maintenance arrangements of the site.
Portia Omo‐Bare
Jackie Doyle
Imogen Shilito
MET
BUSINESS
AS USUAL
MET
BUSINESS
AS USUAL
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CQC Update Report
2012
meets the needs of its
populations.
commissioned to arrive in June
2012. Leaflet and map under
review to ensure signage is in
context of better overall patient
information.
Hyperlinks to the maps are given below:
http://www.bhrhospitals.nhs.uk/for‐patients‐and‐visitors/mapof‐queens.htm
http://www.bhrhospitals.nhs.uk/for‐patients‐and‐visitors/mapof‐king‐george.htm
PREMISES 51. Review the emergency
department paediatric facilities
at Queen’s Hospital in line with
the standards outlined in
Services for children in
Emergency
Department’s document and
then develop an appropriate
strategy involving both the
emergency and paediatric
departments.
PREMISES 52. Finalise and implement
plans to improve x‐ray facilities
and ensure that patients
waiting for x‐rays in the
emergency department are
appropriately cared for.
Paediatric waiting areas reviewed
and funding agreed to improve
observation of sick children;
project group set up to implement
Health for NEL redesign of
paediatric services.
Review of x‐ray services including
department layout linked to
Health for NEL programme; project
group set up with dedicated
project management support.
Current process of caring for
patients in waiting area addressed
via a short‐term solution using a
mobile x‐ray device to limit patient
waiting times.
The Paediatrics A&E is a 24 hour unit.
The Paediatric A&E is a stand alone area of the main department,
with a dedicated entrance and waiting area.
The Paediatric assessment Unit is currently part of the Paediatric
ward Tropical Lagoon.
There are currently plans being developed to extend A&E which
will include Paediatrics, PAU and the HDU being housed alongside
A&E.
No child under the age of 16 is admitted onto an adult ward. Sick
children are resuscitated in a Paediatric cubicle within the main
adult resuscitation area.
Seriously ill children are transferred via CATS to appropriate High
Level units across London.
The Paediatrics Early warning skills are currently being developed
for A&E in collaboration with the Paediatric department.
Work is planned to align facilities with health 4 NEL agenda.
The current waiting facilities are deemed sufficient for the needs
of patients currently. A programme of continuous review is on
going and will form part of a focus visit for the new Director of
Nursing.
The redevelopment of the A&E and local waiting areas is under
review. Schemes are under development and will be deployed
when capital funding and complimentary schemes are realised.
In the short term, two HCAs have been appointed to chaperone
patients between A&E and A&E Radiology. This means that
although the patients are still waiting on the hospital street, they
Jackie Doyle
Carol
Drummond
Stephen
Griffiths
Judith Douglas
MET
BUSINESS
AS USUAL
MET
BUSINESS
AS USUAL
Page 16 of 22

CQC Update Report
2012
are now supervised during part of the working day. This is an
improvement because prior to this, patients were left unescorted
outside of the A&E Radiology department. We also now have
dedicated changing room facilities so that patients are afforded
greater dignity and privacy. The Trust has also purchased a Digital
Radiography Mobile X ray unit. This unit is based in Resus but has
the potential to be used to support the service if the A&E
Radiology room breaks down and services have to be diverted to
the main X Ray Department.
PREMISES
53. Ensure that appropriate
waiting facilities are available
for patients and relatives in the
urgent care centre.
As above, these waiting facilities
are being reviewed as part of the
Health for NEL programme.
The current waiting facilities are deemed sufficient for the needs
of patients currently. A programme of continuous review is on
going and will form part of a focus visit for the new Director of
Nursing.
Jackie Doyle
PART MET
BUSINESS
AS USUAL
PREMISES 55. Review and take any
necessary action in all inpatient
areas to ensure that there are
clear lines of sight so that
patients can be observed at all
times.
The ‘hourly staffing of wards’
element of the Safer Nursing Care
Tool and other tools are being
used to try to ensure there is
suitable observation of patients,
although concerns about staffing
levels suggest there is room for
improvement.
The Trust has decided against a ‘line of sight’ audit and opted to
focus efforts on Ward Establishments, Patient Acuity scoring,
Professional Judgement module; Dependency scoring; Patient
safety tool
These elements are also considerate of Hourly rounding and
single sex accommodation in assessing patient safety issues
• Reflect and mitigate results from the National Patient
Survey.
Julie Meddings
MET
BUSINESS
AS USUAL
PREMISES 56. Develop appropriate
facilities to ensure the day case
surgical patients are cared for in
appropriate environments at
Queen’s Hospital.
The use of overnight recovery has
been reviewed and works are
underway to Improve facilities
subject to funding. There is a plan
in place to develop a 23‐hour
facility in the day surgery unit and
allow space in Recovery to be used
as a ‘day of surgery’ admissions
area, but these are pending the
outcomes of the bed‐modelling
work stream.
Appropriate use of Day Case and O/N recover is a standing
agenda item on the Daily Bed Meetings.
Any single‐sex or ‘step down’ breach is treated seriously and
investigated via RCA methodology
Eileen Moore
MET
BUSINESS
AS USUAL
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CQC Update Report
2012
RADIOLOGY
31. Develop its planning and
bed management processes to
ensure all patients are cared for
in appropriate facilities.
Matrons and ward sisters are
monitoring this but the Trust has
not yet established how best to
measure success in this area. The
X‐Ray department has introduced
appropriate checklists for ensuring
patients are properly prepared.
The Department has developed Standard Operating Procedures
attached below which are evidence based and serve as the
baseline expectation for all staff. These have been ratified
internally, and are based on good practice examples.
These are well publicised throughout the department, and
subject to internal review.
• A Plan is in place to ensure publicity and accessibility at
ward level
• The impact of these documents is subject to audit in 6
months time.
Stephen
Griffiths
MET
BUSINESS
AS USUAL
RADIOLOGY
32. Put in place clear protocols
for the management of
interventional rradiology
patients with audit and
improvement cycles to ensure
standards are attained and
maintained.
Audit processes are in place and
are monitored at interventional
radiology meetings and at the
Divisional Board. SOPs are in place
and are being implemented for
each procedure in interventional
radiology.
CQC’s compliance activity supports
the Trust’s assessment of
significant progress in this area,
although more audit activity needs
to be delivered for this to be
considered fully met.
The Department has developed Standard Operating Procedures
attached below which are evidence based and serve as the
baseline expectation for all staff. These have been ratified
internally, and are based on good practice examples.
These are well publicised throughout the department, and
subject to internal review.
Stephen
Griffiths
MET
BUSINESS
AS USUAL
RECORDS
80. Improve its systems for
records management to ensure
that notes can be retrieved
effectively and expediently, and
reduce the risks associated with
multiple sets of temporary
notes and poor data handling.
The Trust’s Medical Records
Committee has been reestablished
with new Terms of
Reference; training levels for
healthcare professionals are
discussed at this Committee on a
regular basis. Weekend transport
for transfer of notes has been
reintroduced and a nursing
documentation booklet has been
piloted across several wards and
will be fully implemented by the
The development of the eHandover system will provide a
Trustwide joined up reference database for the use in patient
care.
A new PAS is being commissioned in 2013 for implementation
which will improve the availability of Patient records and reduce
the incidence of Temporary folders.
It is anticipated that patients will be migrated onto one hospital
number covered by barcode scanning options as part of the rollout
and implementation.
Ian Grant
Alex
Hammerton
PART MET
BUSINESS
AS USUAL
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CQC Update Report
2012
autumn.
RECORDS
81. Develop integrated patient
administration and information
systems to ensure that, where
ever a patient is being treated
within the trust, their full
healthcare history can be
accessed by all staff.
A procurement process is
underway to introduce an
effective system to enable access
to patient histories. Funding
challenges have slowed
introducing of a full electronic
patient record.
A new PAS is being commissioned in 2013 for implementation
which will improve the availability of Patient records and reduce
the incidence of Temporary folders.
It is anticipated that patients will be migrated onto one hospital
number covered by barcode scanning options as part of the rollout
and implementation.
Paul Richards
RESPECT &
INVOLVEMENT
27. Make sure that proactive
and mandatory training and
education regarding dignity,
respect and tolerance is
delivered to all staff.
Dignity and respect benchmarking
has been done; compliance
reports on non‐attendance are
being reviewed and a mandatory
training programme is being
developed. A leaflet for new staff
about the Trust’s expectations of
behaviour has been drafted and is
due to be reviewed with the staff
engagement group before roll out.
The BHRUT Code is being reviewed
and will be issued to all new
starters with contract. Quality of
Care audits of dignity and respect
have been carried out in
December and March so far and
will continue in order to audit
feedback from the real time
patient survey.
Bank managers to ensure that
competence of all temporary
clinical staff in this respect is
monitored; if concerns are raised
about temporary staff they should
either not be booked again or only
done so with documented
supervision.
Mandatory training development, reports on non‐attendance,
leaflet re Behaviour and expectations; reviewed BHRUT Code;
Survey Feedback, Update from Gill Perry re Bank competency
framework monitoring.
Gill Perry
Claire O’Toole
Alison Crombie
MET
BUSINESS
AS USUAL
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CQC Update Report
2012
STAFFING 60. Continue to review its
human resource information
systems and ensure that
accurate data is available for
the entire organisation, so that
a clear and comprehensive
understanding of vacancies can
be established.
The Trust has introduced a phased
programme to consolidate
establishment data against the
electronic staff record, including
cleansing the record of posts that
are no longer in use, and with
finance support. There have been
challenges in aligning the HR
ledger data with the electronic
record. Further work is needed
and there is, as yet, no formal
process in place or agreed for
managing establishment control.
The move to electronic staff
change / termination forms has
been difficult to implement, and
there has been a delay in getting
fully accurate reporting on
vacancies and establishment.
The Trust systems to reconcile ledger and ESR will ‘go live’ on
07/11/12 and will be evaluated for compliance on 30/11/12.
The work is led by Gill Perry; Leigh Malyon supported by Mark
Greene (Finance)
Sept 12 update: A great deal of work has taken place to align the
financial ledger with ESR. This work is now complete except for
the updating of the old subjective codes for medical staff within
the finance ledger. Updating these codes by finance will
completely align the ledger to ESR. Finance are in the process of
cleansing the old subjective codes ,
it is envisaged that this work will be complete in the next few
weeks. A process & procedure for establishment control has been
developed and agreed. Next step is the development of the
electronic change form and testing of the system – it is
anticipated this will be complete by beginning November.
Mark Smith
MET
BUSINESS
AS USUAL
STAFFING 61. Continue to review its
workforce strategy to ensure
that it meets the needs of the
organisation and reflects the
reality of service delivery.
A review of the Workforce
Strategy has been completed and
is now being tested via the staff
engagement group.
A Number of work streams are currently active which affect the
current workforce strategy. These schemes are led by senior
managers and report to the Director of Transformation and the
Transformation Board initially.
• Length of Stay Work stream (Julie Meddings & Ernst
and Young)
• AHP Review (Nick Hume, Director of Strategy)
• Workforce Transformation (Mark Smith, Head of
Workforce Transformation)
Mark Smith
BUSINESS
AS USUAL
STAFFING
62. Undertake systematic skill
mix and staffing needs analysis
to ensure that they have the
right staff with the right skills at
the right locations and that
trust is receiving value for
money.
Skills for Health are supporting the
Trust in this, funded via NHS
London Financial Support. Pilot
work in the Emergency and
Maternity Departments is
underway. Future phases are
heavily dependent on the success
Sept 12 update: Paediatric skill mix project has now commenced
Plan now in place to link overall SfH project with Clinical
transformation lead’s work in relating to review of the ward
nursing establishments. Meeting scheduled for Wed 3rd October
to include discussions on implementing A&E recommendations
provided by SfH in their review.
Linda Baker
PART MET
Page 20 of 22

CQC Update Report
2012
of the pilot analysis and capacity to
roll its findings out across the Trust
and this will only be able to be
assessed in the longer term. CQC
compliance activity continues to
suggest that the Trust faces
challenges in terms of building a
sustainable workforce with the
right skills mix.
STAFFING 63. Continue to recruit
appropriate permanent staff to
ensure that it reduces its
reliance on agency and locum
staff improving the quality of
care, and have in place effective
retention strategies.
An accelerated recruitment project
and reduced use of agency staff
have been put in place, with
recruitment needs assessed on a
monthly basis. Exit interviews are
now in place as part of KPIs and
are reviewed by Directors.
The Trust has introduced suitable
procedures here, but CQC
compliance activity has identified
on‐going challenges around locum
use, particularly in A&E.
Sept 12 update: Improved bank & agency controls have been
introduced which are linked to more proactive booking of bank
staff. E‐rostering KPI’s are measured at the same time as bank
usage is requested in order to ensure every possible use of
permanent staff has been explored first.
Gill Perry
Mark Smith
MET
BUSINESS
AS USUAL
STAFFING
66. Support a skills escalation
programme in the emergency
department that seeks to
develop nurses who have
already successfully completed
an emergency nurse
practitioner or advanced clinical
practitioner course and reduce
reliance on them undertaking
traditional nursing duties due to
shortages of staff.
A review of the A&E workforce has
been completed and the unit has
been benchmarked against other
comparable trusts. A review of the
skills mix, current roles, and
supporting roles has been
undertaken and budgets reviewed
in light of this. Current staff are
taking part in an on‐going training
programme to ensure staff update
and refresh their skills. CQC’s
compliance activity has identified
on‐going staffing challenges in A&E
and the longer term impact of this
review work will need to be
Head of Nursing for A&E appointed and in Post September 2012.
Lead for ANP
•Review of KGH ED nursing workforce has commenced and is
being led by the Clinical Nurse Director for Emergency Care. A
review of the paediatric nursing workforce on both sites and the
RAT (rapid, assessment and treatment) area nursing workforce at
QH will also be undertaken in October.
•Training competencies are being reviewed for all roles in the
department to ensure that all staff have clear responsibilities and
competencies to undertake that role. This work is being led by
the Clinical Nurse Director with support from the Matrons.
•Advanced nurse practitioners have started in the ED.
•Established weekly middle grade and SHO teaching is in place
with a clear and structured training curriculum
Derek Hicks
Clare Dixon
Samantha
Elden‐Lee
MET
BUSINESS
AS USUAL
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CQC Update Report
2012
assessed at some point in
the future
STAFFING 67. Ensure that its
whistleblowing systems and
processes allow staff a route to
raise concerns early so that
quick action can be taken and
staff feel empowered to raise
concerns.
The Trust’s whistleblowing policy
has been revised and
communicated to staff through
Team Brief, the Link and the
intranet. Staff feedback on the
effectiveness of the policy is now
part of the staff engagement
strategy and new starters will be
audited after six months to see if
they are aware of it. Delivery of
this recommendation is contingent
on cultural change embedding
itself across the Trust (although it
should be noted that CQC has
usually found staff open and
willing to talk frankly about
challenges during inspections,
whether in confidence or openly).
We are now launching a further communications exercise to raise
the profile of the new policy and offer training to staff. In
October 2012 this will include a payslip message and wide
circulation of the attached letter signed by the Chief Executive
and Staff side lead.
Training sessions have now also been arranged on both sites and
will initially run from the end of October to beginning of
December 2012 when they will be reviewed
Claire O’Toole
MET
BUSINESS
AS USUAL
Page 22 of 22

EXECUTIVE SUMMARY
TITLE:
Information Governance (IG) Strategy 2012/13
BOARD/GROUP/COMMITTEE:
Trust Board
7 th November 2012
1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:
Information Governance (IG) is a framework □ PEQ ……………..….. □ STRATEGY……….….…….
that brings together best practice, standards
□ FINANCE ……..……… □ AUDIT ………….……..….
and requirements that apply to the handling of
information. This includes sensitive and □ CLINICAL GOVERNANCE …………..………….....……
personal information, of patients and employees □ CHARITABLE FUNDS ………………………………...…
as well as commercially sensitive information.
√ TRUST BOARD …05/09/12…..………
This strategy sets out Barking Havering and □ REMUNERATION ………………………………….…...
Redbridge University Hospitals NHS Trust’s □ OTHER … ……………………..……. (please specify)
(BHRUT’s) approach to providing a robust
Information Governance framework. It is
essential that appropriate management
structures, leadership and organisational
processes are in place to deliver successful
information governance, and important the
Information Governance agenda is adequately
resourced.
Purpose:
• To ensure that patient and corporate data
collected or created is of the best possible
quality.
• To ensure that data is held in such a
manner as to prevent unauthorised access
to loss, but to available to those authorised
when required for the provision of patient
care or for commissioning purposes.
• To ensure that its policies and procedures
reflect the requirements of the Information
Governance agenda, in clearly outlining to
staff their responsibilities.
• To ensure there is a management structure
to reflect IG requirements
2. DECISION REQUIRED: CATEGORY:
To approve the Information Governance
Strategy.
√ NATIONAL TARGET □ CNST
√ CQC REGISTRATION □ HEALTH & SAFETY
√ ASSURANCE FRAMEWORK
□ CQUIN/TARGET FROM COMMISSIONERS
□ CORPORATE OBJECTIVE ……………………………....
□ OTHER … …………………….. (please specify)
AUTHOR/PRESENTER: Neill Moloney
Director of Planning and Performance
DATE: 29 October 2012

3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:
4. DELIVERABLES
Level 2 or above in all 45 IG Toolkit standards to achieve satisfactory IG compliance
5. KEY PERFORMANCE INDICATORS
Compliance with the IG toolkit
AGREED AT ______________________ MEETING
OR
REFERRED TO: __________________________
DATE: ____________________________
DATE: ____________________________
REVIEW DATE (if applicable) ___________________________
2

INFORMATION GOVERNANCE
STRATEGY
2012/2013
Barking, Havering & Redbridge University Hospitals NHS Trust Page 1 of 9
Information Governance Strategy Version 1.4 Issued October 2012

BACKGROUND
Information Governance (IG) is a framework that brings together best practice, standards
and requirements that apply to the handling of information. This includes sensitive and
personal information, of patients and employees as well as commercially sensitive
information.
Information Governance provides a way for employees to deal consistently with the many
different rules about how information is handled, including those set out in:
• The Data Protection Act 1998
• The common law duty of confidentiality
• The Confidentiality NHS Code of Practice
• The NHS Care Record Guarantee for England
• The Social Care Record Guarantee for England
• The international information security standard: ISO/IEC 27002: 2005
• The Information Security NHS Code of Practice
• The Records Management NHS Code of Practice
• The Freedom of Information Act 2000
• The Caldicott Report
This strategy sets out Barking Havering and Redbridge University Hospitals NHS Trust’s
(BHRUT’s) approach to providing a robust Information Governance framework. It is essential
that appropriate management structures, leadership and organisational processes are in
place to deliver successful information governance, and important the Information
Governance agenda is adequately resourced.
Information Governance sits alongside clinical and corporate governance in providing the
service users and other organisations with the assurance that personal and commercially
sensitive information is handled in a confidential and secure manner to appropriate legal,
ethical and quality standards.
The Information Governance strategy is monitored by the Connecting for Health (CfH)
Information Governance Toolkit. This is a performance tool produced by the Department of
Health (DH) which draws together the legal rules and central guidance set out above and
presents them in one place as a set of Information Governance requirements.
This document should be read in conjunction with the Information Governance Policy. The
Action Plan sets out a delivery of actions to satisfy the requirements.
PURPOSE
1. To ensure that patient and corporate data collected or created is of the best possible
quality.
Barking, Havering & Redbridge University Hospitals NHS Trust Page 2 of 9
Information Governance Strategy Version 1.3 Issued August 2012

Information is a vital asset in terms of the clinical management of individual patients and
the efficient management of services and resources. It plays a key part in clinical
governance, service planning and performance management. It is therefore important
that information is efficiently managed within the Trust through a robust Information
Governance Framework to assure and demonstrate that all information is dealt with
legally, securely, effectively and efficiently in order to deliver the best possible care to
patients, staff and other service users.
As accurate, timely and relevant information is essential to deliver the highest quality
health care, it is the responsibility of all clinicians and managers to ensure and promote
the quality of information and to actively use information in decision making processes.
2. To ensure that data is held in such a manner as to prevent unauthorised access to loss,
but to available to those authorised when required for the provision of patient care or for
commissioning purposes.
As there is a need for an appropriate balance between openness and confidentiality in
the management and use of information, the Trust fully supports the principles of
corporate governance and recognises its public accountability. However it equally
places importance on the confidentiality of and the security arrangements to safeguard
personal information about patients and staff and commercially sensitive information.
The Trust also recognises the need to share patient information with other health
organisations and other agencies in a controlled manner.
To achieve this aim BHRUT will:
• Require the ongoing support of the Trust Board in placing IG as a high
organisational priority, which promotes the importance to all staff of maintaining
confidentiality and following policies/procedures outlined
• Establish and maintain policies to ensure the secure management of its
information assets and systems
• Comply with legal and regulatory requirements, introducing best practice guidance
relating to Information where appropriate
• Ensure patient, staff and commercial information is treated as confidential
• Ensure records are stored and transported securely
• Ensure that Directorate and Service procedures and processes relating to
information and data flows are fully mapped
• Provide Information Governance training to staff at induction, and through
mandatory training sessions/via e-training
• Monitor information security alerts through the Trust incident reporting process
• Ensure contracts with companies processing data on behalf of the Trust include
clauses with reference to Information Governance, the expectations to follow this
requirement and the consequences of non-compliance
3. To ensure that its policies and procedures reflect the requirements of the Information
Governance agenda, in clearly outlining to staff their responsibilities.
Barking, Havering & Redbridge University Hospitals NHS Trust Page 3 of 9
Information Governance Strategy Version 1.3 Issued August 2012

There are three key components underpinning this strategy:
• The Trust Information Governance Framework, which provides a
summary/overview of how the Trust is addressing the IG agenda
• The Trust Information Governance Policy, which outlines the objectives for
Information Governance; and
• The annual action plan arising from a baseline assessment against the standards
set out in the NHS Connecting for Health Information Governance Toolkit
4. To ensure there is a management structure to reflect IG requirements
Within the Trust, the Chief Executive Officer (CEO) has overall responsibility for
Information Governance (IG), this responsibility is discharged through the Executive
Chief Information Officer (from 3 rd December 2012). This individual is responsible for all
aspects of IG including the submission of the Connecting for Health’s Information
Governance Toolkit, is the chair of the Information Governance Steering Group (IGSG),
as well as being the Trust’s Senior Information Risk Officer (SIRO).
The SIRO is responsible for understanding how the strategic business goals of the
Trust may be impacted by information risks and for the ongoing development and dayto-day
management of the Trust’s Risk Management Programme for information privacy
and security. The SIRO will review and agree action in respect of identified information
risks, ensure that the Trust’s approach to information risk is effective in terms of
resource, commitment and execution and that this is communicated to all staff. In
addition they will provide a focal point of resolution and/or discussion of information risk
issues, and ensure the Board is adequately briefed on information risks.
The IGSG comprises of senior representatives from across the Trust and its
professional disciplines, to promote a holistic approach to IG. It has overall
responsibility for overseeing the implementation of the Information Governance
Strategy, Framework, IG Policy and any IG actions plans, by embedding IG within the
organisational structure, and sharing the responsibility for completion of the annual IG
Toolkit assessments. It is therefore vital to the development of best practices which are
acceptable, practicable, ‘owned’ and therefore better supported across the whole Trust,
and influences the integration and inclusion of IG standards with other governance,
strategies, work programmes and projects, e.g. IT programmes.
The IGSG is accountable to the Trust Board through the Executive Chief Information
Officer, the named Director on the Board with responsibility for Information Governance
(IG). This post is supported by the Director of Clinical Strategy who is the Trust’s
Caldicott Guardian, the Head of Commissioning, Information and Planning, the IG Lead
and members of the IGSG. The IGSG is a sub-group of the Quality and Safety
Committee. Terms of Reference and membership of the IGSG are defined in the Trust
document, ‘Information Governance Steering Group Terms of Reference’.
Developing an IG culture within the Trust will be achieved through IG training being
provided as part of the Trust’s mandatory corporate induction programme for new
Barking, Havering & Redbridge University Hospitals NHS Trust Page 4 of 9
Information Governance Strategy Version 1.3 Issued August 2012

starters as well as being mandatory for all Trust staff as part of the Trust’s IG training
program, requiring all staff to undertake IG training annually, either at face to face
presentations or by e-learning.
The Director of Clinical Governance and the Executive Chief Information Officer will
ensure that IG requirements are reflected in the annual Clinical Governance
Development plan and ICT strategy.
IG PROCESS
The wide range of processes covered by the IG Toolkit and the diversity of specialisation
resulted in the IGSG taking the decision that responsibility for IG within the Trust should not
be allocated to one individual or department. The Trust approach is to identify senior
managers who will have responsibility for the management and co-ordination of IG
Requirements. These senior staff will be Executive Directors, Directorate Managers or, in
some cases, General Managers. They will be referred to in IG documentation as
Requirement Owners. All Requirement Owners will be full members of the Information
Governance Steering Group. Other staff with specific areas of expertise will be co-opted onto
the Group when required.
As there is often an overlap between IG Requirements, by agreement; one Requirement
Owner may provide evidence for another IG Requirement. However, the identified
Requirement Owner has ultimate responsibility for ensuring that the Requirement is complete
and with evidence uploaded to support the compliance level.
The IG Lead will be supporting the standard owners in developing their action plans, and is
responsible for submitting the baseline, performance and final assessment to CfH. The
Director of Planning and Performance will sign off a report from the IG Toolkit, to confirm he
has authorised the final submission for 31st March 2013.
The Trust’s IG performance will be monitored by the IGSG throughout the year with reports
that monitor achievements against requirements. These regularly presented reports and
minutes of the IGSG meetings where they were approved, will provide the evidence to be
uploaded into the IG Toolkit.
In February 2013 an independent audit will be undertaken of a selection of IG standards, to
highlight to standard owners changes and improvements required before the final
submission.
PAST PERFORMANCE
Although in 2010/11 64% IG compliance was reported to CfH, following further review the
IGSG considered that evidence submitted needed strengthening, policies and procedures
needed to be improved and updated, and the IGSG governance strengthened to reflect a
more structured approach to completing the requirements. With a baseline return of only 9%
in July 2011, reliance was being placed on old evidence submitted, which was now either not
fit for purpose or required updating.
Barking, Havering & Redbridge University Hospitals NHS Trust Page 5 of 9
Information Governance Strategy Version 1.3 Issued August 2012

The IGSG was changed to ensure that attendance at meetings was improved with deputies
attending in place of absentees. In addition minutes were more structured to accurately
reflect the subjects discussed, outstanding and completed action logs were developed to
ensure action points were resolved, and an overall IG action plan was added as a regular
agenda item. To support the evidence required for the standards and ensure IG key subjects
are regularly discussed, monthly, quarterly and yearly reports were introduced with a
standard format for presentation.
It was also identified that IG awareness needed improving across the organisation. To
support this the intranet pages were rebranded and improved to provide a good source of
information for staff, including grouping all IG policies in one place for ease of reference. An
IG local brochure was also developed to be given to staff at training sessions.
In light of the Department of Health (DH) requirement to train staff annually in Information
Governance, the current training presentation was rebranded to incorporate all aspects of
Information Governance, and added to the Central Induction to capture all new starters. An
e-learning system was also procured which reflected the IG content of face to face training
sessions, to improve the choice to staff for completing their training and the potential to
achieve the requirements of CfH for 95% of staff to be trained annually.
Improvements were also made to the information given to patients and service users, by
rebranding the Trust website pages and updating the patient information leaflet.
An audit was undertaken of the IG policies and procedures, and any gaps where these were
missing or out of date, allocated to areas to resolve.
These improvements enabled us to submit a final assessment of 62%.
2012/13 PERFORMANCE
With a strengthened IGSG the overall managerial commitment has improved, including joint
working between standards owners where the standard covers several areas.
Several standard owners have also developed action plans for their standards and uploaded
evidence currently available, rather than waiting until the final submission date. As such the
baseline return submitted 31 st July 2012 was 28%. However, it was noted that further
improvements are required in:
• All members of the IGSG regularly attending the IGSG
• The presentation of all reports required to the IGSG
• All polices and procedures identified as requiring updating/creation completed in
2012/2013
• All standard owners reviewing the IG Toolkit standards and removing out of date
information
• All standard owners developing action plans for each of their standards to chart their
progress
There is a commitment by the IGSG to achieve at least a level 2 in all 45 standards, which as
required by the CfH will provide satisfactory assurance of the Trust’s IG compliance.
Barking, Havering & Redbridge University Hospitals NHS Trust Page 6 of 9
Information Governance Strategy Version 1.3 Issued August 2012

The standards are split into the areas of information governance management, confidentiality
& data protection assurance, information security assurance, clinical information assurance,
secondary use assurance and corporate information assurance. As such the standard
owners have been allocated reflecting their knowledge and skill set in the subjects, to ensure
both an understanding of the requirements and an ability to achieve these.
To make sure adequate progress is being made with all standards, all standard owners will
be presenting their individual action plans at the September 2012 IGSG. This will highlight
any potential barriers to achieving the level 2 required, which as appropriate will be fed
through to the Trust Board.
In addition, recommendations from the 2011/12 internal audit of 20 IG Toolkit standards
received in August 2012 will be developed into an action plan agreed with the Executive
Director of Planning and Performance. Where appropriate, these will then be incorporated
into the individual standard action plans to ensure compliance.
The over-arching IG action plan (see below) continues to be reviewed at the IGSG, and in
co-ordination with the individual standard action plans there is the potential to achieve at
least 73% compliance rate by the final return on 31 st July 2013.
Barking, Havering & Redbridge University Hospitals NHS Trust Page 7 of 9
Information Governance Strategy Version 1.3 Issued August 2012

Over-arching IG action plan
Action Plan for improvements to IG compliance
Task Programme of work Task owner Current
status
Status
date
1 Consistent attendance from all
standard owners in IGSG and
support for IG Toolkit compliance
2 Submission of monthly, quarterly
and yearly reports to IGSG
3 Review latest version of IG toolkit
to identify any changes to
requirements
3a Advise all standard owners of
requirements/function changes
and need to start work on version
10
3b
Remove out of date information
on Version 10 of IG toolkit and
upload current information where
available
4 Development of standard owner
action plans
4a Presentation of standard owner
action plans at September IGSG
4b Further discussion concerning
standard owner action plans
5 Submission of baseline return by
31/07/12
6 Updating of IG policies required
out of date to IGSG for approval
7 Review of IG toolkit report from
auditors
7a Formulate Trust response to
audit report
7b Incorporation of auditor
comments into standard owner
action plans
8 Conclude distribution of IG local
Guide
9 Update e-learning instructions for
IG module and include on the
Intranet
10 Promote annual training
requirement via the Link,
updating Learning &
Development prospectus
Standard
owners
Standard
owners
Completion
due date
In progress 02/10/2012 On going
through the
year
In progress 02/10/2012 On going
through the
year
SB Completed 01/06/2012 01/06/2012
SB Completed 01/06/2012 01/06/2012
Standard
owners
Standard
owners
Standard
owners
Standard
owners
In progress 02/10/2012 Imminent
for
remaining
standard
owners
In progress 02/10/2012 Imminent
for
remaining
standard
owners
Completed 02/10/2012 26/09/2012
To start 02/10/2012 22/10/2012
SB Completed 31/07/2012 31/07/2012
Standard On going 02/10/2012 31/12/2012
owners
NM/SB/NMk Completed 22/08/2012 24/08/2012
NM/SB/NMk To start 22/08/2012 30/09/2012
Standard
owners
To start 02/10/2012 31/10/2012
SB Started 02/10/2012 on-going via
training
courses
SB Completed 17/05/2012 17/05/2012
SB Completed 17/05/2012 17/05/2012
Barking, Havering & Redbridge University Hospitals NHS Trust Page 8 of 9
Information Governance Strategy Version 1.3 Issued August 2012

10a Reapproval of IG training
programme with DOH
11 Sub group to review risk
assessments/information flows
from Parkhill project
11a Ensure current risk register
captures all systems and
appropriate risk owners
11b
11c
Proposal from Auditors of IG
work programme for 2012/13 for
improving risk assessment and
information flow standards
Auditor IG work programme roll
out
12 Submit IG Toolkit performance
return by 31/10/12 deadline
13 Fax directory - work to identify all
fax numbers, ensure
confidentiality posters displayed,
update fax directory on the
intranet
14 Distribute Patient Information
Leaflets
15 Review Data Quality processes -
linked with Data Quality Group
16 Review Business Continuity
Management plans
SB To start 02/10/2012 Imminent
Sub-group Completed 30/05/2012 30/05/2012
SB/Subgroup
NMk/agreed
with NM
NMk in coordination
with SB
To start 02/10/2012 31/12/2012
Completed 31/07/2012 31/07/2012
Started 02/10/2012 30/10/2012
SB To start 02/10/2012 31/10/2012
SB/Telecoms To start 02/10/2012 31/12/2012
GE In progress 02/10/2012 on-going
CB To start 02/10/2012 on-going
DB/JH In progress 02/10/2012 31/12/2012
17
Development of survey monkey
training evaluation forms SB In progress 02/10/2012 31/12/2012
17a Sending of evaluation forms SB To start 02/10/2012 31/01/2013
17b
Evaluation of training evaluation
forms SB To start 02/10/2012 28/02/2013
18
Review and update Information
Governance Information on the
Trust website SB Completed 22/08/2012 22/08/2012
18a
Update FOI Publication Scheme,
update on website SB To start 02/10/2012 28/02/2013
19
Arrange audit date for 2012/13
Toolkit return NM/SB To start 02/10/2012 31/12/2012
20
All evidence uploaded to IG
toolkit
Standard
owners To start 02/10/2012 15/03/2013
20a
Final review of evidence,
marking all standards as
complete SB To start 02/10/2012 25/03/2013
20b Sign off of final IG toolkit return NM To start 02/10/2012 28/03/2013
20c
Submission of final IG toolkit
return by 31/03/13 deadline SB To start 02/10/2012 29/03/2013
Barking, Havering & Redbridge University Hospitals NHS Trust Page 9 of 9
Information Governance Strategy Version 1.3 Issued August 2012

EXECUTIVE SUMMARY
TITLE:
Board Assurance Framework – 2012 Quarter 2
BOARD/GROUP/COMMITTEE:
Trust Board
1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and
DATE:
Attached is the Board Assurance Framework for the second quarter of
2012.
The purpose of the BAF is for the risks which impact on the Trust’s strategic
& principal objectives to be assessed and current controls reviewed to
provide assurance to the Board that mitigating actions are undertaken to
reduce the impact and risk level.
Progress
Following detailed review at the October Trust Executive Committee,
elements of the BAF have been amended to reflect a more detailed risk
profile. This continues to be work in progress.
The following improvements have been made:
1. The recommendations from the recent TEC meeting have been
implemented.
2. Risk Review forms were introduced to ensure efficiency of risk
reporting.
3. Closure Forms were introduced to ensure that Clinical Directors
and General Managers gave approval for risk closure
4. Corporate Risk Register training including the use of controlling
documents is ongoing
5. Evidence of updated Action plans for each Extreme and High Risk will
streamline management of the BAF and is ongoing.
□ TEC ……….. □ STRATEGY……….…..…
□ FINANCE ……..……… □ AUDIT ………….
□ QUALITY & SAFETY
…………..………….....……….…
□ WORKFORCE
………………………………………….…
□ CHARITABLE FUNDS
………………………………...…
□ TRUST BOARD
……………………………….……….….
□ REMUNERATION
………………………………….….....
□ OTHER …………………………..……. (please
specify)
6. Continued review has resulted in the following changes to the BAF this
month: Risks Removed or Added to the BAF:
Trust Information
Status
Ref:
339 Complaints has been removed from the BAF Removed
the controls have reduced the residual risk
impact on the Trusts but it would remain on
the corporate risk register and monitored via
action plans
311 Potential severe disruption to services arising Removed
from the removal of London Deanery posts pose
major difficulties in the delivery of quality care at
KGH obstetric services. This risk was removed
following TEC review, this was approved by
the Clinical Director
323 Risk of adverse impact on profitability due to Removed
introduction of new London wide GU and FP
Tariff in April 2012, this risk would be
managed within the Women Directorate
342 Risks: Executive leadership changes would Removed
compromise the strategic agenda This risk
was closed by the CEO because of
successful recruitment of suitable strategic
directors to progress BHRUT's plans / goals.
341 End of life Strategy because the internal
control and action plan was instrumental in
reducing the risk scoring and there is
reasonable assurance that it is managed
adequately with the aid of the Life Boards
Removed
1

343 Directorate Anaesthetic:
Risk: Failure to comply with NSPA directive
(see BAF P.7 for more details)
Added /
New
7. Action Plans
Monthly review and management of the action plans in place to mitigate all
of the extreme and high risks is in place.
2. DECISION REQUIRED: CATEGORY:
The Trust Board is asked to note the changes to the BAF.
□ NATIONAL TARGET
□ CQC REGISTRATION
□ RMS
□ HEALTH & SAFETY
X ASSURANCE FRAMEWORK
□ CQUIN/TARGET FROM COMMISSIONERS
□ CORPORATE OBJECTIVE
……………………………....
□ OTHER …………………….. (please specify)
AUTHOR/PRESENTER Pam Strange Clinical
Governance Director/ Donna Kinnair, Director of
Governance
DATE: 26th October 2012
3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:
4. DELIVERABLES
Trust key objectives.
5. KEY PERFORMANCE INDICATORS
As detailed in the BAF.
AGREED AT ______________________ MEETING
OR
REFERRED TO: __________________________
DATE: ____________________________
DATE: ____________________________
REVIEW DATE (if applicable) ___________________________
2
EXECUTIVE SUMMARY/ Clinical Governance Pam Strange

BOARD ASSURANCE FRAMEWORK 2012
2nd Quarter: July to September 2012
BHRUT BAF 2nd Quarter 2012: SB/PS
1

Table of Contents
TRUST PRINCIPAL OBJECTIVES ........................................................................................................................................................... 3
BHRUT STRATEGIC OBJECTIVES WITH EACH PRINCIPAL OBJECTIVE ............................................................................................ 4
BHRUT RISK TREND ANALYSIS FOR 2007- 2012 .................................................................................................................................. 5
RISKS DETAILS ........................................................................................................................................................................................ 8
Strategic Objective 1 – Deliver Safe, Quality Effective Care ............................................................................................................................... 8
Strategic Objective 4: Services Are Rated Positively By Patients. Families & All Stakeholders ................................................................... 13
Strategic Objective 5 – To Ensure BHRUT is Financially Secure...................................................................................................................... 14
RISK DESCRIPTORS.............................................................................................................................................................................. 16
TABLE: RISK SCORING = SEVERITY X LIKELIHOOD (S X L) .......................................................................................................................... 17
BOARD ASSURANCE FRAMEWORK ELEMENTS .............................................................................................................................................. 18
CARE QUALITY COMMISSION: Regulations and Outcome Guide ................................................................................................................... 19
BHRUT BAF 2nd Quarter 2012: SB/PS
2

TRUST PRINCIPAL OBJECTIVES
BHRUT Strategic Objectives are: To Deliver Safe, Quality and Effective Care, To Deliver Operational Excellence ensuring that all standards are met, To
Provide a First -Class Educational Experience, Services are Rated Positively by Patients, Families and all Stakeholders, Ensure that BHRUT’s Trust is
Financially Secure and Staff Actively engaged in the Success of the Trust.
Introduction: The Board Assurance Framework (BAF) evidences the Board control over delivery of its principle objectives. The BAF directly underpins the
annual statement on Internal Control (SIC) and is the subject of annual enquiry by its host commissioning body and Internal and External Audit.
Function of the BAF
The BAF is a tool for the Board corporately to assure itself (be assured based on evidence) about successful delivery of the organisation’s principle objectives.
The framework is designed to focus the Board on controlling principle risks threatening the delivery of those objectives. The BAF aligns principle risks, key
controls and assurances on controls alongside each objective. Gaps are identified where key controls and assurances are insufficient to reduce the risk of
non-delivery of objectives. This enables the Board to develop and subsequently monitor a Board Assurance Action Plan for closing gaps. The Direction of the
Board in these matters ensures appropriate allocation of resources to improve the effectiveness of management.
The process and purpose of the BAF may be summarised as:
• Description of the risks which present a major threat to achievement of any of the objectives and are not well controlled.
• Identify and evaluate the design of key controls intended to manage these principle risks, underpinned by self assessment against the Care Quality
Commission regulated standards.
• BHRUT CQC development action plan is referenced to each risk on the BAF
• All significant risks whether to the objectives or otherwise are also described on the Trust Risk Register. Those risks are identified initially through
review of the objectives themselves. Alternatively they may initially be identified by Directorates as operational risks.
• The BAF and the Risk Register will provide confirmation that there are action plans to put in place controls for the risks they contain and that there is
assurance that plans and controls are robust.
• Those risks which present a major threat to any of the objectives and are not well controlled are defined and graded as Extreme (red). By definition all
the Trust’s residual Extreme risks appear on the BAF. Q1 BAF: An action plan would be attached Extreme risks.
• Significant risks which require high level attention but do not present a major threat to any of the objectives are defined and graded as residual High
(orange) and are described on the Risk Register but not on the BAF unless a potential for major threat.. Oversight of their control and assurance is
allocated to the responsible Directorate. This is monitored and tracked by the Compliance Team at the Directorate level.
• Extreme risks that threaten any of the objectives but which then become better controlled will be downgraded to a less threatening High or Moderate
risks will be relegated from the BAF to the Risk Register alone and oversight of their control will be allocated to the responsible Directorate.
• The Framework will be reviewed by the Audit Committee at each meeting and by the Board quarterly.
BHRUT BAF 2nd Quarter 2012: SB/PS
3

BHRUT STRATEGIC OBJECTIVES WITH EACH PRINCIPAL OBJECTIVE
VISION: BHRUT is a flourishing Foundation Trust providing first class services to patients and families,
in which the public and commissioner’s have full confidence
MISSION: To become a Foundation Trust
THERE ARE 6 STRATEGIC OBJECTIVES
1. DELIVER SAFE,
QUALITY, EFFECTIVE
CARE
2. DELIVER OPERATIONAL
EXCELLENCE ENSURING
THAT ALL STANDARDS ARE
MET
3. TO PROVIDE A FIRST
CLASS EDUCATIONAL
EXPERIENCE
4. SERVICES ARE RATED
POSITIVELY BY PATIENTS,
FAMILIES & ALL
STAKEHOLDERS
5. TO ENSURE BHRUT
TRUST IS FINANCIALLY
SECURE
6. STAFF ACTIVELY
ENGAGED IN SUCCESS OF
TRUST
THERE ARE 4 PRINCIPAL OBJECTIVES FOR EACH STRATEGIC OBJECTIVE
Ensure that robust plans
are in place to produce and
deliver the Schedule of
Information (Quality
Accounts)
Achieving excellence in
patient safety and clinical
effectiveness including:
Developing and using
technology and information
systems to improve quality
Deliver all local / national
standards and targets
including comply with CQC,
RMS & HSE regulations.
To ensure service line
reporting is fully established
and working effectively
To increase service quality,
delivery and choice
Ensuring learners and new staff
have an excellent experience
and that all elements of
education and training are
delivered in a safe environment
for patients, staff and learners.
All staff to undergo a high
quality Personal Development
Plan, identifying opportunities
for staff development
To embed a reputation of being
a high performing Trust with the
best outcomes for patients
,families, visitors, all
stakeholders & the media
Continuous improvements to
be demonstrated in staff &
patient surveys (locally &
nationally)
Maintain efficient economic
use of resources : costs
reduced productivity improved
income collected
Ensure capital programme is
effectively prioritised.
Staff have the necessary
values and behaviors to
enhance the quality of the
patient experience through
education, training and
Personal and Professional
development
To establish the correct
governance arrangements
and ensuring we recruit and
retain staff to deliver our
objectives
Maintain patient flow at all
times through the
organisation
- 4 Hour
- Cancer
- 18 Weeks
-
To ensure the patient
safety agenda is fully
established in all areas of
the Trust.
A system to ensure that
infection, prevention and
control is in place
Full achievement of all
contract KPIs & CQUIN
indicators resulting in
maximum contract
income
Achievement of all mandatory
training targets
Robust & successful systems
in place for succession
planning & talent
management
To fully embed the patient
experience framework &
demonstrate improvements
made to patient experience
Improve stakeholders
relationship to deliver a
seamless service that improves
health outcomes for patients /
service users
The CIP be delivered fully to
the agreed timescales without
affecting the quality of care
adversely
Meet our in-year
financial targets
(including net
I&E surplus, liquidity,
Productivity)
Ensure that capacity and
demand planning is based on
robust health and workforce
demographic information
To manage a positive,
inclusive and engaging
culture within the Trust
BHRUT BAF 2nd Quarter 2012: SB/PS
4

BHRUT RISK TREND ANALYSIS FOR 2007- 2012
CORPORATE RISKS ON BAF
6
High
Extreme
45
40
CURRENT RISKS ON CORPORATE RISK REGISTER
43
34
Low
Moderate
High
Extreme
6
4
2
1
35
30
25
20
15
10
7
12
0
High
Extreme
5
0
Low Moderate High Extreme
CORPORATE RISKS BY TYPE
4 2 6
Risks on the BAF: The BAF only reflects residual risks after controls / assurance have been
agreed. Currently there are 2 High and 7 Extreme risks.
Risks Removed:
17
Risk 339: Complaints has been removed from the BAF, the controls have reduced the
residual risk but it would remain on the corporate risk register and monitored via action plans.
30
Risk 323: Risk of adverse impact on profitability due to introduction of new London wide GU
and FP Tariff in April 2012, this risk would be managed within the directorate
18
19
Accreditation
Clinical
Health & Safety
Finance
Service Delivery
Security
Reputation
Risk 341: End of life Strategy. The internal control and action plan was instrumental in
reducing the risk scoring and there is reasonable assurance that it is managed adequately
with the aid of the Life Boards
Risk 311: Potential severe disruption to services arising from the removal of London Deanery
posts pose major difficulties in the delivery of quality care at KGH obstetric services. The
London Deanery agreed plans have removed the risks.
It is evident that the Internal risk management processes have successfully reduced the
number of corporate of risk by mitigating the risk either with local resources or closure
because the risk no longer impacts the Department or the Trust objectives. This is widely
contributed by the willingness of management and employees to embrace the BHRUT risk
management framework of action plan, risk validation forms, closure forms and exception
reporting.
BHRUT BAF 2nd Quarter 2012: SB/PS
5

DIRECTORATES RISKS REVIEW
12
10
8
6
4
2
0
3
2
Acute Med
Anaest.
Child ren
3
NO. OF RISKS BY DIRECTORATES
11
0
6
4
0
Emerg.Care
Neuro Scie
Pathology
Radiology
Surgery
9
6 6
10
Spec. Surg
Spec.M ed
Supp. Serv
Women
Estates
1
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
ANAESTHETIC RISKS
1
1
0
0
Low Moderate High Extreme
EM ERGENCY CARE RISKS
WOMEN RISKS
7
6
7
6
6
5
4
3
2
1
1
2
1
5
4
3
2
1
1
3
0
0
Low Moderate High Extreme
0
Low Moderate High Extreme
BHRUT BAF 2nd Quarter 2012: SB/PS
6

SPECIALISTS MEDICINE RISKS
SUPPORT SERVICES RISKS
4
6
4
3.5
6
5
3
2.5
2
1.5
1
0.5
0
0
1 1
Low Moderate High Extreme
4
3
2
1
0
0 0
Low Moderate High Extreme
0
New Risk on the Corporate Risk Register
Trust Reference: 343
Area: Directorate Anaesthetic:
Risk: Failure to comply with NSPA Alert to change over to a non-Luer connection on needles used for Neuroaxial procedures can potentially cause serious harm to patients
Controls: All current safety measures are in keeping with recommendations made by the Royal Colleges of Anaesthesia and Pharmacology. NPSA has recommended the use
of one system but this is at present untested and potentially unsafe. All Anaesthetic and Pharmacology Professional Agencies and the Medical Director for NHSL have voiced
concern in proceeding to the change without assurance of safety. Paper presented to Quality and Safety for decision on way forward where it was agreed that it would be unwise
to invest in an untested and potentially unsafe system and this would be raised with the Commissioners.
Directorates
The Directorates that are not reflected currently on the BAF have risks that are controlled within their own Directorate and mirrored on their locals risk registers. All risks are
renewed regularly.
The Directorates are increasingly building their local risk management systems by a continuous process which is demanding awareness and proactive action. The drivers are to
base each risk on reducing the likelihood and consequences of adverse impacts on agreed objectives and on increasing the opportunities for improvement.
This requires infusing risk management into organisational culture and everyday business operations including planning, reporting and governance. This is monitored by the
Clinical Governance team.
BHRUT BAF 2nd Quarter 2012: SB/PS
7

RISKS DETAILS
PRINCIPAL RISK
What could prevent the objective being
achieved
Risk no, Date on Risk Register
& Risk Scoring:
KEY EXISTING CONTROLS
What controls/systems are in
place to assist in securing delivery
of objective and managing
principle risks?
CQC REF:
RESIDUAL RISK
ASSURANCES ON
CONTROLS & IMPACT
Where we gain evidence
that our controls/systems, on
which we are placing
reliance, are effective? The
impact following assurances.
PROGRESS AGAINST
RISKS/ ACTION
PLAN UPDATE
What Actions are undertaken to
mitigate the actual risks?
GAPS IN ASSURANCE
Where we are failing to gain
evidence that our controls /
systems, on which we place
reliance, are effective
GAPS IN
CONTROL
Where are we
failing to put
controls / systems
in place? Where are
we failing in making
them effective?
LEAD
Strategic Objective 1 – Deliver Safe, Quality Effective Care
Principal Objective: Achieving excellence in patient safety and clinical effectiveness – Corporate Clinical
Risk No 87: The inability
to manage patient flow
through the Trust could
result in patients
attending the ED
experiencing delays in
care and treatment which
would be detrimental to
patient safety and
experience.
Date on Register: 01.04.2009
Rating Scoring: Impact:4 x
Likelihood:4 = 16
Area: Emergency Care
Trust Objective: To deliver 95%
of patients seen in 4 hours
Impact on:
Patient: Patient safety
Staff: increase stress levels,
workforce development and
recruitment
Stakeholder: Confidence is
compromised
Trust: Viability of the Trust
Constantly monitored by TEC
Paper presented to Trust
Board which addresses
processes in place to reduce
length of stay – Jonah
programme will assist in this
issue.
Emergency Care Programme
superseded by RESET
programme approved by Trust
Board
4 9 6 16
Extreme Risk
(RESET) Rapid End to
End Sustainable
Emergency
Transformation Steering
Group and Programme
Board in place.
Transformation
Reports to TEC and Trust
Board
This risk is cross
referenced to the BHRUT
CQC related
development plan and
the references are G4 5
6. 7 10 11 12 18 53 54
Maintain improved resilience
within the A&E systems and
throughput to the MAU
There are 4 work -streams:
• Emergency care
• EMAU
• Medicine
• Care of the Elderly
Work-streams plans are led by
Consultants
Emergency Care action plan
is currently being audited for
effectiveness.
The focus is on
Emergency Care and
Medicine and doesn’t
include other speciality -
these can impact on
Emergency Departments
waiting times and bed
occupancy
Failure to improve
against the 95%
compliance within
the four hour
standard
Manpower
resources to
maintain systems
Whilst
improvement in
trajectory is
moving upward
the day to day
stability is
variable resulting
in increased
number of
breaches often
during or
immediately after
the weekend
Financial
implication for the
Directorate in
delivering the
programme.
Claire Dixon (GM) / Dr Derek Hicks Clinical Director
Details updated: 15.10.12
There has been no major change
Educating
Directorates
ensuring support
for: Consultant
leadership and
prompt discharge
BHRUT BAF 2nd Quarter 2012: SB/PS
8

PRINCIPAL RISK
What could prevent the objective being
achieved
Risk no, Date on Risk Register
& Risk Scoring:
KEY EXISTING CONTROLS
What controls/systems are in
place to assist in securing delivery
of objective and managing
principle risks?
CQC REF:
RESIDUAL RISK
ASSURANCES ON
CONTROLS & IMPACT
Where we gain evidence
that our controls/systems, on
which we are placing
reliance, are effective? The
impact following assurances.
Principal Objective: To ensure the patient safety agenda is fully established in all areas of the Trust – Nursing
Risks No 251: Failure to Admission screening for all
protect our patients
elective and emergency
against Health Care
admissions.
Associated Infections Decolonisation therapy for
(HCAI’s)
known positive patients.
Limit set at 7 for MRSA Patients known to be
Bacteraemia and 59 for previously positive are flagged
on PAS.
C.difficile
Date on Register: 25.01.2010
Rating Scoring: Impact:4 x
Likelihood:4 = 16
Area: Trust
Impact on:
Patient: Poor patient outcomes
Staff: Risk to Trust reputation
affecting staff morale
Trust: In year financial risk of
every C.difficile cases over the
limit and on ability for Trust to
reach FT status
Details updated: 24.10.2012
Detailed RCA of all
bacteraemia led by DIPC.
Daily reporting on MRSA
bacteraemia numbers and
C.difficile
CQC supporting actions have
been completed
Re-launching hand hygiene
awareness training in
September
All clinical staff are being
taught and assessed on
aseptic non-touch technique
started in July 3 sessions
occurred – ( FY1 51junior
doctors trained)
8 16
Extreme Risk
RCA summary action
sheets highlights key non
compliances, screening
of patients, appropriate
decontamination of
positive patients,
documentation of such
and the practice of blood
culture taking. Training
implementation of
policies is actively
reviewed.
Internal –Internal Audit,
Infection Prevention
Control Committee
External – CQC
PROGRESS AGAINST
RISKS/ ACTION
PLAN UPDATE
What Actions are undertaken to
mitigate the actual risks?
A Trust wide RCA action plan
has been developed.
Learning from previous RCA’s
– this is included in the annual
infection prevention control
plan for 2012/ 2013
Monthly action plan is being
developed
Plans to be developed for
rapid reduction in rate of
progress in C.difficile curve
GAPS IN ASSURANCE
Where we are failing to gain
evidence that our controls /
systems, on which we place
reliance, are effective
MRSA trajectory target
breached for 2012, ( 8
incidents)
C.difficile 59 or
exceeding this target
with 38 cases mid year
GAPS IN
CONTROL
Where are we
failing to put
controls / systems
in place? Where are
we failing in making
them effective?
Targets set but
not achieved
consistently
because of lack
of understanding
and also
insufficient
implementation of
the controls.
Requires
constant
monitoring and
evaluation.
LEAD
Ian Hosein, Director of Infection Control
Full review of all C difficile
case to date to be undertaken
to determine key themes on
causation. Action to be
completed by mid Nov. for
review by DIPC
BHRUT BAF 2nd Quarter 2012: SB/PS
9

PRINCIPAL RISK
What could prevent the objective being
achieved
Risk no, Date on Risk Register
& Risk Scoring:
KEY EXISTING CONTROLS
What controls/systems are in
place to assist in securing delivery
of objective and managing
principle risks?
CQC REF:
RESIDUAL RISK
ASSURANCES ON
CONTROLS & IMPACT
Where we gain evidence
that our controls/systems, on
which we are placing
reliance, are effective? The
impact following assurances.
PROGRESS AGAINST
RISKS/ ACTION
PLAN UPDATE
What Actions are undertaken to
mitigate the actual risks?
GAPS IN ASSURANCE
Where we are failing to gain
evidence that our controls /
systems, on which we place
reliance, are effective
GAPS IN
CONTROL
Where are we
failing to put
controls / systems
in place? Where are
we failing in making
them effective?
LEAD
Principal Objective: Deliver all local / national standards and targets including comply with CQC, RMS & HSE regulations - NHSLA
Risks 298: Failure to achieve
Level 2 Accreditation of Risk
Management Standards
(RMS) which will achieve
increased patient safety
systems recognised by NHS
Litigation Authority and
reduction in annual premium,
causing increased scrutiny
from external regulators.
Date on Register: 17.08.2011
Rating Scoring: Impact :4 x
Likelihood:4 = 20
Area: Trust
Impact on:
Patient: Increased patient safety
Staff: Morale and pride in care
provided.
Trust: The Trust sustaining
progressive quality improvement
measures
Up-to-date gap analysis,
Medical Devices Committee,
Medical Records keeping
committee, RMS co-ordinating
committee.
16
High Risk
Frequent meeting with
Risk Management
Criterion Leads the
feedback is filtered in the
gap analysis report
Risk Management
Steering Group monitors
the status
This risk is cross
referenced to the BHRUT
CQC related
development plan and
the references are G 40 -
45
Proposal to provide a
businesses case for staff to
support the RMS process, job
descriptions are currently
reviewed in light of potential
posts
Review in resourcing as part
of the clinical governance
overview was presented to
TEC and Trust Board.
Quality and Safety Committee
approved resource plan in
principle. An “ invest to save”
business case being
developed against the
achievement of level 2 and 3
RMS standards.
Financial resourcing
required
Areas of high risk:
Medical Devices
Lead Trainer,
Centralised
training records,
Release of staff
for training,
Medical record
keeping
(documentation)
Collecting
evidence of Risk
Management
Standards
Storage of data
(electronic)
Lyn Wilson/ Pam Strange Clinical Governance Director
Details updated: 15.10.12
No change
BHRUT BAF 2nd Quarter 2012: SB/PS
10

PRINCIPAL RISK
What could prevent the objective being
achieved
Risk no, Date on Risk Register
& Risk Scoring:
KEY EXISTING CONTROLS
What controls/systems are in
place to assist in securing delivery
of objective and managing
principle risks?
CQC REF:
RESIDUAL RISK
ASSURANCES ON
CONTROLS & IMPACT
Where we gain evidence
that our controls/systems, on
which we are placing
reliance, are effective? The
impact following assurances.
PROGRESS AGAINST
RISKS/ ACTION
PLAN UPDATE
What Actions are undertaken to
mitigate the actual risks?
GAPS IN ASSURANCE
Where we are failing to gain
evidence that our controls /
systems, on which we place
reliance, are effective
GAPS IN
CONTROL
Where are we
failing to put
controls / systems
in place? Where are
we failing in making
them effective?
LEAD
Principal Objective: To ensure a robust IM&T infrastructure to an improve our care and service delivery
BHRUT BAF 2nd Quarter 2012: SB/PS
11

PRINCIPAL RISK
What could prevent the objective being
achieved
Risk no, Date on Risk Register
& Risk Scoring:
KEY EXISTING CONTROLS
What controls/systems are in
place to assist in securing delivery
of objective and managing
principle risks?
CQC REF:
RESIDUAL RISK
ASSURANCES ON
CONTROLS & IMPACT
Where we gain evidence
that our controls/systems, on
which we are placing
reliance, are effective? The
impact following assurances.
PROGRESS AGAINST
RISKS/ ACTION
PLAN UPDATE
What Actions are undertaken to
mitigate the actual risks?
GAPS IN ASSURANCE
Where we are failing to gain
evidence that our controls /
systems, on which we place
reliance, are effective
GAPS IN
CONTROL
Where are we
failing to put
controls / systems
in place? Where are
we failing in making
them effective?
LEAD
Risk No 340: The contract
for the current PAS
system provided by
McKesson terminates on
1 st April 2014. This is a
national contract awarded
via CFH. Following this
date PAS will become
“read only” and not
available as a “live”
system. Failure to
procure another system in
time will seriously
compromise service
delivery.
Business case is going to the
Trust Board for sign off and
NHS London for approval and
funding
Received Trust board
approval for replacement of
PAS with the additional
functionality of order
communications.
The recently appointed
Chief Information Officer
will review this risk as a
priority on joining the
Trust.
The Trust must plan to
procure and deploy a new
PAS. This procurement
process is at an advanced
stage
Awaiting on NHS London for
ratification and financial
approval
None identified during
review
Reliant upon the
timeliness of the
approval process.
The timeline is
very tight, a
typical PAS
implementation is
12 - 18 months
19.6.2012: none
identified to date
Simon Adams IMT Manager
Date on Register:13.04.2012
Rating Scoring:Impact:4 x
Likelihood: 4 = 16
11 21
Extreme Risk
Area: Trust
Impact on:
Patient: Poor patient outcome
Staff: Inability to access key
information.
Trust: major impact on service
delivery including disruption to
service
Details updated: 25.09.2012
No change
BHRUT BAF 2nd Quarter 2012: SB/PS
12

PRINCIPAL RISK
What could prevent the objective being
achieved
Risk no, Date on Risk Register
& Risk Scoring:
KEY EXISTING CONTROLS
What controls/systems are in
place to assist in securing delivery
of objective and managing
principle risks?
CQC REF:
RESIDUAL RISK
ASSURANCES ON
CONTROLS & IMPACT
Where we gain evidence
that our controls/systems, on
which we are placing
reliance, are effective? The
impact following assurances.
PROGRESS AGAINST
RISKS/ ACTION
PLAN UPDATE
What Actions are undertaken to
mitigate the actual risks?
GAPS IN ASSURANCE
Where we are failing to gain
evidence that our controls /
systems, on which we place
reliance, are effective
GAPS IN
CONTROL
Where are we
failing to put
controls / systems
in place? Where are
we failing in making
them effective?
LEAD
Strategic Objective 4: Services Are Rated Positively By Patients. Families & All Stakeholders
Principal Objective: To embed a reputation of being a high performing Trust with the best outcomes for patients with all external stakeholder & the media
Risk No: 258 Failure to
provide timely quality of
care will compromise the
Trusts reputation which
will impact on future
service business,
development & recruitment
opportunities.
Date on Register: 23.02.2011
Rating Scoring: Impact: 3 x
Likelihood:5 = 15
Area: Trust-wide
Impact on:
Patient: Outcomes/ service/
developments/achievements
Staff: ~ Staff morale and staff
engagement
Trust: Media interest which
compromised the Trust Reputation
Quality and Safety Committee
to identify root causes and to
disseminate learning and
monitor improvements in care.
Quality and Improvement plan
focus and resource for
improvement.
Clinical Governance Team
monitor Directorate
implementation.
16
Extreme Red
Quality & Safety
Committee bi-monthly
reviewed the risks
Learning Lessons Group
meeting identify trends
from PALS, Complaints,
Incidents and other
feedback.
Audit quarterly patient
experience reports
Reputational risks are
escalated to the
Executive and impending
media coverage alerted
to the Trust Board. Trust
Board is also made
aware by satisfaction
surveys
CQC Action plan provides the
knowledge of key issues and
concerns liable to affect
reputation.
Whistle blowing policy is being
widely promoted
There is a drive to strengthen
the relationship between all
stakeholders and the Trust.
CQC Report on Maternity
Directorate reflected that out
of the 16 recommendations 9
were fully met and 6 were
partly met and only 1 was not
met, this was added to the
BHRUT development plan for
review on the 1/11/12.
Evidence for reputation
rebuilding, particularly
focusing on Emergency
department performance,
improved patient
experience, complaints
handling, finance.
Resourcing of expanded
programmes of staff and
community engagement.
None identified
following review
Imogen Shillito, Director of Comms
Details updated: 19.10.2012
BHRUT BAF 2nd Quarter 2012: SB/PS
13

PRINCIPAL RISK
What could prevent the objective being
achieved
Risk no, Date on Risk Register
& Risk Scoring:
KEY EXISTING CONTROLS
What controls/systems are in
place to assist in securing delivery
of objective and managing
principle risks?
CQC REF:
RESIDUAL RISK
ASSURANCES ON
CONTROLS & IMPACT
Where we gain evidence
that our controls/systems, on
which we are placing
reliance, are effective? The
impact following assurances.
PROGRESS AGAINST
RISKS/ ACTION
PLAN UPDATE
What Actions are undertaken to
mitigate the actual risks?
GAPS IN ASSURANCE
Where we are failing to gain
evidence that our controls /
systems, on which we place
reliance, are effective
GAPS IN
CONTROL
Where are we
failing to put
controls / systems
in place? Where are
we failing in making
them effective?
LEAD
Strategic Objective 5 – To Ensure BHRUT is Financially Secure
Principal Objective: The CIP be delivered fully to the agreed timescales without affecting the quality of care adversely
Risk No: 292 Clinical
Directorates will not
achieve financial target
and CIP deliveries
Previous descriptor: Trust
would not achieve financial
balance
Date on Register: 15.06.2011
Rating Scoring:
Severity:5 x Likelihood:5 = 25
Area: All Clinical
Impact on:
Patient: Poor patient outcome
Staff: none
Trust: The Trust sustaining
progressive measures
Details updated 24.10.12
**All financial risks will be
reviewed by the newly
appointed Finance Director
8.10.12
- Trust has prepared Clinical
Strategy and Long-Term
Financial Model (with support
from EY) - reviewed at
October Trust Board. Model
shows Trust reducing but not
eliminating deficit by 2017/18,
although further options are
now being reviewed.
- PMO with support from EY is
developing CIP plans for
2013/14 and ensuring full year
benefit from existing schemes
meets 2012/13 target
4 16
Extreme Red
8.10.12
- Review of Clinical
Strategy, LTFM,
CIP/Transformation
programme by
Transformation Board,
Finance Committee,
Trust Board, NHS
London and
Commissioners.
Executive sponsorship of
all programmes.
8.10.12
Ongoing work to finalise
clinical strategy and LTFM
and CIP plan for 2013 /14
8.10.12
- Further options to be
fully developed to
demonstrate financial
viability in the longer
term
- Full year CIP
programme yet to be fully
developed
None identified
following review
David Gilburt Finance Director / Alan Davies Deputy Director of Finance
BHRUT BAF 2nd Quarter 2012: SB/PS
14

PRINCIPAL RISK
What could prevent the objective being
achieved
Risk no, Date on Risk Register
& Risk Scoring:
KEY EXISTING CONTROLS
What controls/systems are in
place to assist in securing delivery
of objective and managing
principle risks?
CQC REF:
RESIDUAL RISK
ASSURANCES ON
CONTROLS & IMPACT
Where we gain evidence
that our controls/systems, on
which we are placing
reliance, are effective? The
impact following assurances.
PROGRESS AGAINST
RISKS/ ACTION
PLAN UPDATE
What Actions are undertaken to
mitigate the actual risks?
GAPS IN ASSURANCE
Where we are failing to gain
evidence that our controls /
systems, on which we place
reliance, are effective
GAPS IN
CONTROL
Where are we
failing to put
controls / systems
in place? Where are
we failing in making
them effective?
LEAD
Principal Objective: Meet our in-year financial targets (including net I&E surplus, liquidity, productivity)
Risk no: 104 Failure in
financial management and
budgetary control including
expenditure restrictions,
leading to reputational
damage.
Date on Register: 18.01.2008
Rating Scoring: Impact 4 x
Likelihood:5 = 20
Area: Trust
Impact on:
Patient: Cash shortfalls may lead
to suppliers suspending deliveries
Staff: Cash shortfalls may lead to
delays in payroll
Trust: Financial Risks
Details updated 24.10.12
8.10.12
- Monthly budget statements,
Business Unit financial reports,
Trust financial reports
- Monthly Business Unit
performance review meetings
(including CIP) to review key
financial risks & agree
mitigating actions.
- Budget training provided to
budget holders (April-June)
- CIP governance
arrangements – Work-stream
Accountability review
meetings; weekly pay controls;
weekly vacancy controls;
Transformation Board.
- Non-pay expenditure and
capital expenditure restrictions
in place
4 6 16
Extreme Red
8.10.12
- Internal Audit of
Financial Management
arrangements - limited
assurance given
8.10.12
- Actions have been agreed
through monthly Business Unit
performance review meetings
to address adverse variances,
including CIP
- Actions being progressed
via CIP Accountability
meetings with work-stream
leads to implement further
savings
- Further discussions with
budget holders to resolve
outstanding budget ownership
issues
- Ongoing discussions with
commissioners regarding
transitional funding
24.10.12: This risk is
currently being reviewed
and will be updated as soon
as we have concluded our
conversations with
commissioners.
8.10.12
- Ownership of budgets
by budget holders
remains a key issue, as
identified by the Internal
Audit report.
- Significant risk of c.
£13m in achieving I&E
control total of £40m,
primarily related to high
risk CIPs £6.3m,
unidentified CIP £5.4m
and transitional funding
risk of £4.3m
Mitigation plan
being drawn up
but at significant
risk
CIP non-delivery
by issue
David Gilburt Finance Director / Alan Davies Deputy Director of Finance
No significant change except risk
descriptor has been changed.
*All financial risks will be reviewed
by the newly appointed Finance
Director
BHRUT BAF 2nd Quarter 2012: SB/PS
15

RISK DESCRIPTORS
OBJECTIVE
SAFE, HIGH
QUALITY
EFFECTIVE
CARE:
EFFICIENT
ECONOMIC USE
OF
RESOURCES:
PROVIDE A
FIRST CLASS
EDUCATIONAL
EXPERIENCE
AND A
EFFECTIVE AND
VALUED
WORKFORCE
MAJOR
High Orange = 9-12 score
Major injury leading to long-term
incapacity/disability
Requiring time off work for >14
days
Increase in length of hospital stay
by >15 days
Mismanagement of patient care
with long-term effects
Uncertain delivery of key objective
/Loss of 0.5–1.0 per cent of budget
Claim(s) between £100,000 and £1
million
Purchasers failing to pay on time
Non-compliance with national 10–
25 per cent over project budget
Schedule slippage / Key objectives
not met
Uncertain delivery of key
objective/service due to lack of staff
Unsafe staffing level or competence
(>5 days)
Loss of key staff or Very low staff
morale
No staff attending mandatory/ key
training
CATASTROPHIC
Extreme Reds = 15-25 score
Incident leading to death
Multiple permanent injuries or
irreversible health effects
An event which impacts on a large
number of patients
Non-delivery of key objective/ Loss of
>1 per cent of budget
Claim(s) >£1 million
Failure to meet specification/ slippage
Loss of contract / payment by results
Incident leading >25 per cent over
project budget
Schedule slippage /Key objectives not
met
Non-delivery of key objective/service
due to lack of staff
Ongoing unsafe staffing levels or
competence
Loss of several key staff
No staff attending mandatory training
/key training on an ongoing basis
OBJECTIVE
CREATING AND
SUSTAINING
PURPOSEFUL
PARTNERSHIPS
DELIVERY
AGAINST BHRUT
PRIORITIES AND
OBJECTIVES:
STRONG
RESPECTED AND
CREDIBLE
LEADERSHIP
MAJOR
High Orange = 9-12 score
Loss/interruption of >1 week
Major impact on environment
Enforcement action
Multiple breeches in statutory duty
Improvement notices
Low performance rating
Critical report
National media coverage with 3 days service well below
reasonable public
expectation. MP concerned
(questions in the House)
Total loss of public
confidence
BHRUT BAF 2nd Quarter 2012: SB/PS
16

TABLE: RISK SCORING = SEVERITY X LIKELIHOOD (S X L)
SEVERITY SCORE
5 CATASTROPHIC - Death or major disaster / loss; loss of
>£1million including litigation settlement. Loss of ability to
achieve/maintain financial stability of BHRUT
4 MAJOR - Significant / permanent harm Major financial loss
(£100K - £1 million) Including litigation settlement.
3 MODERATE - Hospitalised or medium term injury Major
financial loss (£20K to £100K) including litigation settlement.
2 MINOR - More than 3 days off sick due to injury moderate
financial loss (£1K to 20K);
1 NEGLIGIBLE - No obvious injury or harm Minimal financial
loss (

BOARD ASSURANCE FRAMEWORK ELEMENTS
STEP1
KEY PILLARS OF THE BAF
Principal Objectives
Principal Risks
Key Controls
Assurances on Controls
STEP2
APPLICATION TO THE BAF
Those strategic and directorate level principal objectives crucial to the Board's overall goals
Risks threatening the achievement of principal objectives
Control (s) to manage one or more principal risks
Confidence, based on sufficient evidence, that internal controls are in place, operating
effectively and objectives are being achieved
.
Regular Board reports, Directorates escalation and recognition of Principal
Risks as well as summary reports from the Audit Committee identify:
Gaps in Assurance
Failure to gain sufficient evidence that policies/ procedures, practices or organisational
resources / structures on which reliance is placed are operating effectively Trust-wide.
Failure to put controls / systems in place to mitigate the risks adequately and effectively.
STEP 3
Gaps in Control
Action plan generated from the Gaps
Board Assurance Action Plan
An action plan approved by the board to improve its key controls to manage its principal
risks, and gain assurances where required and mitigate the gaps in assurance.
BHRUT BAF 2nd Quarter 2012: SB/PS
18

CARE QUALITY COMMISSION: Regulations and Outcome Guide
Regulation 17 Outcome 1: Respecting and involving people who use services
Regulation 18 Outcome 2: Consent to care and treatment
Regulation 9 Outcome 4: Care and welfare of people who use services
Regulation 14 Outcome 5: Meeting nutritional needs
Regulation 24 Outcome 6: Co-operating with other providers
Regulation 11 Outcome 7: Safeguarding people who use services from abuse
Regulation 12 Outcome 8: Cleanliness and infection control
Regulation 13 Outcome 9: Management of medicines
Regulation 15 Outcome 10: Safety and suitability of premises
Regulation 16 Outcome 11: Safety, availability and suitability of equipment
Regulation 21 Outcome 12: Requirements relating to workers
Regulation 22 Outcome 13: Staffing
Regulation 23 Outcome 14: Supporting workers
Regulation 10 Outcome 16: Assessing and monitoring the quality of services
Regulation 19 Outcome 17: Complaints
Regulation 20 Outcome 21: Records
BHRUT BAF 2nd Quarter 2012: SB/PS
19

EXECUTIVE SUMMARY
TITLE:
Risk Management Strategy and Policy
BOARD/GROUP/COMMITTEE:
Trust Board
1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:
The attached Risk Management Strategy and Policy
describes the Trusts expectations of how the management
of risk at different levels within the organisation must be
managed. This has been updated in line with national
guidance and local developments and changes to systems
and processes.
The key changes to this document over the previous one
include:
Update to comply with the revised NHS Litigation Authority
Risk Management Standards issued this year.
The Roles and Responsibilities have been revised in line
with leadership and responsibility changes. (P.6)
Introduction of the NPSA recently revised risk grading
matrix. (Appendix 1 P.33)
Framework for Risk Management self assessment tool to
support staff in the development and monitoring of risk
management systems. (Appendix 3 P. 38)
The routine systems for all staff remain essentially the
same.
□ TEC ……………... □ STRATEGY……….….…….
□ FINANCE ……..……… □ AUDIT ………….……..….
x QUALITY & SAFETY …………..………….....……
□ WORKFORCE
□ CHARITABLE FUNDS ………………………………...…
□ TRUST BOARD ……………………………….………….
□ REMUNERATION ………………………………….…...
□ OTHER …………………………..……. (please specify)
Training on the document is provided at every Induction,
Mandatory Training and Junior Doctor training.
.
2. DECISION REQUIRED: CATEGORY:
It is a requirement of the NHSLA Risk Management
Standards that the Trust Board approve the attached
Strategy and Policy
NATIONAL TARGET x RMS
x CQC REGISTRATION x HEALTH & SAFETY
x ASSURANCE FRAMEWORK
□ CQUIN/TARGET FROM COMMISSIONERS
CORPORATE OBJECTIVE ……………………………....
□ OTHER …………………….. (please specify)
AUTHOR/PRESENTER: Dr Mike Gill
DATE: 26.10.12
3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:
4. DELIVERABLES
5. KEY PERFORMANCE INDICATORS
AGREED AT ______________________ MEETING
OR
REFERRED TO: __________________________
DATE: ____________________________
DATE: ____________________________
REVIEW DATE (if applicable) ___________________________

RISK MANAGEMENT STRATEGY AND POLICY
This policy can be made available in other formats and languages
upon request to the PALS office on 01708 435454
Contents Include: Purpose, Definitions, Risk Management Approach, Tools, Risk Register
Policy Number:
Ratified by:
Approved by:
Name & Title of originator/author:
Responsible committee/individual:
Responsible Division:
Date issued:
Target audience:
Policy Template Issued 2nd November 2011
Version:
Date:
Date:
Review Date
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Contents
Section
Page
1 Introduction 3
2 Purpose 3
3 Definitions 4
4 Roles and Responsibilities 6
4.1 Trust Committees with responsibility for Risk Management 9
4.2 Strategic Objectives 11
4.3 Trust Risk Management Approach 11
4.4 The Risk Management Process 12
4.5 Risk Identification tools 13
4.6 Risk Grading and acceptable/unacceptable risk 16
4.7 Assessments, control and acceptance of risk 16
4.8 Risk Register 19
4.9 Board Assurance Framework 19
5 Development of the Policy 20
5.2 Equality Impact Assessment 21
5.3 Approval and Ratification 21
6 Review and Revision Processes 21
7 Dissemination and Implementation 22
7.1 Implementation 22
8 Monitoring 22
9 References 25
10 Associated Documents 26
11. Amendments 26
Appendices
1 Risk Grading Matrix 32
2 Reporting Structure for Risk 36
3 Framework for Risk Management 37
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1. INTRODUCTION
"Barking, Havering & Redbridge University Hospitals Trust is committed to the
control of risks in a strategic and organised fashion, to ensure that risks can be
eliminated or reduced to an acceptable level thereby improving the experience and
safety of patients, staff, visitors and the public. This commitment is commensurate
with the Trust's aim to provide Excellence in Healthcare. Managing business risk
is fundamental to achieving this aim.”
Barking, Havering & Redbridge University Hospitals NHS Trust (the Trust) is aware that, as a
large organisation, it is exposed to a very wide range of risks and threats to the delivery of key
services and it has a responsibility to identify, evaluate and manage those risks. There is a
structured approach to risk management through its systematic identification, assessment,
evaluation and treatment of risk. It is a continuous process aimed at reducing and monitoring
risks to the organisation and individuals alike. The Trust Board expects staff to adhere to the risk
management processes outlined in this document.
The increasing numbers of recommendations from the National Patient Safety Agency (NPSA)
and National Institute of Health and Clinical Excellence (NICE), developments in Information
Governance, Care Quality Commission (CQC) Quality Standards and the NHSLA Risk
Management Standards for CNST are all factors which require the Trust Board to consider and
regularly review the organisational arrangements for integrated governance and risk
management.
To support this it is essential that the appropriate policy is in place to minimise risk.
The Trust adopts an inclusive approach to risk management:
• The Trust board sets the strategy for the organisation and identifying the risk to that
strategy, determining appropriate mitigating actions and/or deciding to ‘carry the risk’
• Each Directorate will identify the operational risk/s that arise within their area which
compromises their delivery of the Trust key objectives and mitigating it where possible, or
escalating the risk for higher level review and decision making.
This Policy sets out the strategy for the continued development of risk management throughout
the Trust and the processes to implement it. This document applies to all staff working within the
Trust, or on behalf of the Trust in other environments.
It is imperative that all Directorates ensure that the message “risk management is everybody’s
responsibility” is well understood and acted upon throughout the Trust
2. PURPOSE
This Risk Management Strategy, Policy and Guidance sets out the Barking, Havering and
Redbridge University Hospitals NHS Trust (BHRUT) key aims and objectives to ensure there are
strong systems to manage risks Trust-wide, with which the staff are familiar.
This document provides advice on implementing effective risk management. It also outlines the
objectives, duties, benefits of managing risk, describes the responsibilities for risk management
and provides an overview of the process that we will implement together to manage risk
successfully.
The Policy describes how the Trust will record all risks and the high and extreme risks which are
identified as potential threats to the delivery of its key objectives within Risk Registers and
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incorporate mitigation controls within action plans, allocating appropriate resources according to
the level of risk exposure and will report findings within the reporting Board Assurance
Framework.
This Policy requires Clinical Directorates, Executive Leads and Employees alike to assist in, and
take responsibility for, the identification, control and reduction of risk and containment of cost in all
aspects of their activities and areas of responsibility.
It explains how the benefits gained with through Risk Management Framework are improved
strategic, operational and financial management, improved decision making, compliance,
improved customer service which result in better outcomes for patients and a safe and secure
environment for patients, staff and visitors.
The document should be read in conjunction with the Trust’s:
• Complaints Policy
• Claims Policy
• Incident & Serious Incident Policy
• Investigating and Learning from Incidents, Claims and Complaints Policy
• Risk Assessment Toolkit
BHRUT requires that the management of risk supports the delivery of the Trust objectives to
enable the provision of high quality services for service users, visitors, stakeholders and staff;
also minimise loss of resources and protect the reputation of the Trust.
3. DEFINITIONS
BHRUT
CAS
CNST
COSHH
CPA
Directorates
ESR
HSE
H&S
MHRA
NCEPOD
NHSLA
NICE
NSF
PALS
Barking, Havering & Redbridge University Hospitals NHS Trust
Central Alerting System
Clinical Negligence Scheme for Trusts
Control of Substances Hazardous to Health
Clinical Pathology Accreditation
Electronic Staff Record
Health & Safety Executive
Health and Safety
Medicines Practice & Healthcare products Regulatory Agency
National Confidential Enquiry into Patient Outcome and Death
National Health Services Litigation Authority - responsible for the Clinical
Negligence Scheme for Trusts
National Institute of Health & Clinical Excellence
National Service Framework
Patient Advice & Liaison Service
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PARTENRSHIP
PFI
SIC
SI
TNA
Partners who provide to the Trust e.g. Sodexo, Siemens
Partners for whom the Trust provide services, e.g. Barts Renal Services, HCA
Harley Street at Queen’s
Commissioning partnerships, e.g. Commissioning Cluster, SLAs with other
commissioners
Private Finance Initiative
Statement of Internal Control
Serious Incident
Training Needs Analysis
Any expression, to which a meaning is given in the Health Service Act, or in the Financial
Directions made under the Act, shall have the same meaning in this Policy:
“Action Owner”
“Serious Incident”
“Clinical Risk”
“Board Assurance
Framework”
“Corporate Risk”
“Information Risk”
“Initial Risk Score”
“Risk List”
“Risk Management
System”
“Risk Mitigation”
Assurance on
effectiveness of
identified controls
“Risk Owner”
The individual responsible for completing the actions to mitigate the
risk.
Any event or circumstance that could or did lead to unintended or
unexpected harm, loss or damage to persons, property or the
organisation.
An uncertain event or set of events which, should it occur, will have
an effect upon patient care
Comprehensive method for the effective and focused management
of the principal risks to meeting the BHRUT objectives.
An uncertain event or set of events which, should it occur, will have
an effect upon the achievement of objectives.
An uncertain event or set of events which, should it occur, will have
an effect on persons, property or the organisation.
The calculation of risk consequence and probability excluding
control mechanisms.
The simple list of areas of risk, derived from relevant objectives
The detailed explanation of how things work in practice. It includes
this procedural guidance, the reporting processes that secure
implementation of the procedural guidance, the standard forms, IT
system and processes to support implementation, together with local
application of the procedural guidance
Is the process of selecting and implementing appropriate controls to
modify the risk. Control – a process (not a committee or group) in
place that contributes to mitigating / managing risk - The real
challenge is not just to design appropriate processes, but to ensure
they are properly embedded into the operations and culture of the
organisation. Integral to this is the quality of the reporting of risk and
operational performance.
Assurance – evidence that control is real and operates effectively in
mitigating / managing risk. (Internal and External) These assurances
must be relevant in time and support the control in its effectiveness.
The individual responsible for:
Completing the entry on the risk register,
Assigning actions to mitigate the risk and completion targets for
these actions (in consultation with action owners)
Reviewing the risk at least every fortnight to ensure that the action
plan is being implemented, the current risk score is calculated and
that all stakeholders are being updated regarding the management
of this risk.
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“Risk Register”
“Risk Register
Manager”
“Risk Register
Owner”
“Risk Tolerance”
“Target Risk
Score”
The register is a refined and developed version of the Risk List. It is
a table which shows – the risk assessment, risk mitigation actions,
re-assessment and action plans. The table thereby shows the risk
portfolio of the whole organisation or a selected part of it.
Is the individual who is responsible for ensuring that the risk register
is kept up to date and reviewed at least once a month.
The risk register owners are as follows:
Directorate Risk Register – Clinical Director
Matrix/Commissioning Risk Register – Senior Commissioners
Board Assurance Framework – Chief Executive/Medical Director
Information Risk Register – Executive Director / Manager of
Information Management and Technology/Information Governance
Lead
Is the level of risk the BHRUT is prepared to tolerate
The calculation of risk consequence and probability including control
mechanisms. This score provides a measure of how controllable the
risk is and will help management decide which risks they should be
4. ROLES AND RESPONSIBILITIES
The Trust Board is a statutory body, governed by the Act of Parliament with the function of the
Trust conferred by legislation. The Code of Accountability requires clear arrangements to be in
place to demonstrate that responsibilities have been delegated to Executive Directors and for
BHRUT this requirement is fulfilled by the Trust’s Standing Orders, Standing Financial Instructions
and Scheme of Delegation, all of which are available on the Intranet.
The arrangements set out in this document regarding identification, assessment and control of
risk, apply to the Trust’s corporate risks as they apply to all other risks. At an Executive level
responsibility for their implementation is allocated as follows:
• Trust Objectives Chief Executive Officer
• Service objectives Chief Operating Officer
• Staffing objectives Chief Operating Officer
• Financial objectives Director of Finance
• Clinical Governance objectives Medical Director / Director of Nursing
• Corporate and Clinical Governance Director of Governance/Clinical Governance Director
• Maternity Services Director of Nursing
Responsibility for the maintenance and assessment of effective internal and external assurances
for organisational risk and patient safety is allocated on the same basis.
The Trust Board
The Trust Board’s monitoring responsibilities, as defined in the Scheme of Delegation are to
‘receive such reports as the Board sees fit from committees in respect of their exercise of
delegated powers’.
The Trust Board is made up of Executive and Non Executive Directors that are required to
implement sound and effective systems of internal control; challenging poor performance and
deciding the priority of risks carried. The Trust Board reviews all risks rated as 'red'/extreme via
the Board Assurance Framework. The Trust Board will review other risks drawn to their attention
through the Quality and Safety Committee and Audit Committee.
The Trust Board will receive regular reports from various Trust Committees which ensures
significant risks are escalated, considered and actioned accordingly. The Trust Board members
will receive annual risk assessment training to support them in their assessment of risk
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Chief Executive
The Chief Executive has overall responsibility for having an effective governance system,
including risk management, in place in the Trust and for meeting all statutory requirements and
adhering to guidance issued by the Department of Health in respect of governance and risk
management. To fulfil this responsibility the Chief Executive will:
• Ensure that full support and commitment is provided and maintained in the risk
management activities;
• Ensure an appropriate Board Assurance Framework is in place;
• Ensure that the Annual Governance Statement adequately reflects the risk
management issues within the organisation
Executive Directors
All Executive Directors have corporate responsibility for risk management within the activities of
the Trust. This is exercised through attendance at Trust Board meetings and through the
reviewing of the Board Assurance Framework.
Non-Executive Directors
The Non-Executive Directors are responsible for providing independent assurance to the Trust
Board on the risk management structure and processes as described in this policy.
Director of Finance
The Director of Finance, on behalf of the Chief Executive has responsibility for systems of
financial control, implementing the Trust’s financial procedures, providing financial advice
to the Trust Board, preparing and maintaining Trust accounts and all areas of financial
and business risk. The Director of Finance is the Accountable Officer who signs the
Annual Governance Statement.
Medical Director
The Medical Director, on behalf of the Chief Executive, is charged with the responsibility for
providing assurance on the outcomes Medical Leadership, Clinical Governance and Risk
Management systems throughout the Trust, with a special responsibility for clinical risk
management.
Director of Nursing
The Director of Nursing, on behalf of the Chief Executive, is charged with the responsibility for
Professional Leadership of Nurses, Midwives and Allied Health Professionals, quality standards
and practice.
Director of Governance and Special Projects.
On behalf of the Chief Executive, the Director of Governance is the nominated lead for
compliance to Care Quality Commission Standards, NHSLA Risk Management Standards,
NHSLA Maternity Clinical Negligence Scheme Standards, and Clinical Governance systems and
is managerially responsible for the Clinical Governance Department.
Clinical Governance Director
On behalf of the Executive Directors, the Clinical Governance Director has the day to day
responsibility for all areas of development of clinical governance and clinical risk management
Chief Information Officer
The Chief Information Officer, on behalf of the Chief Executive is responsible for Information
Governance and is the designated Senior Information Risk Owner (SIRO)
Partnerships
In order to deliver a successful partnership, risk management must form an integral part of the
incident management system and evaluation process. Partners need to understand what
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potential risks they may face in achieving the planned objectives and identify these in a
partnership risk register. Key decision making processes should be the subject of a risk
assessment and where necessary risk management plans to identify timelines, responsible
individuals, contingency plans and financial monitoring arrangements need to be agreed
confirming what action should be taken should the risks be realised.
All directorates are required to formerly identify and record their major partnerships in accordance
with the Trust Key Objectives and Code of Practice for Partnerships
Clinical Directors
The Trust has 11 Clinical Directorates:
1. Emergency care
2. Acute Medicine
3. Neurosciences
4. Surgery
5. Specialist Surgery
6. Anaesthetics
7. Specialist medicine
8. Pathology
9. Women
10. Children
11. Support services
The risk management responsibilities of the Trust are shared by the Executive Directors
(corporate risks) and the Clinical Directors who are responsible for ensuring Clinical Directorates
operational risks are assessed, mitigated as appropriate and reported upon when they cannot be
mitigated locally. Each Clinical Directorate has its own Risk Register.
The Clinical Directors are responsible for the implementation of risk management in all areas
within their Clinical Directorate and the process to be followed is described in Section 7.1,
Assessment Process.
Clinical Directors are responsible for implementing and monitoring any identified risk management
control or assurance measures within their designated area/s and scope of responsibility. Any
serious risks to Corporate and Directorate objectives must be brought to the immediate attention
of the Clinical Governance Director.
In situations where significant risks have been identified and where local control measures are
considered to be potentially inadequate and local resolution has not been satisfactorily achieved,
Clinical Directors are responsible for and have the authority to;
• Add risks to the local and Directorate risk register
• Monitor and review the risks
• Bring these risks to the attention of the Clinical Governance Director
General Managers/Line Managers
General Managers/Line Managers must ensure that all staff are aware of the risk management
processes and report risks for consideration. There is a requirement, where significant risks have
been identified and where local resources/control measures are considered inadequate, that
Managers report such risks to their Clinical Director
They are required to:
• understand and implement the Trust’s Risk Training Policy, Risk Management
Strategy/Policy and other Trust policies and procedures, all relevant legislation and ensure
that they and all staff can access appropriate expert advice where required
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• ensure that they keep up to date records of staff attendance at all mandatory and best
practice training as per the Trust’s TNA
• ensure that all staff are given the necessary information and training together with the
appropriate resources and that these are monitored, to enable them to;
o work safely
o raise concerns
o make risk assessments
o take appropriate risk reduction measures
o report risk to their line managers and /or Directorate Leads when applicable.
All managers have a key responsibility to ensure that risk assessment is undertaken to minimise:
• Potential harm to patients, staff and visitors
• Risks to the achievement of Directorates business plans and service
Clinical Governance Team
The Clinical Governance Team will provide leadership, advice and support in the implementation
of this policy.
The Clinical Governance Team will ensure that all reporting to Trust Committees is co-ordinated
and provide reports, training and on-going support in relation to Ulysses database and risk
registers.
All Staff
All staff have a key role in identifying and reporting risks and incidents promptly thereby allowing
risks to be managed and added to the local risk register if appropriate. In addition, staff have the
responsibility for taking steps to avoid injuries and risks to patients, staff, visitors. If in fulfilling this
role, it involves staff in raising concerns about standards, staff must report this following the
Trust’s Speaking Up for a Healthy Trust (Whistleblowing) Policy.
It is the responsibility of All Staff (including agency, locums, volunteers and contractors) to be
alert to, identify and report risks including those relating to patient care, health and safety or the
hospital environment. It is also their responsibility to be aware of and comply with all risk
management requirements including Trust policies. Information and training will be provided as
necessary to enable contractors and agency/bank staff to fulfil this responsibility.
All Trust employees are accountable, through the terms and conditions of their employment,
professional regulations, clinical governance and statutory health and safety regulations.
This responsibility also includes reporting incidents, being aware of any emergency procedures
relevant to their role and place of work, e.g. resuscitation, evacuation and fire precaution
procedures; being aware of the risk management strategy/policy and attendance at training as
specified in the Trust’s Risk Management Training Needs Analysis.
All staff have a responsibility to manage risk within their sphere of responsibility. It is a statutory
duty to take reasonable care of their own safety and the safety of others who may be affected by
acts or omissions of Trust employees.
4.1 TRUST COMMITTEES WITH RESPONSIBILITY FOR RISK MANAGEMENT
There are two committees with delegated responsibility from the Trust Board for
overseeing the management of risk in the Trust, the Quality and Safety Committee and
the Audit Committee. A chart showing the relationship to the Board of its delegated Sub
Committees is shown in Appendix 2.
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4.1.1 Quality and Safety Committee
The Committee meets six times per year and the core membership comprises two Non
Executives, of whom one acts as Chairman, the Director of Nursing, the Medical Director and the
Clinical Governance Director. The purpose of the Committee is to provide assurance to the Trust
Board on all aspects of patient safety, patient outcomes and patient experience. Attendance from
finance and human resources will be dependent on agenda topics for discussion.
The key risk management responsibilities of the Quality & Safety Committee are as follows:
• To make recommendation on the quality aspects of implementing the Board’s objectives
based on consideration of the adequacy of controls, action plans and sources of
assurance relating to major risks escalated from the Trust’s Risk Register to the Board
Assurance Framework.
• To review and make recommendations relation to the Trust’s performance with particular
focus on proposed changes to its strategic directions, i.e. re-structuring of organisational
service and care delivery framework. Ensuring that the impact of any organisational
change is risk assessed to ensure delivery of safe, quality patient care and effective levels
of performance and outcome.
• To develop and monitor a Dashboard of key performance indicators that incorporate topics
such as mortality data, incidents/near misses, claims, complaints and findings of
investigations into serious incidents/events. Ensuring the monitoring data is measurable
and incorporates maternity and general acute services and enables the Committee to
define priorities and make recommendations.
• To provide strategic leadership for ensuring systems and processes are in place
throughout the organisation to support risk management, quality assurance and
governance.
The Committee’s full terms of reference are available on the Trust Intranet. The Quality and
Safety Committee reports to the Trust Board.
4.1.2 Audit Committee
The Audit Committee has responsibility for assuring that appropriate financial and corporate
governance risk management arrangements are in place. The Committee meets not less than
four times per year and the membership comprises not less than three Non Executives, of whom
one acts as Chairman. The Director of Finance, the Financial Controller, the Chief Internal
Auditor, and a representative of the External Auditors normally attend meetings.
The key risk management responsibilities of the Audit Committee are to review:
• the establishment and maintenance of an effective system of internal control and risk
management;
• the adequacy of all risk control related disclosure statements, together with any
accompanying Head of Internal Audit Statement, prior to endorsement by the Board;
• the structures, processes and responsibilities for identifying and managing key risks facing
the organisation;
• Policies for ensuring that there is compliance with relevant regulatory, legal and code of
conduct requirements as set out in the Department of Health Directions and other relevant
guidance.
The Audit Committee receives information on a number of topics primarily on the Trust’s financial
position, assurance framework, local development plans, corporate objectives, counter fraud
issues, charitable funds and reports from both the internal and external auditors.
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The Statutory Safety Committee, a feeder committee of the Audit Committee, has specific
responsibility for ensuring risks to patients, staff and visitors are managed robustly. The Statutory
Safety Committee takes reports on Health, Safety & Fire, Major Incident & Emergency Planning,
Safety Alerts, health & safety key performance indicators, Manual Handing and Radiation issues,
and approval of risk policies.
Any risks identified by the Audit Committee are reported to the Trust Board for information /
action. The Committee’s full terms of reference are available on the Trust Intranet.
4.2 STRATEGIC OBJECTIVES
BHRUT has Standing Orders, Standing Financial Instructions and a Scheme of Delegation, which
include the roles and responsibility of its sub-committees. BHRUT’s risk management processes
aim to ensure:
• There is a common framework within which risks are identified and assessed via the Risk
Assessment Tool Kit for inclusion in the Trust Risk Register.
• Risks to the effective functioning of the Trust in its principal objectives are systematically
and consistently identified.
• Action plans are in place to prevent or mitigate the adverse effects of identified risks.
• Obstetric risks are managed through the Maternity Risk Management Strategy
• All other risks, including financial risks, are identified, managed and audited through the
Trust's risk management procedures
• Action is taken to manage identified risks so that they are kept to an acceptable level.
• There is recognition that innovation and improvement within the wider NHS has to include
an element of risk.
• The Risk Management Strategy/Policy is communicated to all staff and is embedded in
everyday practice.
• The Risk Management Strategy and policy is available to the public and other
stakeholders.
4.3 TRUST RISK MANAGEMENT APPROACH
This Trust will approach the management of risk from two aspects:
• Strategic Risks
• Operational Risks
Strategic risks are considered as:
Those business risks that if realised, could fundamentally affect the way in which the organisation
conducts its business financially and complies with the Health and Social Care Act 2008
standards. Strategic risks will have a detrimental effect on the achievement of the key business
objectives. Strategic risks are detailed in the Trust Board Assurance Framework and are mapped
against the Trusts strategic objectives.
Operational risks are considered as:
Those risks associated with the delivery of the key business processes and the delivery of patient
care in a safe environment. Issues arising from operational risk assessments will be considered at
Directorate level and escalated through the directorate structure before these are reported on the
Trust Corporate Risk Register. Operational risks can include:
• Clinical risks: risks associated with the inpatient, day case, outpatient and diagnostic
activities of the Trust.
• Non-clinical risks: risks associated with the environment of care e.g. use of the building
and facilities by staff, patients, contractors and other visitors; health and safety risks; staff
management; availability and use of information.
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• Financial risks: risks associated with income, expenditure, fulfilment of contracts and the
correct application of Standing Orders, Standing Financial Instructions, Scheme of
Delegation and other financial obligations.
• Reputational risks: risks associated with public opinion and risks which may damage the
credibility or good name of the Trust.
It is recognised that the boundaries between these categories are not always clear, and that some
risks may fall into more than one category.
Business Planning & Risk Management
Operational risks should link to each Directorate’s Business Plan. The Business Plan is a
document that brings key information together in one place and demonstrates the service’s focus
on service and Trust’s priorities. All major risks impacting the provision of service and to other
services and partners resulting from the consequences, then a risk assessment and action plan
should be recorded with brief mitigation.
4.4 THE RISK MANAGEMENT PROCESS
The Trust’s strategy is to apply the following principles to the management of risk:
Establish the context
A strategic, organisational, operational and risk management context will be established in
which the process will take place. A criteria against which risk will be evaluated should be
established and the structure of the analysis defined.
Identify Risks
Identify what, why, when and how risks can arise as the basis for further analysis.
Risk Assessment
Decide who might be harmed and how. Using the Trust’s generic risk assessment template
and transferring the results to a comprehensive risk register. Escalating the findings to line
management and all staff.
Analyse risks
Determine the existing controls and analyse risks in terms of consequence and likelihood in
the context of those controls. The analysis should consider the range of potential
consequences and how likely those consequences are to occur. Consequence and likelihood
will be combined to produce an estimated level of risk.
Evaluate risks
Evaluate the risks and decide on precautions. Compare estimated levels of risk against the
pre-established criteria. This enables risks to be ranked so as to identify management and
Board priorities. It is essential that the evidence used to compare the risk to these criteria is of
known standards of quality and reliability, otherwise the risk may be over or under rated or not
identified at all.
Treat risks
Accept and monitor low-priority risks. For other risks, develop and implement a specific
Management action plan that includes consideration of the resources required to address the
risk, the impact that treating the risk as well as not treating the risk will have in other service
areas, whether the risk, if realised would be reversible and in what context, if any, realising the
risk would be defensible. Record your findings.
Service development planning process
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Where there are actual or potential risks with high or extreme consequences and/or likelihood
that require additional resources, the relevant Directorate will submit Risk assessment and
action plans for consideration by Trust Executive Leads and Trust Board.
Monitor and Review
Monitor and review the performance of the risk action plan, undertake assessment to identify
gaps and improvement. Review your risk assessment and update if necessary
Communicate and consult
Communicate and consult any difficulties with the Clinical Governance Director as appropriate
at each stage of the risk management process and concerning the process as a whole.
Shared Learning
Share knowledge and learning across other directorates. It is essential to safeguard against
incidents that could have been prevented had lessons learned elsewhere been passed on and
adopted across the organisation.
4.5 RISK IDENTIFICATION TOOLS
It is the policy of the Trust to make systematic use of the risk management tools which are
available for the identification of all risks affecting its activities.
4.5.1 What is a Risk?
Risks will and can be identified using the following approaches:
• Risk Assessments using standard tools e.g. COSHH,
• Legal Risk (mainly risks arising through non-compliance with existing legislation,
national guidance e.g. occupational health & safety legislation)
• Clinical risks (mainly associated with the diagnosis and treatment of patients)
• Incidents Management (Near misses, Serious Incidents)
• Complaints/PALS
• CQC
• Expressed concerns by service users ,visitors or stakeholders
• External reviews/ Services user satisfaction surveys
• Audits
• Organisational Risk (mainly risks arising from ineffective implementation of policies
and procedures, poor communication, poor staffing and management structures).
• Staff survey
• Sickness/Absence information
• Mortality & Morbidity review
• NICE
• NCEPOD
• NHSLA RMS
• Central Alerting system
• Information Risk (mainly risks arising from ineffective management and security of
information, including decisions on when and when not to share personally
identifiable information)
• Business and Financial Risk (mainly concerned with Contracts, revenue, capital
fund)
Proactive Risk Identification
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Proactive risk assessment enables the Trust to identify actual or potential hazards or
threats that may or may not have resulted in actual incidents and ensure adequate control
measures are in place to eliminate or reduce the risk of harm occurring. From this
information, the Trust can assess whether or not there are sufficient precautions in place
or if more needs to be done to mitigate the risk in order to prevent a particular harm or
threat materialising. Proactive risk assessment also fulfils the Trust’s statutory obligations
in terms of Health and Safety risk assessments.
Under the management of Health and Safety at Work Regulations 1992, employers are
required to make a “suitable and sufficient” assessment of the risks to the health and
safety of employees whilst at work as well as the risks to non employees as a
consequence of work activities.
Ongoing proactive risk assessment will minimise the likelihood of both patient safety and
non-clinical incidents occurring and supports safety improvements across the
organisation.
Range of Internal Inspections
There are a number of internal inspection processes carried out by specialists such as
Infection Control or Fire Safety Officer and where risks are pro-actively identified. There is
a requirement for all services to carry out a quarterly Health and Safety Inspection and
ensure improvements are made if indicated.
Nursing and Midwifery Audit
There are monthly visible leadership audits undertaken in patient areas. The audits are a
proactive way of measuring compliance with High Impact Actions for Nursing and
Midwifery and Essence of Care. Action plans are developed and implementation
monitored by the Nursing and Midwifery Board
Self Assessment of Risk
Upon identification of an individual risk at any time a staff member can complete a generic
risk assessment proforma or one of the specific non clinical assessment proforma’s which
are available on the Trust’s intranet site. The risk will be reported to and discussed with a
line manager and scored using the Trust risk scoring matrix. Action plans will be
developed and the risk will populate the Risk Register and be escalated in line with the
Trust risk escalation process. If immediate action is required steps must be taken to
mitigate the risk in the short term whilst longer term plans are implemented. If a staff
member has concerns regarding the practice of another employee of the Trust, they
should raise their concerns using the Trust Raising Concerns Policy available on intranet
Evaluation of National Reports
As key reports are published appointed members of staff will be directed to review the
content to evaluate the relevance of the report and standards that will be required of the
Trust. This includes deficits in compliance with a range of standards
such as Maternity or any of the National Inquiry reports such as those into Peri-Operative
Care or Maternal and Child Deaths. It also includes Independent Inquiries where risks are
identified that apply to services within this Trust including those that relate to
Safeguarding Children and Vulnerable Adults, clinical services and health and safety.
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Central Alert System (CAS)
Review and response to CAS which is an electronic system developed by the Department
of Health, the National Patient Safety Agency (NPSA), NHS Estates and the Medicines
and Healthcare products Regulatory Agency (MHRA) that includes medicines, healthcare
products, medical device, National Patient Safety Agency alerts and NHS Estate warning
notices. Where alerts are issued and the Trust is not compliant a risk will be registered
and an action plan implemented
Reactive Risk Identification
Incident Reporting / Near Miss Reporting
Incident and near miss reporting by staff is an efficient and effective system for identifying
risk. Rapid action in resolving how and why an incident may have occurred can facilitate
the organisation in learning how to avoid repeat occurrences of similar incidents. The
Trust operates within a just and fair blame culture, to ensure that staff feel safe in being
open to report events. Incidents and near misses are scored using the Trust’s risk matrix
Complaint Reporting
Complaint reporting is a very effective way through which an organisation can learn to
manage its services and risks. Complaints are responded to by the Clinical Directorates /
Corporate Departments and the Trust has a systematic approach which attempts a
frontline instant response where possible, followed up and escalated through the line
management structure in the Division if necessary. Formal complaint responses are coordinated
in accordance with the Trust's Complaints Policy and Procedure
Informal concerns also provide useful information to support the Trust to enhance the
patient experience. Concerns are assigned a risk score by the Patient Advice and Liaison
Service (PALS)
Claims
The review of claims is also an effective way through which the organisation can learn to
prevent the reoccurrence of incidents, manage its risks and improve the quality of care
delivered. The Trust response to claims is managed on behalf of the Trust by the Legal
Services Team in accordance with the Trust’s Claims Handling Policy, Clinical
Directorates are involved in reviews to support the management of risk locally and review
closed claims as they arise.
External Assessments and Reviews
Care Quality Commission (CQC)
A review is undertaken of standards across the Trust that identify lapses, lapses identified
result in action plans developed which are monitored for implementation via the
Transformation Board
Risks highlighted during service reviews and the audit work that is undertaken by the
Trust’s auditors are sources of risk identification. Risks identified are scored using the
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Trust’s risk matrix and will populate the Trust’s Risk Register and be escalated in line with
the Trust’s escalation process.
4.6 RISK GRADING AND ACCEPTABLE / UNACCEPTABLE RISK
4.6.1 Grading
Once risks are identified, it is the policy of the Trust that they must be prioritised for full
assessment and management by initially grading them, according to their impact and the
likelihood that they will occur again in the future.
The Trust has adopted a risk assessment matrix for grading all non-financial risks whether
clinical, non-clinical or organisational. The matrix is set out in the Trust’s Risk Assessment Tool
Kit, which can be found on the Trust’s Intranet. The grading matrix is attached in Appendix 1. It
has four grades of risk - low, moderate, high and extreme, which are identified respectively by the
four colours: green, yellow, orange and red.
Incidents are also graded using the same matrix in accordance with the Trust’s Incident Reporting
& SI Policy which can be accessed on the Trust’s intranet.
4.6.2 Acceptable / Unacceptable Risk
It is the policy of the Trust that control action is:
• considered for all risks where the initial grading is more than green / low
• implemented to reduce the residual risk after the action to green / low, unless the impact
and likelihood of the risk is such that the burden of the available action is disproportionate
to the reduction of risk to be achieved.
Thus, risks graded low / green need to be revisited annually unless further concerns arise.
Yellow and low orange (under a risk score of 9) represent increasing levels of risk and therefore
require control action and review at intervals depending on the impact of the risk and the
likelihood of recurrence as identified through risk assessment processes.
Red represents extreme levels of risk which are by definition unacceptable and require control
action and review at intervals to reduce them as far as reasonably practicable.
4.7 ASSESSMENTS, CONTROL AND ACCEPTANCE OF RISK
4.7.1. Assessment Process
It is the responsibility of each Clinical Directorate Directors, Senior Nurses, Directorates General
Managers/Managers, Clinical Leads, Nurse Consultants and Ward / Service Managers to ensure
that the Trust’s risk assessment programme is implemented within their areas in accordance with
this policy.
Each Directorate must undertake risk assessments locally in accordance with the Trust Risk
Assessment Tool Kit. Directorates have the responsibility to assess their clinical, environmental,
health, safety, financial and performance related risks.
The local management of risk will be carried out by various different groups of senior staff
according to the grading of the risk identified but would have an overview in regards to mitigation
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y the Directorate Lead and or General Manager. The following table describes the type of
evidence that will be used to demonstrate compliance with the aims of this policy.
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Risk Grading Staff Group Evidence
Red/Extreme
Orange/High
Yellow/Moderate
Green/Low
Executive Directors
Clinical Directors
Directorates Manager
Matron
Other relevant senior staff
Clinical Directors
Directorates Managers
Matron
Other relevant senior staff
Matrons
Service Leads
Ward/Departmental Manager
Directorates Risk Registers
Investigation report
Risk Assessment and action plan
Committee minutes
External reporting - STEIS, HSE
MHRA etc
IR1 Form
Investigation report
Risk Assessment and action plan
Minutes of Directorates directorate
meetings
IR1 Form
Local investigation
IR1 Form
Local investigation
Where risks cannot be effectively managed or responded to locally that is where they require
resources and/or authority beyond the remit of the local area, or where the risk is common to
more than one area the risk assessment should be forwarded to:
#riskregister@bhrhospitals.nhs.uk for inclusion in the Trust Risk Register
Newly identified risks that are rated high/extreme will be added to the Trust corporate risk register
and for risks that require immediate action these will be reported via the Trust SI process (see SI
policy)
Review of Assessments
A quarterly review will be undertaken by the directorates on their risks to ensure that the
information recorded on their Local risk register is reflective of the Trust Corporate Risk Register
(high orange and extreme risks). Failure to receive review from Directorates will be noted on the
register and this information is cascaded to the Audit Committee and Trust Board via the Board
Assurance Framework.
Risk Closure Form
This ensures that risks are considered and agreed prior to closure. It also prevents unauthorised
closure of Corporate risks by any staff
Risk Review Form
Risk assessments must be reviewed regularly and immediately if there is any reason to suspect
the assessment is no longer valid such as there has been significant change to the work of to the
risks of the work
Exception Report
To identity the material deviation between actual risk occurrence and controls in a report, which
warrants management investigation
Risk Validation Report
The risk validation report is a very effective way to define and determine efficient methods to
reduce emotional risk scoring. It reduces the unnecessary cost and where appropriate promotes
a robust process.
Archiving of risk assessments
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All risk assessments must be archived by the local area in accordance with the records
management policy. The length of time individual risk assessments will be dependent on the
particular subject of the assessment for instance clinical assessments form part of the patients
medical records and therefore should be retained as such. Assessments made in relation to
human resource issues such as workplace assessments should be kept in accordance with the
personnel file. Generic risk assessments or environmental risk assessments should be kept as a
minimum for five years following the last review date.
4.7.4 Other Escalation Processes
Other mechanisms are open to Executive Directors and/or Directorates to escalate risks for wider
discussion before they become high level risks; this may be as exception reports to the Quality &
Strategy Committee or presentations/reports as part of the rolling assessment programme of the
Audit Committee. Lower level risks should be discussed and risks fully considered at feeder
committees throughout the organisation that are specific to particular topics ie the Drugs and
Therapeutic Committee or the Clinical Risk Committee. An overview of this process is described
in section 13, Key Performance Indicators.
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4.8 RISK REGISTER
The Risk Registers set out the existing controls that relate to the risk as most are already subject
to some degree of management. This helps BHRUT to set a more realistic or “real” prioritisation
of the issues by assignment of a residual risk score. This means effort and resource can be
targeted to mitigate or manage the risk and actions with responsibilities and target dates being set
out in the Risk Register. Through this reassessment of priority scores (using the “Residual Risk
Score) further work or “solutions” can be planned to address the risk until it reaches an
acceptable level (i.e. within the risk appetite set).
Managing risk is part of everyday management in the NHS, however due to the time that is
required to implement solutions to risks and financial constraints; the concept of Risk Registers
has been developed to provide an on-going log of these risks. Risk Registers are primarily an
internal management tool to support Directorates/corporate departments in managing their risks
whilst there is an opportunity to raise/escalate particular risks for inclusion on to the Trust’s
Corporate Risk Register and the Board Assurance framework for input on mitigation of the risk.
It is the policy of the Trust to maintain a Risk Register recording financial and non-financial risks
as identified by its processes for continuous risk identification and risk assessment. For the
avoidance of doubt, non-financial risks include clinical, non-clinical and organisational risks.
The Risk Register is maintained and updated by the Risk Management Team and provides
quarterly reports to the directorates via the Safeguard Risk Management system to enable them
to scrutinise their risk to ensure that they are adequately described and graded and that action
plans are formulated the Risk register.
4.8.1 Clinical Directorate risk registers
All risks must be submitted with a risk assessment and an action plan which would be updated to
reflect the current Directorate risk profile, Risk action plan with details of key dates and
individual responsibility for action should be integrated into service plans and project
plans. Appropriate review is needed to keep the risk register current. Each risk owner will
need to have a securely retained copy of the register and a clear
history of changes made as risk registers may be requested at any time by
decision makers, project boards, the Risk Manager, Internal or External Auditors
or any interested parties in the interest of openness & accountability
Local Monitoring of incidents, complaints and claims including serious incidents
Make reference to policies
4.9 BOARD ASSURANCE FRAMEWORK
The Board Assurance Framework (BAF) will identify which of BHRUT’s principal objectives are at
risk because of inadequacies in the operation of the organisational controls or areas where the
organisation has insufficient assurance about the effectiveness of the controls in place. At the
same time the Board Assurance Framework will provide structured assurances where key risks
are being managed effectively and which principal objectives are being delivered.
The Board Assurance Framework will form the key document for the Trust Board in ensuring all
principal risks are controlled, that the effectiveness of these key controls has been assured, and
that there is sufficient evidence to support the Annual Governance Statement
Review by the Trust Board of the BAF provides the opportunity for risk to prioritisation and ensure
effective performance management. The structure of the BAF allows for the identification of where
the Trust’s objectives may not be met because of inadequacies in the operation of controls or
where the organisation has insufficient assurances.
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The Trust’s BAF is audited by the Trust’s internal auditors and will be the basis for reports to the
Audit Committee. It is the policy of the Trust to maintain effective assurance of the risk
management arrangements for its organisational risks, through:
• identification, assessment, review and control of the risks associated with its principal
service, staffing, financial and governance objectives, at both the corporate and
departmental / directorate level;
• assessment of both the internal and external assurances available of the effectiveness of
the control of those risks;
• action to put in place effective assurance where assessment indicates that to be
necessary;
• recognising gaps in the controls and
• regular review of organisational risk management and its associated assurance
arrangements by the Trust Board.
The BAF demonstrates the sequential actions taken quarter by quarter to reduce and remove
risks facing the organisation.
4.10 EXTERNAL RISK MANAGEMENT STANDARDS
The Trust is committed to pursue best practice in its risk control measures by continuously
applying external risk management standards, advice and recommendations relevant to its
activities.
To that end it will maintain continuous comprehensive compliance programmes with relevant
standards, including the following:
• The Care Quality Commission’s (CQC)
• The NHS Litigation Authority’s (NHSLA) risk management standards - Clinical Negligence
Scheme for Trusts (CNST)
• The standards of Clinical Pathology Accreditation Ltd (CPA)
• The advice of the National Confidential Enquiries into patient mortality
• The guidance of the National Institute for Health & Clinical Excellence (NICE).
• The guidance within National Service Frameworks and High Level Enquiries
• The Health & Safety at Work Act and subordinate legislation.
• Patient Environment Action Team
5. THE DEVELOPMENT OF THIS POLICY
This policy was written using the Trust Policy Template and giving consideration to all the
elements required within the Trust Policy for the Development and Management of Trust-
Wide Procedural Documents.
The individual/group nominated as responsible for this Policy is the Trust Board.
This Policy was developed through an update to the existing policy, consultation with
stakeholders and discussion/agreement at the Quality & Safety Committee, the Audit
Committee and the Trust Board.
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5.1 Consultation and Communication with Stakeholders
Stakeholders identified for this process are
• Clinical Governance Director
• Trust Board
• Clinical Directors
• Managers
• Clinical Governance Staff
• All Staff
They were included in the development of the updated Policy by consultation, either
individual or as part of the approving Committees.
They were included in the approval of the Policy by representation at the Audit Committee
or the Quality & Safety Committee.
All involved stakeholders received a copy of the final approved policy or were notified that
it is available on the Intranet.
5.2 Equality Impact Assessment
This policy has been equality impact assessed to ensure that the guidance provided does
not place at a disadvantage any service, population or workforce over another. A
completed Equality Impact Assessment is shown page 30
5.3 Approval and Ratification
A copy of the Checklist for Review and Approval of Procedural Documents has been
completed for this Policy and submitted with the final draft for approval and ratification.
This policy was reviewed and approved by the Quality & Safety Committee on
………………….
This policy was reviewed and approved by the Audit Committee on ……………………….
This policy was reviewed and ratified by the Policy Ratification Committee on
………………………..
6. REVIEW AND REVISION ARRANGEMENTS
6.1 Review
This policy will be reviewed every 2 years or sooner if there are pertinent legislative or
organisational changes.
6.2 Revision
Details of all/any revision to this Policy are documented in Amendments – Section 11.
7. DISSEMINATION AND IMPLEMENTATION
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7.1 Dissemination
Once approved, the Strategy will be placed on the Trust’s intranet site for ease of access by staff.
Risk and patient safety issues will be raised frequently through the weekly electronic newsletter
‘The Link’, ‘MISSES’ maternity newsletter and ‘PHAT’ public health midwives newsletter. Key
information from this Strategy will be used to provide guidance and advice at the Trust’s corporate
and specialist induction sessions and mandatory risk management training to ensure the
maximum coverage of staff at all levels in the organisation.
A Plan for Dissemination of Procedural Documents has been completed and submitted
with the final draft for approval and ratification.
7.2 Implementation
The Trust will ensure that training is provided in order that the objectives of this document are
met.
There is corporate responsibility to ensure a framework of corporate, local and specialty
inductions are in place together with mandatory and risk management training for all permanent
staff at all levels of the organisation. The Trust carries out an annual training needs analysis to
assess the training requirements of the organisation to ensure there is sufficient risk management
training provision to enable its workforce to perform their duties safely. Details of the courses
available are contained within the Learning & Development Prospectus.
A copy of the current training needs analysis is incorporated within the Guidance for Accessing
Education & Learning Opportunities.
Examples of training that the Trust provides:
Risk management training for Board members and members of Executive Team by
representative from Clinical Governance Team, Non attendance is followed up by Clinical
Governance Team. Attendance is recorded on a database kept by Clinical Governance centrally
Mandatory Nurse Training (three day course)
Root cause analysis – (one-day course)
8. MONITORING
It is the policy of the Trust to monitor adherence to the relevant standards by means of
programmes of annual self-assessment and audit and it is the responsibility of the Clinical
Directors to ensure the Trust’s rolling programme of corporate audits is undertaken.
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The Trust recognises the importance of collecting meaningful and relevant data in a statistical
format so the analysis and trends can be monitored and appropriate action taken. Where
possible both qualitative and quantitative information is sought to inform decision-making, and is
aggregated to provide a holistic interpretation of the risks faced by the organisation via the Board
Assurance Framework and quarterly Aggregated Data reports sent to the Directorates and
reviewed by the Quality and Safety Committee.
Each Directorate has an allocated clinical governance lead that attends the Directorates Board
meetings and can assist with risk issues if required, and a named complaints manager that can
offer advice and guidance. Audit advice and guidance can be provided through the Trust’s Audit
Department. Each Directorate also has financial and human resource support from named leads.
It is the policy of the Trust that the impact of its risk management processes should be monitored
continuously via appropriate, quantified key indicators, capable of indicating progress over time.
The following key performance indicators will be used to monitor implementation at both a
corporate and local level.
It is the policy of the Trust that comprehensive quarterly monitoring reports on the identified risks
are produced and considered at each meeting of the Audit Committee. Copies of the reports are
also made available at the appropriate level of detail to internal stakeholders including all levels of
management with responsibilities for risk management and to relevant external stakeholders as
requested.
The matrix below identifies all the monitoring of this policy which will be carried out, how
this will be done (e.g. audit), frequency, who is the lead person responsible for ensuring
that the monitoring is carried out, where reports from monitoring are reported, who
(individual/group/committee) is responsible for ensuring that any gaps or deficiencies are
recorded on an action plan which is followed up and who is responsible for ensuring that
implementation of any changes which follow the action plan completion are implemented
and, where appropriate, information disseminated within the Trust to enable learning from
the experience
What will be
monitored
and/or
Standard To Be
Achieved
How/Method Frequency Lead Reported to Deficiencies/gaps
recommendations
and action plans
followed up by
Implementation
of any required
change
responsibility
of
In date risk
management
strategy in
place with
risk
management
structures
described
Significant
risk register
reviewed by
Audit
Committee
Board
Assurance
Framework is
scrutinised
by the Audit
Strategy in place
and approved
Assurance that
the Trust Board
are aware of the
organisations
significant risks
Minutes of
meetings
evidence review
Every two
years
Quarterly
Clinical
Governance
Director
Audit
Committee
Audit
Committee
Relevant
Directorates
Quarterly Trust Board Relevant
Directorates
/ Relevant
Executive
Policy and
Ratification
Committee
Audit
Committee
Audit
Committee
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Committee
Review and
monitoring of
risks
Incident
Reporting
(Patient
Safety)
Reporting to
external
agencies to
support
shared
learning
(NRLS)
Information
on
complaints,
claims and
incidents is
aggregated,
analysed and
disseminated
Incidents
graded
according to
severity
Serious
Incident
investigations
compliant
with Incident
and SI policy
Safety Alerts
implemented
within
Evidence of
review and
actions
undertaken -
recorded on
Ulysses database
quarterly reports
Assurance that
delivery and
performance
against the
Trust’s objectives
are being
appropriately
monitored.
Incident reporting
rate > NPSA
average
Evidence of
timely reporting to
NRLS
Aggregated data
reports are
presented to
Committees,
Directorates and
are published on
the Trust Intranet
including
commentary on
organisational
learning
All incidents are
triaged and coded
accurately, in line
with severity as
set out in the
Incident and SI
policy
Audit of reports
shows
compliance with
Incident and SI
policy
CAS alerts are
implemented
within time frames
Quarterly
Risk
Management
Team
Performance
Efficiency
and Quality
Committee
Audit
Committee
Quality &
Strategy
Committee
Relevant
Directorates
/ Relevant
Executive
Monthly Trust Board Relevant
Directorates
On
publication
Quarterly
On-going
On-going
Quarterly
Clinical Risk
Management
Committee
Clinical Risk
management
Committee
Statutory
Safety
Committee
Audit
Committee
Quality and
Safety
Committee
Directorates
Patient
Safety
Adviser
Patient
Safety
Adviser
Clinical
Governance
Director
Clinical Risk
Management
Committee
Relevant
Directorates
Relevant
Directorates
Relevant
Directorates
Relevant
Directorates
Relevant
Directorates
Audit
Committee
Quality and
Safety
Committee
Clinical Risk
Management
Committee
Clinical Risk
Management
Committee
Clinical Risk
management
Committee
Statutory
Safety
Committee
Audit
Committee
Quality and
Safety
Committee
Directorates
Patient Safety
Adviser
Patient Safety
Adviser
Clinical
Governance
Director
Clinical Risk
Management
Committee
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timescale
with supporting
evidence
provided
Annual
Health and
Safety review
Annual report
detailing Health
and Safety Issues
within the Trust
submitted to
Statutory Safety
Committee
Annual
Audit
Committee
Relevant
Directorates
Audit
Committee
Clinical
Governance
Review
Annual report
regarding Clinical
Governance
within the Trust
submitted to
Quality and
Strategy
Committee
Annual
Quality and
Safety
Committee
Relevant
Directorates
Quality and
Safety
Committee
Procedural
documents
are reviewed
in line with
review date
Annual report to
Clinical
Governance Risk
Committee
Annual
Relevant
Committees
Quality
Systems
Manager
Quality
Systems
Manager
Service
Users
Annual Patient
Survey
Annual
Clinical Risk
Management
Committee
Quality and
Safety
Committee
Relevant
Directorates
Clinical Risk
Management
Committee
Quality and
Safety
Committee
Complaints
compliant
with national
targets for
responses
Trust
performance with
acknowledgement
within 2 days and
30 days targets
Monthly
Quarterly
Trust Board
Relevant
Directorates
Quality and
Safety
Committee
Any deficiencies identified during monitoring will be recorded and reported to the Quality
and Safety Committee. The nominated persons and, ultimately, the Quality and Safety
Committee, will be responsible for ensuring that an action plan has been developed, is
followed through, all required actions taken to remedy the deficiency/s identified and,
where appropriate, information disseminated within the Trust to enable learning from the
experience.
9. REFERENCES
NHSLA Risk Management Strategy Checklist March 2012/13
The NHS Improvement Plan; 2006: Department of Health www.doh.org
Making it Happen – a Guide for Risk Managers on How to Populate a Risk
Register. Controls Assurance Support
The How to Guide for Leadership for Safety. Patient Safety First Campaign.
2008.www.patientsafetyfirst.nhs.uk
The Healthy NHS Board Principles for Good Governance.
The Handbook to the NHS Constitution. Department of Health
Quality governance in the NHS – a guide for provider boards – National Quality Board 2011
Compliance Framework - Monitor
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10. ASSOCIATED DOCUMENTATION
Other Trust policies and procedures with links to this Risk Management Strategy are
listed below:
• Blood Transfusion Policy
• Claims Policy and Procedure
• Clinical & Non Clinical Documentation
• Clinical Audit & Effectiveness Strategy
• Clinical Governance Annual report
• Complaints Policy and Procedure
• Consent to Examination or Treatment Policy
• Control of Contractors Policy
• Corporate Governance Manual
• COSHH Policy
• Display Screen Equipment (DSE)
• Fire Policy and Procedures
• Guidance for Accessing Education & Learning Opportunities
• Incident Reporting & SI Policy
• Induction Policy
• Infection Control Policy
• Latex Policy
• Learning & Development Prospectus
• Lockdown Policy
• Lone Workers Policy
• Major Incident Plan.
• Manual Handling Operations Policy
• Maternity Services Risk Management Strategy 2009-10
• Medical Devices – Policy for the Safe Use of
• Mental Capacity Act 2005 Interim Policy
• NCEPOD at BHR Policy on Compliance
• Evidence Based Practice Policy & Procedure
• PALS Policy
• Pandemic Flu (H1NI) and Winter Resilience Plan
• Patient Identification Policy
• Patient Information Policy
• Policy on Policies
• Radiation Protection Policy
• Risk Assessment Tool Kit
• Aggregated Data reports
• Safety Alert Broadcast System Policy
• Safety Policy
• Service Improvement & Reconfiguration Policy
• Slips Trips and Falls Policy
• Transportation of Dangerous Goods Policy
• Violence and Aggression Policy
11. AMENDMENTS
To be completed only when the Policy has been reviewed and changed.
Page/Section
Strategy and Policy
updated to reflect
2012/2013 risk
management standards
Change
Whole document
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Checklist for the Review and Approval of Procedural Documents
To be completed and attached to any procedural document when submitted to the appropriate
committee for consideration and approval or ratification.
1. Title
Title of document being reviewed:
Is the title clear and unambiguous?
Is it clear whether the document is a policy,
protocol or guideline?
2. Rationale
Are reasons for development of the document
stated?
3. Development Process
Is the method described in brief?
Are individuals involved in the development
identified?
Do you feel a reasonable attempt has been made
to ensure relevant expertise has been used?
Is there evidence of consultation with stakeholders
and users?
4. Content
Is the objective of the document clear?
Is the target population clear and unambiguous?
Are the intended outcomes described?
Are the statements clear and unambiguous?
5. Evidence Base
Is the type of evidence to support the document
identified explicitly?
Are key references cited?
Are the references cited in full?
Are local/organisational supporting documents
referenced?
6. Approval
Does the document identify which committee/group
will approve it?
Does the document identify which committee/group
will ratify it?
If appropriate, have the joint staff side committee
(or equivalent) approved the document?
7. Dissemination and Implementation
Yes/No/
Unsure
Comments, including where
information is included in the
document
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Title of document being reviewed:
Is there a completed Plan for Dissemination of
Procedural Documents which identifies how this will
be done?
Does the plan include the necessary
training/support to ensure compliance?
8. Document Control
Does the document identify where it will be held?
Have archiving arrangements for superseded
documents been addressed?
9. Process for Monitoring Compliance
Are there measurable standards or KPIs to support
monitoring compliance of the document?
Is there a plan to review or audit compliance with
the document?
10. Review Date
Is the review date identified?
Is the frequency of review identified? If so, is it
acceptable?
11. Overall Responsibility for the Document
Is it clear who will be responsible for coordinating
the dissemination, implementation and review of
the documentation?
Yes/No/
Unsure
Comments, including where
information is included in the
document
Individual/Group/Committee Approval
If you are happy to approve this document, please sign and date below and forward to the chair of the
committee where it will receive ratification.
Name
Signature
Date
On behalf of
Committee Ratification
If the committee is happy to ratify this document, please sign and date below and forward copies to the person
with responsibility for disseminating and implementing the document and the Quality Systems Manager.
Name
Date
Signature
On behalf of
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Equality Impact Assessment Tool
To be completed and attached to any policy when submitted to the appropriate committee/group for
consideration and approval or ratification.
Policy Title
Policy Number
Responsible Individual/Committee
Approving Committee
Ratifying Committee
1. Does the policy affect one group less or more
favourably than another on the basis of:
Age
Disability – learning disabilities, physical disability,
sensory impairment and mental health problems.
Race
Nationality
Ethnic origin – including gypsies and travellers
Gender / Gender reassignment
Religion
Beliefs
Sexual orientation – including lesbian, gay and
bisexual people
Domestic circumstances
Social and employment status
Marital/partnership status
HIV status
Political affiliation
Trade Union membership
2. What is the overall purpose of this policy area,
function or activity?
3. What approaches are currently used to measure
progress and performance in this area?
4. What counts as success in this area?
5. Are there opportunities within this policy to:
Eliminate illegal discrimination
Promote equality of opportunity
Promote good relations between people of different
groups?
Yes/No
Comments
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6. Is the impact of the policy likely to be negative
e.g. is their risk of:
Illegal discrimination
Reducing equality of opportunity for some groups?
Harming relations between different people of
different groups?
7. If you have identified potential discrimination,
are any exceptions valid, legal and/or
justifiable?
8. If so, what action could be taken to reduce
adverse effects and promote or enhance
positive effects?
9. Please describe the options available for
incorporating equality monitoring into routine
arrangements?
Yes/No
Comments
If you have identified a potential discriminatory impact of this policy document, please refer the issue
to the Workforce Equality Lead, together with any suggestions as to the action required to
avoid/reduce this impact.
For advice in respect of answering the above questions, please contact the Workforce Equality Lead,
HR Department, Queen’s Hospital on extension 3294.
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Plan for Dissemination of Procedural Documents
To be completed and attached to any procedural document when submitted to the appropriate
committee for consideration and approval or ratification.
Title of document:
Dissemination lead (name and contact details):
Date finalised:
Previous document
already being used?
Yes / No
(Please delete as
appropriate)
Date due to be reviewed:
If yes, in what format and where?
Proposed action to retrieve out of date copies of the document:
Have any training needs been identified and addressed (give details):
To be disseminated to:
How will it be disseminated,
who will do it and when?
Format (i.e.
paper
or electronic)
Comments:
Quality Systems Manager
Originator to send after
ratification at committee
Electronic
For numbering, logging and issue
Web Manager
Sent by Quality Systems
Manager once numbered and
logged
Electronic
For inclusion on Trust Intr@net
and, where appropriate, archiving
previous version.
Originator
Sent by Quality Systems
Manager once issued
Electronic
For dissemination
All staff
Placed on Intr@net
(fill in date once issued)
Dissemination Record - to be used once document is approved, ratified and issued
Disseminated to: (either
directly or via meetings, etc.)
Format
(i.e. paper or
electronic)
Date
disseminated:
No. of
copies
sent:
Contact details /
comments:
Please add as many extra lines as required to this document to ensure it reflects the dissemination
plan for the Policy.
Issued November 2010 Version 1
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APPENDIX 1
RISK GRADING MATRIX
Likelihood
Likelihood score 1 2 3 4 5
Rare Unlikely Possible Likely Almost certain
5 Catastrophic 5 10 15 20 25
4 Major 4 8 12 16 20
3 Moderate 3 6 9 12 15
2 Minor 2 4 6 8 10
1 Negligible 1 2 3 4 5
1 - 3 Low risk
4 - 6 Moderate risk
8 - 12 High risk
15-25 Extreme risk
RISK
GRADING
ACTION TO BE TAKEN
EXTREME
Urgent senior management attention needed. For risks graded as extreme the investigation should be led by a Director, General Manager or Matron.
HIGH
Urgent senior management attention needed. A decision about risk acceptability must be made within 4 weeks and an action plan for controlling the risk must be devised.
MODERATE
Management responsibility for risk control must be identified (unless a decision is made to accept the risk). Any action requirements must be added to a ward / department action
plan.
LOW
Risks can be / are already being managed by routine procedures – no further action required.
Consequence Scoring table (C)
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Consequence score (severity levels) and examples of descriptors
1 2 3 4 5
Domains Negligible Minor Moderate Major Catastrophic
Impact on the safety of patients, staff
or public (physical/psychological
harm)
Minimal injury requiring
no/minimal intervention or
treatment.
Minor injury or illness,
requiring minor intervention
Moderate injury requiring
professional intervention
Major injury leading to long-term
incapacity/disability
Incident leading to death
No time off work
Requiring time off work for >3
days
Increase in length of hospital
stay by 1-3 days
Requiring time off work for 4-14
days
Increase in length of hospital
stay by 4-15 days
Requiring time off work for >14
days
Increase in length of hospital
stay by >15 days
Multiple permanent injuries or
irreversible health effects
An event which impacts on a
large number of patients
RIDDOR/agency reportable
incident
Mismanagement of patient care
with long-term effects
An event which impacts on a
small number of patients
Quality/complaints/audit
Peripheral element of
treatment or service
suboptimal
Informal complaint/inquiry
Overall treatment or service
suboptimal
Formal complaint (stage 1)
Local resolution
Single failure to meet internal
standards
Minor implications for patient
safety if unresolved
Treatment or service has
significantly reduced
effectiveness
Formal complaint (stage 2)
complaint
Local resolution (with potential
to go to independent review)
Repeated failure to meet
internal standards
Non-compliance with national
standards with significant risk to
patients if unresolved
Multiple complaints/
independent review
Low performance rating
Critical report
Totally unacceptable level or
quality of treatment/service
Gross failure of patient safety if
findings not acted on
Inquest/ombudsman inquiry
Gross failure to meet national
standards
Human resources/ organisational
development/staffing/ competence
Short-term low staffing
level that temporarily
reduces service quality (<
1 day)
Reduced performance rating if
unresolved
Low staffing level that reduces
the service quality
Major patient safety implications
if findings are not acted on
Late delivery of key objective/
service due to lack of staff
Unsafe staffing level or
competence (>1 day)
Low staff morale
Poor staff attendance for
mandatory/key training
Uncertain delivery of key
objective/service due to lack of
staff
Unsafe staffing level or
competence (>5 days)
Loss of key staff
Very low staff morale
No staff attending mandatory/
key training
Non-delivery of key
objective/service due to lack of
staff
Ongoing unsafe staffing levels or
competence
Loss of several key staff
No staff attending mandatory
training /key training on an
ongoing basis
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Statutory duty/ inspections
Adverse publicity/ reputation
Business objectives/ projects
Finance including claims
No or minimal impact or
breech of guidance/
statutory duty
Rumours
Potential for public concern
Insignificant cost increase/
schedule slippage
Small loss Risk of claim
remote
Breech of statutory legislation
Reduced performance rating if
unresolved
Local media coverage –
short-term reduction in public
confidence
Elements of public expectation
not being met
25 per cent
over project budget
Schedule slippage
Key objectives not met
Non-delivery of key objective/
Loss of >1 per cent of budget
Failure to meet specification/
slippage
Loss of contract / payment by
results
Service/business interruption
Environmental impact
Loss/interruption of >1
hour
Minimal or no impact on
the environment
Loss/interruption of >8 hours
Minor impact on environment
Loss/interruption of >1 day
Moderate impact on
environment
Loss/interruption of >1 week
Major impact on environment
Claim(s) >£1 million
Permanent loss of service or
facility
Catastrophic impact on
environment
Likelihood Scoring table (L)
Likelihood score 1 2 3 4 5
Descriptor Rare Unlikely Possible Likely Almost certain
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Frequency
How often might it/does it
happen
This will probably never
happen/recur
Do not expect it to happen/recur
but it is possible it may do so
Might happen or recur
occasionally
Will probably happen/recur but it
is not a persisting issue
Will undoubtedly
happen/recur,possibly frequently
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APPENDIX 2
REPORTING STRUCTURE
FOR RISK
TRUST BOARD PUBLIC
Quality and Strategy
Committee
Audit Committee
Clinical Risk Management Committee
(CRC)
Statutory Safety Committee
Safeguarding Children Committee
(SCC)
Safeguarding Adults Committee
(SAC)
Evidence Based Practice Board
(EBPC)
Drugs and Therapeutic Committee
(D&TC)
Infection Control Committee
(ICC)
Clinical Audit Committee
(CAC)
Research & Development Committee
(R&DC)
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Appendix 3
Framework for Risk Management
Self Assessment tool for Directorates/Departments
Key Element Required Action Complaint
Yes
No
N/A
Leadership The Directorate/Department has a local clinical governance or risk
management group which evaluates implementation of risk management
systems and strategies and aggress service changes as necessary
The Directorate group considers matters pertaining to risk management
including incidents, complaints and claims
There is an indentified lead for risk management who is part of the local
clinical governance (or similar) group and whose remit includes sharing
information and learning on incidents, complaints, claims and health and
safety
The Clinical Directorate team provide the medical director with an annual
governance report outlining their progress against directorate and corporate
objectives
Culture
Accountability
The Clinical Director receives copies of all relevant guidance including NICE
guidelines and Centralised Alerting Systems (CAS) alerts, national
confidential enquiries and ensures that appropriate action is instigated
All leaders behave in a way which is consistent with and demonstrates
commitment to being open and fair
The Directorate identify areas of required improvement through both
corporate and local risk management systems and implement appropriately
Incidents, near misses and risks are regularly reported using the Trust Risk
Management reporting system
Incidents and near misses are investigated and analysed and where specific
areas of learning are identified or changes to practice required appropriate
action is taken
Major Incident
Planning
Incident investigation to the level appropriate for severity (as per policy) and
final approval is undertaken within the agreed timescales
The Directorate/Department managers are aware of the Trust Major Incident
Plan
The Directorate/Department managers are aware of their responsibilities in
relation to the Major Incident Plan
Business
Continuity
Management
Strategy
External
Assessments
Where relevant staff have received briefing/training on the Major Incident
Plan and associated policies
Directorate/Department Business Continuity plans are maintained
The Directorate/Department teams participate in Business Continuity
planning
The Directorate/Department is aware of the objectives of the Trust Risk
Management Policy and Strategy and has formulated a plane to enable these
to be achieved locally
The Directorate/Department has an action plan to meet local objectives
related to risk management
The Directorate/Department are aware of the safety and risk management
standards as indentified by external agencies such as Care Quality
Commission and NHS Litigation Authority
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External Reporting
Responsibility
Induction
Training
Requirements and achievements against external assessments are
communicated to all relevant staff
Directorate/Department managers are aware of their responsibilities in
relation to reporting incidents and near misses to external agencies
All staff are aware of their responsibility in relation to risk management and
health and safety
All permanent staff have attended the Trust corporate induction programme
All staff including temporary staff and volunteers have completed the local
induction process
A training needs assessment is undertaken within the
Directorate/Department on an annual basis
There is a system for monitoring attendance at mandatory training and for
following up those that fail to attend
All permanent staff have completed the required mandatory training
programme
The Directorate/Department participates in the system for assessment and
training for medical equipment and devices
Relevant staff have received training in risk management techniques such as
risk assessment and root cause analysis
Patient and Public
Involvement
Risk Assessment
Relevant staff have received training in incident reporting and management
of risk register
There is patient information available to support patients to be guardians of
their own safety
Patients and where relevant carers are informed of incidents as per Being
Open Policy
The Directorate/Department have undertaken risk assessments and reported
compliance with regards to health and safety
Risk assessment of patient falls is undertaken buy nursing staff on
admission, if clinical condition changes or at a minimum weekly
Infection Control
Risk assessment of VTE is undertaken by the doctors on each admission
The Trust has a designated representative for infection control
Infection control high risk areas have been identified and the
Directorate/Department is working with Infection Control to minimise and
manage risk
All relevant areas have access to infection control policies
There is evidence that staff received appropriate training and updates in
infection control issues
There is a system for reporting, analysing and learning from serious incidents
associated with infection control
Each clinical team can demonstrate consistently high levels of compliance
with the Hand Hygiene Policy
Medical Equipment
and Devices
The local cleaning arrangements are informed by Trust Infection policies
The Directorate/Department is aware of the training in the use of Medical
Devices Policy
• Ensuring that all equipment used and is recorded on Trust inventory
• Agreeing with individual members of staff which equipment from the
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Risk Register
inventory they are expected to use and process for training and
competency assessment, including frequency of updates
• Ensuring that training is made available for all uses of devices where
training is necessary and that all equipment users are properly
trained and competent
• Ensuring that users complete competency records for appropriate
medical devices
• Reviewing the inventory annually and/or when the new
equipment/devices are introduced into their area of responsibility
• Identifying training and assessment needs at appointment, local
induction and as part of annual reviews
The Directorate/Department has a Risk Register which is compiled and kept
up to date by nominated trained staff following risk assessment and data
from incidents, complaints and claims
The Risk Register is reviewed and updated on an ongoing, live basis
Where risks have been indentified, risk reduction measures are developed
and included in action plans
Medicines
Management
The Risk Register is linked to local business planning and service
development and is assessed at each Directorates performance review
All clinical areas are aware of the Procedure for the Prescribing, Recording
and Administration of Medicines
All medication errors are reviewed by a senior nurse, pharmacist and/or
clinician
All areas of non-compliance should be indentified on the Risk Register with
appropriate controls, risk reduction measures and action plan
Completed by …………………………………………
Directorate/Department …………………………….
Date ……………………………………………………
Planned date of next review ……………………
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EXECUTIVE SUMMARY
TITLE:
BOARD/GROUP/COMMITTEE:
Quality and Patient Standards Performance
Report – September 2012
Trust Board
1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:
The Quality and Patient Standards Performance Report
provides an analysis of performance against trust-wide
and national targets for the following domains:
• Patient Safety and Quality
• Performance
• Workforce
• Productivity
• Finance
The following areas where monthly performance is of
concern are discussed within the report:
• Clostridium Difficile
• MRSA
• MRSA Screening – Emergency
• MRSA Screening - Elective
• Complaints not Responded To over 3 months old
• Patients Assessed as Risk Free
• Elective and Non-elective Re-admissions

2. DECISION REQUIRED: CATEGORY:
The Trust Board is asked to note the content of the report
and support the actions to bring the performance back in
line with trajectory/target.
NATIONAL TARGET □ CNST
□ CQC REGISTRATION □ HEALTH & SAFETY
□ ASSURANCE FRAMEWORK
CQUIN/TARGET FROM COMMISSIONERS
□ CORPORATE OBJECTIVE ……………………………....
□ OTHER …………………….. (please specify)
AUTHOR: Claire Burns, Head of Planning, Commissioning
and Information
3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:
Not applicable.
PRESENTER: Neill Moloney, Director of Performance and
Planning
DATE: Oct 2012
4. DELIVERABLES
The delivery of the Trust wide objectives.
5. KEY PERFORMANCE INDICATORS
Please see attached Trust Performance Dashboard.
AGREED AT ______________________ MEETING
OR
REFERRED TO: __________________________
DATE: ____________________________
DATE: ____________________________
REVIEW DATE (if applicable) ___________________________
2

Performance Report
September 2012
Performance Indicators - Exception Report
1. Introduction
This report provides the Board with an overview of mitigating actions identified by the Business
Units to improve performance such that it brings it back into line with target. Finance and Human
Resources performance are subject to separate reports to the Trust Board.
2. Patient Safety and Quality
MRSA bacteraemia –.2 MRSA bacteraemia were reported this month, both of which were found
to be deep seated infections related to septic arthritis. One patient had this in multiple sites and
for the other patient only in the shoulder. On investigation some clinical practice issues were
identified which are now being addressed.
The New Director of Infection Prevention and Control is now in post. There is a change of focus
to infection prevention and the current action plan is being reviewed to identify the high impact
actions, one of which is ANTT.
ANTT has been introduced across the Trust and to date 60% of Matrons and 72% of senior
sisters have achieved Train the Trainer competencies. These staff will now roll out the training
across the wards. New hand washing campaigns and training programmes introduced. Training
for doctors has commenced for FY1/2s, Consultants and is being planned for staff grades.
Clostridium difficile infection – There were 7 cases of infection reported during September,
none of the patients acquiring the infection occurred as a result of cross contamination. No
primary cause was identified for the infection on Heather ward but the ward has been required to
produce an action plan to address the issues highlighted by the Infection Control team
investigation of the infection. The Infection Control Committee will monitor the ward’s progress
against this action plan.
MRSA screening – Elective
A number of actions have been identified to improve performance to ensure delivery of this
standard. These include:
• A review of the pathway for
patients who go straight to a
procedure without attending a preadmission
clinic to ensure that
these patients are swabbed prior to
admission. This pathway will be
implemented from October and so
will improve performance during
December 2012 and reported to
the Board in January 2013.
Page 1 of 8

• A review of data capture to ensure that all swabs are matched correctly to admissions –
this will be completed in September and therefore will be shown in the performance at the
November Board meeting.
• Training of Admissions Team Leader on data accuracy, which will improve data quality
when patients are added to waiting list and thereby improve coverage of data for MRSA
elective screening; this will be completed in September and therefore will be shown in the
performance at the November Board meeting.
MRSA screening – Emergency. A number of actions have been identified to improve
performance to ensure delivery of the standard for September. These include:
• A change of process in the
Emergency Day Unit (EMDU) to
screen patients who currently do
not qualify for screening was
implemented in September and
will be demonstrated in the data
received at the November Board
Meeting.
• Using the ward board rounds to
check patents have been
screened. The Ward Sponsors
will work with the wards to
ensure that screening takes place.
• Staff to be reminded to write legibly on test requests to ensure that the Lab is able to
identify which patient the swabs have come from. This error will be addressed by the roll
out of order communications for Pathology in December 2012, and will be reflected in the
performance reported to the Board in January 2013.
• Review of the data to ensure patients who do not require screening are excluded from the
data. This will be completed in October and therefore will be shown in the performance at
the November Board.
Number of complaints not yet responded to over 3 months old - The number of complaints
over 3 months old has reduced from 55 last month to 53 this month, this figure includes both new
and reactivated complaints. The Complaints Team continue to agree a closure timescale for a
formal response with each complainant. Extending an agreed response date can now only be
agreed either by an Executive Director or an Associate Director. In order to ensure there is a
clear line of responsibility for responding to complaints during October the complaints handling
process will be re-launched via Associate Directors, who will cascade the procedure down to
General and Services Managers. In addition the Medicine Directorate is piloting a new tracking
process to identify earlier issues which may prevent the timely resolution of a complaint. If
successful the process will be rolled out across the Trust.
Page 2 of 8

% Patients assessed as risk free - This indicator measure the % of patients free from the four
harms of 1.Venous Thromboembolism (VTE),
2.category 3 and 4 pressure ulcers, 3.catheter
associated urinary tract infections (CAUTI) and
4. falls resulting in harm.
The main areas of concern within the trust remain
pressure ulcers and falls. These are being
addressed by the relevant action plans and
significant progress has been made. More
detailed analysis is now being undertaken as six
months data is now available to identify where the
trends for harm are occurring from both a community and hospital perspective.
Re-admissions Elective and Emergency

Pilot Wards
Division
Discharges
Per
Ward
Surveys
ompleted
%
ompleted
Surveys
NPS Score
Bluebell B Medicine 62 17 27.4 68
Ocean A Surgery 48 35 72.9 23
Coral Ward Maternity 185 137 74.1 47
Cornflower B Women 109 16 14.7 6
Pilot Ward Totals 404 205 50.7% 31
Following evaluation of the pilot the paper based survey will, during October, be rolled out across
all wards areas and A&E
Same sex breaches –.There were 13 single sex breaches for the month of September 2012.
These occurred within the High Dependency Unit (9), Intensive Therapy Unit (3), and Coronary
Care Unit (1) at Queen’s Hospital. This is an improvement from August position when 18 single
sex breaches were reported.
All of the breaches occurred due to delays in the
transfer out of patients who had been ‘stepped
down’ to general care. This was due to
constraints on the availability of suitable beds
for ‘step down’ due to patient flow delays across
the organisation. A root cause analysis on all
patients who breach will commence on the 1 st
October 2012.
The Deputy Director of Nursing has received
feedback from a number of patients who
breached in September who were interviewed following the breach and they confirmed that the
reason for the breach was explained to them and that their privacy and dignity was maintained
during this period of their care.
Page 4 of 8

3. Performance
Referral to treatment – delivery in all specialties Specialties continue to fail on the
admitted RTT pathway. The Trust has not been commissioned to deliver RTT by
specialty in 2012/13 but is required to meet the target as a cumulative performance.
Discussions have commenced with Commissioners regarding the approach in 2013/14.
The Trust requires an early decision as to whether specialty performance will be
purchased as this will require an additional investment in 2013/14 over and above that
already agreed as specialty backlog will need to be cleared. A scoping exercise is
currently under way.
Cancer - 62 days urgent RTT from hospital specialist – this is an in-month problem due to
the small number of patients who are affected. The year to date performance is 88.6% for
this measure against an 85% target. Three patients breached the standard in the month
and these were complex clinical cases.
Four hour wait in A&E – in September the Trust failed to meet the 95% standard and has
deteriorated from the August performance. The Trust achieved Trust 89.37% with Queens at
85.14 and KGH at 95.79%
% of patients referred to specialist team < 2hours of registration - the percentage of patients
waiting more than 2hrs from registration to referral has remained the same. Daily performance
information is shared with Emergency Department senior staff with peer challenge of decision
making to identify alternatives to referrals by using care pathways such as ambulatory care /
virtual ward.
% Patients seen by speciality team within less than 30 minutes of request – the percentage
of patients seen by specialty teams within 30 minutes has deteriorated in September. Any that
occur are fed back daily to the specialties concerned to discuss with their teams with feedback
requested at the daily bed meetings.
Number of ambulance black breaches - there were 14 black breaches in September all of
which occurred during the week beginning 17th September. Full Serious Incident investigations
were undertaken for each patient and in the main these breaches were caused by lack of bed
availability. The extended Rapid Assessment and Treatment area will be completed by the end of
November and will improve offload times and support a reduction in the number of black
breaches.
Page 5 of 8

Workforce
Appraisals – the actions included in last month’s report have not improved performance – the
performance has deteriorated from last month. Business Units have been asked to provide plans
showing dates for all outstanding appraisals and the forward plan for appraisals that will be due in
the coming months.
Basic life support training (BLS) – Resuscitation training compliance for this month is 75.09%.
This is the same overall compliance rate as last month. Uptake on all advertised resuscitation
training sessions has increased slightly since last month’s report. Monthly compliance reports
continue to be sent to the Business Units to highlight those staff that still need to book onto a
training session. Projected overall compliance for the year end (December 31 st 2012) is estimated
at 80.17%, based on bookings already made. This would be a slight improvement on the same
time last year when compliance stood at 72.15%.
Page 6 of 8

4. Productivity
Length of stay (LOS) – elective and non-elective.
Non elective LoS has increased slightly in September and Elective had decreased (including
and excluding 0 days). The reason for this is considered to be due to the closure of Foxglove
ward resulting in medical wards keeping their patients on the main wards and discharging
straight patients from there (Foxglove was a step-down ward). The LoS work-stream
continues to focus on three main areas of delay:
• Therapy input
• Discharge paperwork
• Family disputes
This work has enabled Foxglove to close and also gradually reduce the medical outliers.
Other key actions in month were:
• Care of Elderly in-reach senior consultant cover is provided within the Acute
Medicine Unit to further support the Care of Elderly admissions and expedite
discharges.
• 7 day Cardiology rota implemented
• 7 day Consultant model agreed to start beginning November.
Page 7 of 8

Delayed transfers of care (DTOC) - The closure of Foxglove ward has necessitated greater
focus on complex discharge support and to that
end a rotational training programme has been
implemented to improve the timeliness of this
process. As yet there has not been a matching
decrease in LoS due to DTOC patients remaining
on their base wards but as outliers reduce this is
expected to follow. This work has been
implemented as part of the Ernest & Young Cost
Improvement Plan (CIP) work-streams with the
outcomes now business as usual.
The 7 day Consultant ward cover starts at the beginning of November and this is expected to
support a reduction in DTOC by more timely completion of the medical reports required for
discharge. In order to improve the discharge interface across the whole health economy the Trust
is working in partnership with the local Boroughs and Community Services, facilitated by
McKinsey, to reduce handover delays.
% Patients discharges between 6am and 11am - these have reduced slightly from August.
This measure is to ensure availability of beds and there has also been work undertaken to reduce
the discharges between 6am and 11am.
Goal directed fluid therapy (GDFT) for planned colorectal and emergency abdominal
patients –To increase performance the follow actions are being taken:
When reviewing the notes to identify when the GDFT method has been used the Enhanced
Recovery Program (ERP) Facilitator will escalate to the General Manager and Lead Anaesthetist
immediately where this is not the case. Performance in emergency has increased from 33% to
57% but the elective pathway has deteriorated. This was raised at the recent audit meeting where
it was agreed that the profile of GDFT needed to be raised further within the Trust.
DNA rates for first and follow-up appointments –
The trust is carrying out three key projects to reduce DNA rates. They are:
• The text reminder service
• Phoning patients who have DNA’d to understand why they did not attend the appointment.
• Exploring additional approaches for appointment reminders
Page 8 of 8

Patient Safety and Quality
July Aug Sept Target red July Aug Sept Target red July Aug Sept Target Red
Reducing hospital mortality
SHMI ‐ quarterly December 11 95.96
93.92 95.00 % untreated waiting less than 18 weeks 92.70% 92.10% 92.60% 92% 87% LOS (Elective) 3.15 3.31 3.01 3.1 3.48
% emergency admitted patients review by
senior clinician within 12 hours ND ND ND 95% 94% RTT admitted in 18 weeks 91.20% 90.50% 90.40% 90% 85% LOS (Non‐Elective) 5.13 5.02 5.22 4.454 5.05
% emergency admitted patients review by
consultant within 12 hours ND ND ND 95% 94% RTT non‐admitted in 18 weeks 99.50% 98.90% 98.50% 95% 90% LOS (Elective‐ excluding 0 LOS) 3.62 3.78 3.53 3.5 3.92
Maternal Death Rate per 100000 ( rolling 12
m) 32.36 21.66 21.73 TBA TBA RTT not delivered in all specialties 9 6 7 0 >20 LOS (Non‐ Elective‐excluding 0 LOS) 6.36 6.27 6.41 5.8 6.53
% Day case rate ‐ All 88% 90% 88% 80% 75%
Serious Untoward Incidents
Cancer
DTOC 4.69 5.54 4.18 3.50% 5.00%
Number 13 23 18 18 19 2 Wk. % seen all urgent refs & ref for breast* 98.8% 95.3% 94.4% 93% 88% admissions on day of surgery 86.04 94.44 93.83 85% 80%
% reported within 48Hours ‐ quarterly 64%
50% 49% 2 Wk. GP RefTo 1st OP for susp cancer* 99.5% 99.5% 98.4% 93% 88% % patients discharged between 6 am and 11 am 11% 13.18% 11.12% 50% 30%
2 Wk GP Ref To 1st OP for breast symptoms* 94.3% 98.9% 97.9% 93% 88%
Infection Control
31 Day 2nd Or Subs Treatment ‐ Surgery* 100.0% 100.0% 100.0% 94% 89%
Enhanced Recovery
MRSA Bacteraemia 6 YTD
6 7 31 Day 2nd Or Subs Treatment ‐ Drug* 100.0% 100.0% 100.0% 98% 93%
% patients with an ERP code entered onto the national
database* 86% 74% 99% 95% 95%
C Diff Infection 37YTD
59 60 31 Day DTT for all cancers* 97.5% 100.0% 99.5% 96% 91% % planned colorectal having GDFT* 57% 78% 37% 80% 80%
MRSA Elective Screening 78% 79% 84% 95% 86% 62 Day RTT From Cancer Screening** 100.0% 90.9% 100.0% 90% 85% % emergency abdominal patients having GDFT* 33% 33% 57% 80% 80%
MRSA Emergency Screening 77% 75% 79% 95% 86% 62 Days ‐ treated from referral ** 88.5% 84.1% 91.4% 86% 80% *one month in arrears * JUNE , JULY and AUG data reported
62 Day RTT From Hosp Specialist** 100.0% 100.0% 77.8% 85% 80%
Outpatients
Complaints
62 Days Urgent RTT of all cancers** 88.2% 82.0% 91.5% 85% 80% FFU Ratio 2.13 2.08 2.06 2.16 2.20
% complaints responded to in line with
agreement with patients 87.00% 86.00% 95.00% 80% 79% 31 Day Subs Treatment ‐ Radiotherapy* 100.0% 100.0% 100.0% 94% 89% DNA First 9.83% 9.42% 10.12% 5.00% 5.50%
number of complaints not yet responded to
over 3 months old 18 42 53 TBA TBA * fully validated data provided one month in arrears ** JUNE , JULY and AUG data reported DNA Follow‐Up 10.58% 10.58% 10.84% 5.00% 5.50%
Dementia
% patients aged over 75% having a mental
test score 55% 60% 78% 50% 49%
Performance
Referral to Treatment
A&E
Productivity
Four‐Hour Maximum Wait In A&E 92.26% 94.59% 89.37% 95% 94%
Finance
Percentage of patients referred to speciality team

EXECUTIVE SUMMARY
TITLE:
Emergency Care Report
BOARD/GROUP/COMMITTEE:
Trust Board
1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:
• To advise Trust Board of the
improvements in the Emergency Care
Pathway
• To advise Trust Board of the Emergency
Access performance
• To advise Trust Board of the action plan
to sustain improved performance
2. DECISION REQUIRED: CATEGORY:
PEQ……….…...…….
□ STRATEGY……….….…….
□ FINANCE ……..……… □ AUDIT ………….……..….
□ CLINICAL GOVERNANCE …………..………….....……
□ CHARITABLE FUNDS ………………………………...…
□ TRUST BOARD
□ REMUNERATION ………………………………….…...
□ OTHER …………………………..……. (please specify)
None
NATIONAL TARGET
□ CQC REGISTRATION
□ CNST
□ HEALTH & SAFETY
□ ASSURANCE FRAMEWORK
□ CQUIN/TARGET FROM COMMISSIONERS
CORPORATE OBJECTIVE ……………………………....
□ OTHER …………………….. (please specify)
AUTHOR: Shelagh Smith/Claire Dixon
PRESENTER: Dorothy Hosein
DATE: 16 th October 2012
3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:
Reduction in temporary staff
4. DELIVERABLES
Improved ED access performance
Improved quality of care
Reduction in the use of temporary staff
5. KEY PERFORMANCE INDICATORS
ED access target
AGREED AT ______________________ MEETING
OR
REFERRED TO: __________________________
DATE: ____________________________
DATE: ____________________________
REVIEW DATE (if applicable) ___________________________

Performance for September
Emergency Care Pathway Report
Four Hour Maximum wait in ED
In September the Trust failed to meet the 95% standard and has deteriorated from August. The Trust achieved Trust 89.37% with Queens at 85.14 and KGH at
95.79%
Ambulance Offload Times
There were 14 black breaches in September all of which occurred during the week beginning 17 th September. Full SI investigations have been done for each patient
and in the main these were caused by lack of bed availability during that week.
Urgent Care Workstream
A significant amount of work has been undertaken within the UCC and the number of breaches in the UCC in August was 4 this is a significant improvement form the
July figure of 174.
Additional actions are being taken and monitored with the Director of Transformation as part of the ongoing action plan for the RESET sustainability programme.
These are:
1. Implemented ED Actions
1.1 Daily Performance Management
• ED breaches are discussed daily with the ED doctors involved to review if alternative management plans could have been taken and provide educational feedback to
prevent reoccurrence.
• Specialty breaches have reduced and any that occur are fed back to the specialties concerned to discuss with their teams.
• Daily performance information is shared with ED seniors both nursing and consultants to identify trends and agree actions to prevent reoccurrence.
• Daily peer challenge of decision making at board rounds and identifying alternatives to referrals by using alternative care pathways such as ambulatory care / virtual
ward is completed.
• Daily productivity monitoring is completed by consultants and performance issues are fedback to juniors
1.2 ED Workforce Actions
• Recruitment of doctor’s ongoing, SHOs and middle grades appointed last week.
• Paediatric ED consultant post advertised and General ED consultant in progress for advertising.
• Review of Senior Medical Cover on the Weekends has been undertaken and additional middle grade shift has been implemented as a trial for Saturday and Sunday
• Clinical Nurse Director in post in Emergency Care
• Review of KGH nursing workforce has been undertaken by the Clinical Nurse Director
• Review of Paediatric workforce to be commenced
• Review of RAT nursing workforce to be undertaken
• Competency skillset has been completed for OIC role, training to be developed with a plan to implement by mid-November
1

• Training competencies are being reviewed for all roles in the department to ensure that all staff have clear responsibilities and competencies to undertake that role.
This work is being led by the Clinical Nurse Director with support from the Matrons.
2. Implemented Acute Medicine Unit Actions
• Additional senior consultant cover is provided to further support the General Medicine junior on call team in ED and to support the team to look at alternatives to
admissions.
• Re-launch to the Trust of the Ambulatory Care / Virtual Ward referral route is being completed
• Continued focus on Category B discharges
• GP calls diverted to KGH daily
3. Implemented General Medicine Actions
• Care of Elderly in reach senior consultant cover is provided within the Acute Medicine Unit to further support the Care of Elderly admissions and expedite discharges.
• 7 day Cardiology rota implemented
4. ED Quality Improvements:
• Patient information leaflet explaining the process of the ED is being drafted which will include a feedback section. This will enable direct feedback to the staff that
cared for the patient.
• Trend information on complaints is being collated to further support feedback to all staff
• Customer service competency checklist is being developed to provide staff with additional training to support improvements in communication skills
5. Enablers to support fundamental changes:
5.1 Estates at QH
• Improvements in the RAT area at QH to be operational by mid-November will improve and sustain the ambulance handover performance times and provide rapid
assessment and treatment for all patients including walk in patients.
• Expediting the redesign of the ‘Majors’ area as per the new designs would facilitate further improvements in the flow in majors in conjunction with the new RAT model
and ensure an improved patients experience.
• Expediting the expansion of the Resuscitation Room is crucial to ensure that the ED critical care capacity matches the current demand, therefore enabling the staff to
provide improved quality or care and ensure patients receive appropriate care in a timely fashion.
• Expediting the redesign of the UCC / minors area would enhance the current service improvements in patient flow.
5.2 Reconfiguration
• Closure of KGH to acute admissions would enable 7 day working for Acute and General Medicine
5.3 Organisation Development
• There has been a high turnover of ED nurse staffing over the last 12 months (45%) a clear recruitment and retention plan is underway and recruitment has improved.
• It is difficult to recruit medical staff to ED therefore in order to avoid agency staff higher salaries should be available to complete with local organisations.
2

3
5.4 Key actions to be delivered
• Implement redesigned medical rotas
• Bed Management review
• Ward reviews to commence
• 7 day working across the Trust including support services
• Reducing Length of Stay by working with partner organisations and families to reduce length of stay
• Improve communication with partner organisation to expedite discharges and forward planning to meet demand

Appendix A: Trajectory for all type performance for Trust and by site
Monthly plan Monthly actuals Quarterly plan Quarterly actuals
Month QH KGH Trust QH KGH Trust QH KGH Trust QH KGH Trust
No. of Black
Breaches
April 77.50% 88.39% 79.50% 77.49% 92.92% 83.90% 55
May 84.63% 93.17% 87.49% 85.71% 94.75% 89.49% 3
June 89.26% 89.26% 89.26% 87.99% 95.77% 91.26% 84.44% 90.42% 85.93% 83.82% 94.51% 88.29% 15
July 89.30% 96.50% 92.90% 88.42% 97.36% 92.26% 0
August 92.50% 97.50% 95.00% 92.96% 97.14% 94.51% 0
September 93.00% 97.00% 95.00% 85.14% 95.79% 89.37% 92.20% 96.33% 94.30% 88.97% 96.76% 92.07% 14
October 95.00% 95.00% 95.00%
November 95.00% 95.00% 95.00%
December 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%
January 95.00% 95.00% 95.00%
February 95.00% 95.00% 95.00%
March 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%
4

EXECUTIVE SUMMARY
TITLE:
Maternity Update – September 2012
BOARD/GROUP/COMMITTEE:
Trust Board
1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and
DATE:
The purpose of this report is to provide the Trust
Board with an update on the monthly performance
for maternity services and other key issues.
The key areas to note are:
• Births continue to be high at 781 and are
red on the maternity dashboard.
• The escalation policy was implemented
once in September.
• 88% of women were seen in the triage by
a doctor within 30 minutes, in hours.
• Out of hours triage achieved 57% however
the data collection is not robust. A new
Proforma has been devised and
implemented. Early results are showing
significant improvements.
• The OAU achieved 95%.
• Women continue to be booked for delivery
at Bart’s Health to reduce activity at
BHRUT. The impact of this will commence
in late November 2012.
• A caseload transfer of women is likely to
occur in November 2012, the impact of this
on the deliveries will be in February 2013.
• A formal consultation on TUPE of staff has
commenced and will finish on 24 th October
2012. It is anticipated that 11 wte staff will
TUPE to Barts Health
• NELC are undertaking an assurance
review on 22 nd October 2012 to assess
readiness for reduction in capacity,
opening of QBC and closure of KGH
• Full recruitment of midwives for Queen’s
Birth Centre has taken place. The staff are
competent and trained.
• Discussions with Deanery continue with
regard to timing of closure of KGH
• Births are to be reduced to 8000 2013/14
• There were 2 SI’s reported SI’s in
September Full RCA are being
undertaken.
• Discussions have taken place with NELC
as to the future structure of the
performance report. The assurance
framework, maternity dashboard and
exemption report will now replace the
monthly reporting template The Directorate
□ TEC …….….. □ STRATEGY…….…….
□ FINANCE …… □ AUDIT ………………
□ QUALITY & STRATEGY ………….....……
□ CHARITABLE FUNDS …………………...…
□ TRUST BOARD ………………….………….
□ REMUNERATION …………………….…...
□ OTHER …………………………..…….
(please specify)

would welcome feedback from the Trust
Board as to whether they would want to
adopt a similar approach. Weekly reporting
continues.
• Maternity Modernisation Board inaugural
meeting to be held in October 2012
2. DECISION REQUIRED: CATEGORY:
The Board are asked to note the content of the
report and feedback comments on replacing the
monthly reporting with assurance framework,
maternity dashboard and exemption report.
□ NATIONAL TARGET
□ RMS
□ CQC REGISTRATION □ HEALTH &
SAFETY
□ ASSURANCE FRAMEWORK
□ CQUIN/TARGET FROM
COMMISSIONERS
□ CORPORATE OBJECTIVE ……………....
□ OTHER ……………….. (please specify)
AUTHOR/PRESENTER: W Matthews
Presenter:
DATE: 30 th September 2012
3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:
N/A
4. DELIVERABLES
Maternity Dashboard, Monthly meeting with NELC.
5. KEY PERFORMANCE INDICATORS
98% of women seen within 15 minutes of arrival within Triage
98% of women seen within an hour of referral to an obstetrician within the obstetric assessment
unit.
All emergency LSCS performed within the graded time allocated.
AGREED AT ______________________
MEETING
OR
REFERRED TO: __________________________
DATE: ____________________________
DATE: ____________________________
REVIEW DATE (if applicable) ___________________________
2

Barking, Havering and Redbridge University Hospitals NHS Trust
Source
Responsibility On Target
Target
Of
Concern
Q1 12/13 Q2 12/13
Q3 12/13
Q4 12/13
Action
Required Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13
Maternity Quality and Safety Committee attendance
Number of guidelines over due for review
SI's- declared with care service problems and contributory factors
S.I panel meeting within 4 days
No of S.I submitted within required time frame
Improved patient satisfaction- 50% of women surveyed
Complaints
CNST JP Quorate
Not
Quorate Quorate Quorate Quorate Quorate Quorate Quorate
CNST CH 5 10 0 25 19 16 10 12
CQUINN JP 0 3 5 5 3 6 2/5 6 / 11 0/2
CQUINN JP 95% 90% 50% 3 7 4/5 11 / 11 2/2
CQUINN JP 75% 60% 55% 0 7 2/5 5 / 13* 9/9
CQUINN WM 50% 40% 30% NA NA NA NA NA 70%
TRUST SL 10 2 5 3 7 8 4
Activity
Workforce
Births Benchmarked to 8,700
KPI SL 710 730 766 667 802 782 823 804 781
Births in acute Queens LW setting
KPI SL 540 560 580 516 605 591 641 636 617
Births taking place at KGH
KPI SL 165 175 185 136 175 166 160 167 147
Midwife led unit (10%) of births
KPI SL 70 75 80 NA NA NA NA NA NA
Homebirths
KPI SL 2% 1% 0.50% 1.00% 1% 1.50% 0.85% 1.30% 1.10%
No of referrals received
KPI SE 741 929(86) 1123(69) 985(66) 1136(59) 869(62) 943(84)
No of referrals received by 10 weeks and 6 days
KPI SE 720 769 621 590 726 521
No: of women booked before 12 weeks and 6 days
KPI SE 90% 85-90%

Maternity Services Monthly Performance Report
Trust Name
Barking, Havering & Redbridge University Hospitals
NHS Trust
Reporting month
This report covers the period:
1 st September to 30 th September 2012
Completed by
Mr Dele Olorunshola
Clinical Director of Obstetrics, Gynaecology and
Sexual Health
Wendy Matthews, Director of Midwifery
Reviewed by
Dorothy Hosein, Director of Transformation
On behalf of
Director of Nursing
Neill Moloney
Director of Planning & Performance
Contact Details
Barking, Havering & Redbridge University Hospitals
NHS Trust
1st Floor Green Zone
Maternity Services, Queens Hospital
Rom Valley Way, Romford, RM7 0AG
Tel: 01708 435 000 x 3894
A monthly report will be provided to; monitor the progress made against the maternity services
improvement plan, provide assurance that the safety and quality of maternity services are
improving within BHRUT. It will summarise the themes and actions that have arisen from the
analysis of activity within the unit.
Mat 2 October 2012 (2).doc
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1

1. Introduction
The purpose of this report is to summarise the progress made in September 2012 against the
maternity service improvement plan and the KPIs outlined in the maternity service specification as
agreed with NELC.
2. Total Number of Births at BHRUT for September 2012
KGH Queens BHRUT (%)
Elective CS 14 53 67
Emergency CS 26 113 139
Others 107 451 558
Total 147 617 764
9%
18%
73%
* There were 17 births outside of the unit, registered as BBA and homebirths. Total birth rate for
the Trust including outside deliveries is 781.
3. Monthly Activity (excluding elective LSCS)
Monthly Hospital Delivery Activity
800
700
600
500
400
300
Queens
Optimum QH
KGH
Optimum KGH
200
100
May Jun Jul Aug Sep
Month
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4. Capping
The maternity service is no longer subject to capping births as BHRUT have moved towards business
as usual. The service continues to use internal escalation and conforms to the pan London escalation
policy.
Discussions are underway with the commissioners to cap maternity bookings to ensure that births
reduce to 8000 by 2013/14
5. Diverts
Diverts occur when the number of labouring women accessing the service is greater than the service
can deal with without compromising care. The Trust has moved to the pan London escalation policy
since the lifting of restrictions in early June. In these instances, women are diverted to the nearest
accepting unit unless their clinical presentation indicates that transfer to another provider would pose a
greater risk. Since the lift of the cap, diverts are recorded based on a 24 hour clock (i.e. 0000 – 2400)
and not between the hours of 18:00 - 18:00 as was the case previously.
The divert policy was activated once across the Trust during the month of September. However, no
women were actually diverted. On that occasion there were no other hospitals that could accept
women from BHRUT which increased the risk at Queen’s Hospital.
6. Triage
The standard is that 98% of women should be seen by a midwife within 30 minutes of arrival at
triage. In September, 1014 women accessed the Triage service at Queen’s. Of these women 88%
were seen within 30 minutes.
The graph below depicts the monthly average percentage of patients seen within 30 minutes of their arrival in triage,
indicated by a single figure for the month
Triage Attendance - % seen ≤ 30 mins and No. of Women Attending
% Seen ≤ 30 minutes
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
STANDARD 1200
STANDARD (98%)
87%
1163
86% 89%
1149 86%
88%
85%
1150
81%
1140 1146
78%
1110 1110
73%
1100
1085
1050
1014
1000
973
950
900
850
Jan Feb Mar Apr May Jun Jul Aug Sep
% SEEN ≤ 30 MINS STANDARD No of women attending
No of Women Attending (Actual)
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The graph below depicts the daily actual percentages of patients seen within 30 minutes of their arrival in triage,
indicated by a collection of figures for each month 1
100
Triage - % of Patients Seen within 30 Minutes of Arrival
(JANUARY 2012 - AUGUST 2012 Inclusive weekly capture)
90
Number of Patients
80
70
60
50
40
30
20
10
0
January
2012
February
2012
March
2012
April 2012
May 2012
June 2012
July 2012
August
2012
September
2012
Day
% of patients Seen within 30 minutes Target
As part of the continuous improvement programme the Triage pathway has gone through several
iterations including most recently in June 2012. This explains day to day the variances during the
month of June. This process is continuing through the work of Maternity Clinical Fellows. It is
anticipated the service will settle with much higher percentages of women seen in 15 minutes once
this work is completed. Phase one of the new pathway commenced on 30 th July.
1 Triage figures Jan – July inclusive were 98% standard against 15 minutes. This has changed in September to 98%
standard against 30 minutes.
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7. Obstetric Assessment Unit (OAU)
It has been agreed that 98% of women should be seen by an obstetrician, where this is deemed
clinically appropriate, within 1 hour of their arrival to the Obstetric Assessment Unit (OAU). The
Trust average for September 2012 was 95%.
% of Patients seen within 1 hour on OAU by an Obstetrician
85
Standard
90 94
92 91
99 96
98 99
Standard
95
65
45
25
Jan
Feb
Mar
Apr
% of patients seen
May
Jun
Jul
Aug
Sep
Seen

.
% of Patients seen within 1 Hour of Referral
120
100
Standard Standard Standard Standard Standard Standard Standard Standard
80
60
40
59
70
65
72
60
58
60
65
57
20
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Seen

10. Serious Incidents Reported
Incidents which meet the NHS London SI reporting criteria are declared as they occur /
are detected. Because they are reported retrospectively, the information below details
incidents that either occurred within September 2012 or were reported in September
2012. There will be overlap and repetition between information provided each month
for this report.
Full summaries and details are to be found on the STEIS system (references numbers
provided).
Summary:
STEIS
number
Site
22405 QH
23880 QH
Issue
controlled
drugs
potentially
missing
NNU
admission /
transfer to
UCLH
Incident
date
Date of
declaration
MDT /
panel
reviews
10/09/12 10/09/12 10/09/12
23/09/12 25/09/12
27/09/2012
2/10/12
Comment
At routine controlled drug check on
morning of 10/9/12 it was found
that the controlled drug book had
been altered (pages removed) and
potentially some controlled drugs
were missing
congenital pneumonia / no
contributory care or service
delivery problems identified at
panel
11. Caesarean Deliveries including Elective Activity
When a decision is made to perform an emergency LSCS, the timing for this is dictated by the
acuity of each case which is graded from 1-4.
Grade 1
Caesarean section is considered as urgent and has an immediate threat to the life of the
woman and foetus. To be performed within 30 minutes.
At BHRUT hospitals, 54% of the audited grade 1 C/S were performed within 30 minutes.
Delays were due to:
• Increased BMI impacting on the procedure
• Difficulty in sitting the spinal
• Delay due to anaesthetic issues.
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Grade 2
Caesarean section is considered urgent with maternal or foetal compromise which is not
immediately life threatening. To be performed within 60 minutes
At BHRUT hospitals, of 63% the audited grade 2 emergency C/S were performed within 60
minutes.
An audit of the grading of emergency caesarean sections is being carried out to ensure that
emergency caesarean sections are not being misclassified.
Grade 3 & 4
Caesarean section is an emergency with no maternal or foetal compromise, but requires
early delivery. To be performed at a time to suit the mother and the department.
At BHRUT, 100% of the audited grade 3/4 emergency C/S were performed within time.
There were no adverse outcomes associated with delayed LSCS.
It should also be noted that the target of 100% achievement is not based on national guidance.
Royal College of Obstetricians and Gynaecologists Good Practice No. 11 2 of 4noted that:
To formalise the concept that urgency of caesarean section represents a continuum of risk:
● four broad categories of risk are defined
● all staff should be aware that, within each category, the degree of risk in individual cases can
vary
● a coloured spectrum is used to emphasise that continuum of risk
● this variance in degree of risk requires an individual, case-by-case approach in deciding the
specific
decision-to-delivery interval (DDI).
The ‘Sentinel’ caesarean section audit suggested that in cases such as cord prolapse, a DDI of 15
minutes was feasible. However, in many category-1 cases, delivery within 30 minutes was not
achieved. Delivery within 75 minutes does not appear to increase the risk of compromise, while
delivery within 30 minutes may not
always result in a good neonatal outcome. Once a decision to deliver has been made, therefore,
delivery should be carried out with an urgency appropriate to the risk to the baby and the safety
of the mother. Units should strive to design guidelines that result in the shortest safely achievable
DDI. Evidence suggests that any delay is usually associated with the delay in transfer to theatre.
A target DDI for caesarean section for ‘fetal compromise’ of 30 minutes is an audit tool that
allows testing of the efficiency of the whole delivery team and has become accepted practice;
however:
• certain clinical situations will require a much quicker DDI than 30 minutes and units should
work towards improving their efficiency
• undue haste to achieve a short DDI can introduce its own risk, both surgical and
anaesthetic, with the potential for maternal and neonatal harm.
Mat 2 October 2012 (2).doc
Page 8 of 9
Compiled by C Frisby 12.07.2012
8

12. Maternity Dashboard
The dashboard and exception report for September 2012 is attached seperatly.
Discussions have taken place with NEC as to the future structure of the performance report. The
assurance framework, maternity dashboard and exemption report will now replace the monthly
reporting template The Directorate would welcome feedback from the Trust Board as to whether
they would want to adopt a similar approach.
.
Mat 2 October 2012 (2).doc
Page 9 of 9
Compiled by C Frisby 12.07.2012
9

Women’s Services
Exception Report for the Maternity Performance Dashboard and
Assurance Framework
September 2012
Red Areas
Guidelines
There are 12 guidelines which have expired; the reasons being:
An Increase has been noted from the previous month due to a large number of
guidelines expiring in September. Most of these have been updated but are waiting
approval or uploading onto the Intr@net.
Deliveries
There were a high number of deliveries at both units during September. This
continues a trend for the first six months of the year. Births are monitored very
carefully and escalation occurred as required. It is anticipated that births should start
to decrease in November due to an increase in the bookings in Barking being
undertaken by Barts Heath for the last five months. The case load transfer has been
delayed by a month to mid November. Discussions are ongoing with the
commissioners; the bookings have reduced over the last month.
Triage
The triage area on the Labour Ward at Queen’s Hospital achieved 88% in seeing women
within 30 minutes. As part of the continuous improvement programme the Triage
pathway has gone through several iterations including most recently in July 2012. This
process is continuing through the work of Maternity Clinical Fellows. It is anticipated the
service will settle with much higher percentages of women seen in 15 minutes once this
work is completed. Phase one of the new pathway commenced on 30 th July.
LSCS Grading.
This continues to be problematic with data recording and appropriate grading of
LSCS with only 54% achievement of grade 1 LSCS. It has been agreed that the clinical
director will identify one of the obstetric team to monitor the doctors to ensure that
they have completed the E3 at the time of LSCS, this will ensure that we have
accurate data. It will also ensure that we are able to accurately record the grading of
the LSCS and any inappropriateness will be addressed with individuals. We hope to
see an improvement in the next month’s figures. There were no poor outcomes
noted from the notes audited.

It should also be noted that the target of 100% achievement is not based on national
guidance. Royal College of Obstetricians and Gynaecologists Good Practice No. 11 2
of 4noted that:
To formalise the concept that urgency of caesarean section represents a continuum
of risk:
● four broad categories of risk are defined
● all staff should be aware that, within each category, the degree of risk in
individual cases can vary
● a coloured spectrum is used to emphasise that continuum of risk
● this variance in degree of risk requires an individual, case‐by‐case approach in
deciding the specific
decision‐to‐delivery interval (DDI).
The ‘Sentinel’ caesarean section audit suggested that in cases such as cord prolapse,
a DDI of 15 minutes was feasible. However, in many category‐1 cases, delivery within
30 minutes was not achieved. Delivery within 75 minutes does not appear to
increase the risk of compromise, while delivery within 30 minutes may not
always result in a good neonatal outcome. Once a decision to deliver has been made,
therefore, delivery should be carried out with an urgency appropriate to the risk to
the baby and the safety of the mother. Units should strive to design guidelines that
result in the shortest safely achievable DDI. Evidence suggests that any delay is
usually associated with the delay in transfer to theatre.
A target DDI for caesarean section for ‘fetal compromise’ of 30 minutes is an audit
tool that allows testing of the efficiency of the whole delivery team and has become
accepted practice; however:
• certain clinical situations will require a much quicker DDI than 30 minutes
and units should work towards improving their efficiency
• undue haste to achieve a short DDI can introduce its own risk, both surgical
and anaesthetic, with the potential for maternal and neonatal harm.
PPH’s
There were 6 PPH’s the governance department has reviewed the care of all these
deliveries and has not noted any specific care issue.

Maternity Services Assurance Framework 2012-13
September 2012
Introduction
This report sets out an assurance framework for patient safety and minimum quality standards at BHRUT. This framework compliments a range of
other assurances both commissioners and the trust boards already have in place.
From 1 st April 2012 Maternity Services is moving back to ward business as normal. However BHRUT will need to continue to provide assurance to
external organisations such as NELC, that the services remain safe.
Following discussions at the monthly NELC Cluster & BHRUT Maternity Sub Group Meeting it was agreed that BHRUT would devise a Maternity
Services Assurance Framework based on several indicators including:
• Key Performance Indicators
• Workforce
• Governance
• Demand and Activity
• Patient experience
Governance Arrangements
Both the trust and the PCT boards have established committees which focus on safety and clinical governance. However, the assurance
framework below outlines how the priority areas will be scrutinised and monitored.
Interim Chairman: George Wood
Chief Executive: Averil Dongworth

Priority Action Lead Monitoring Tool Current Risk
Rating
Risk rating
previous
month
Antenatal
Access to maternity
services
Intrapartum
Ensure that Labour Ward
remains safe and
appropriate escalation
occurs
Women where the referral received by
10+6weeks to be booked by 12+6 weeks for
90% of maternities
90% of women to be triaged within 30
minutes of arrival
Number of bookings must not exceed cap
C:\Data\matthews w\
Bookings\New Templa
Escalation policy in place
NELC informed of diverts as per PAN London
divert policy
W
Matthews
Monthly reporting to Trust Board and
on maternity dashboard
92% 92%
A Archibald Monthly performance report 88% 89%
W
Matthews
Avril
Archibald
Weekly teleconference, weekly
submission of booking data
*Evidence of BHRUT escalation
implemented.
NELC informed of escalation in line
with agreed process.
Evidence of LSA database updated
with escalation details.
Awaiting cap
implementation
date
1 3
Ensuring woman receive
1:1 care by a midwife in
established labour
Staffing levels on Labour Ward to allow for
1:1 care in labour.
Clinical pathways facilitator to have an
overview of staffing levels across maternity in
hours, out of hours this is undertaken by
Labour Ward co-ordinator
Avril
Archibald
BHRUT to maintain a minimum
midwife ratio of 1:29.
Weekly audit of one to one care
Review of patient feedback.
Dashboard entry monthly
100% 100%
All women presenting to the
unit are assessed in a
timely way.
High risk women identified
*BHRUT to ensure that 90% of women seen
within 30mins of arrival to triage.
*Daily percentage of high risk women seen
within target time (98% within 1hour).
2
Monthly reporting. 88% 89%

Priority Action Lead Monitoring Tool Current Risk
Rating
and treated in a timely way.
Risk rating
previous
month
100%Grade 1 LSCS are
performed within 30
minutes
Maintain high standard of
care for women. Women
cared for in appropriate
location.
Audit appropriateness of grading LSCS
Identify reasons why grade 1LSCS not
undertaken within 30 minutes
Once Birthing Centre is open ensure that low
risk women are encouraged to birth there.
Agree trajectory with NELC
D
Olorunshola
J
Richardson
Monthly monitoring report 54% 65%
% Births in Birthing Centre
Monthly Dashboard entry
Decision still
awaited on
opening of QBC
To ensure that maternal
and neonatal morbidity and
mortality is in line with
national targets
Revise maternity dashboard to include
national benchmarks.
S Lovell
Monthly Dashboard
Exemption reporting on outliers
3 2
Postnatal
Ensure that neonatal
readmissions is not an
outlyer
Audit pathway for neonatal readmissions
Revise pathway to ensure that neonates are
readmitted in the most appropriate
environment
M O’Leary
D Jones
Dashboard entry monthly.
Exemption reporting if outlying
1 2
To review discharge
pathway and reduce LOS
NPAN midwife rota 100% coverage
Pathway review through Clinical fellow
programme
Clinical
Fellows
Helen
Mansfield
Dashboard entry
Monthly performance report
87% coverage 87% coverage
Workforce
Strengthen the levels of
statutory supervision of
midwives within the Trust
Ratio of SOM to Midwives improves. Current
position 1:20.
D Jones
J Read
Shift in ratio towards 1:15 1:18 1:19
Review midwifery numbers Agree baseline based on Birthrate Plus D Jones 1:29 midwife to birth ratio 1:29 1:29
3

Priority Action Lead Monitoring Tool Current Risk
Rating
as births decrease
findings.
Review WTE on a quarterly basis depending
on birth numbers
W
Matthews
Reduction in bank and move towards
removing agency midwives
Risk rating
previous
month
Governance
Information and
Governance Arrangements
*Ensure that BHRUT are recording and
reviewing all serious untoward incidents
Compliance with CQUIN requirements.
D Jones
J Piper
Monthly performance report.
SI’s notified to NHS London
CQUIN performance
2 11
Patient Experience
Ensure that women receive
a positive experience
Monitor complaints and ensure timely
response.
Appoint patient experience midwife
50% of delivered women to use patient
tracker device
Action Plan developed to improve patient
experience.
Collate positive feedback from women
W
Matthews
D Jones
Monthly reporting of complaints
Milestone of CQUIN
70% compliance
on pilot ward
N/A
C:\Data\matthews w\
Patient experience\03
September 2012
4

Complaints Annual Report
2011 - 2012

Contents
Section No: Description Page No:
1. Introduction 3
2. Overview of the Service 3
3. Complaints Activity 4
4. Actions taken in Response to Complaints 10
5. Service Developments 11
6. The Year Ahead - Future Plans 12
2

1. Introduction
Under the Local Authority Social Services and NHS Complaints (England) Regulations
2009, all NHS bodies are required to prepare an annual report on complaints received. The
report should include the number and subject matter of all complaints received during the
year, the number upheld, the number known to have been referred to the Parliamentary
and Health Service Ombudsman (PHSO) and any actions taken to improve services as a
result of complaints.
This report provides a summary of complaints received by Barking, Havering & Redbridge
University Hospitals NHS Trust (BHRUT) in relation to its own services during the period 1 st
April 2011 - 31 st March 2012.
2. Overview of the Complaints Service
2.1 Barking Havering & Redbridge University Hospital NHS Trust (BHRUT) complaints service
is accessible to all patients who have used the services provided by the Trust.
Specifically these services are delivered on the two main hospital sites - King George
Hospital (KGH) and Queen’s Hospital, but also include any outreach services provided.
Every effort is made to ensure that complainants are able to access the service in a way
which meets their needs. The service operates Monday to Friday, 9am - 5pm.
The Complaints Team can be contacted in the following ways:
Telephone - there is a dedicated complaints telephone number which is supported by
an answer phone facility at busy times and outside of core working hours.
Email - there is one dedicated complaints email address where enquirers can send
their complaint.
Letter - enquirers can write to the Complaints Team at either of the two main hospital
sites.
The complaints process in the Trust is for all formal complaints to be received, logged and
acknowledged by the core Complaints Team. They are then sent to the Directorates who
are responsible for liaising with the complainant, agreeing the complaint plan, agreeing
appropriate response times, undertaking a full investigation and providing a draft response.
The core Complaints Team then resume responsibility for the complaint, checking the
investigation and response before it is reviewed and signed by the Accountable Officer.
During 2011 - 2012, the core Complaints Team was resourced by:
1 WTE Band 7 Complaint Manager
1 WTE Band 6 Complaint Manager
2.92 WTE Band 4 Complaints Administrators
The service is also supported by four Band 3 Directorate Complaint Co-ordinators and adhoc
Directorate administrative support as needed.
During 2011 - 2012, the budget for complaints was £305,131.
3

3. Complaints Activity
3.1 Total Complaints Received
During the year, the Trust received 1096 formal complaints. There was a significant rise in
the number of complaints received this year compared with the previous year of 671.
During the year, the Trust was the subject of a Care Quality Commission (CQC)
investigation which highlighted a number of areas of concern across the Trust, and the
increase in the number of complaints received reflects this.
The chart below shows the total activity received on a monthly basis:
140
120
100
80
60
40
20
0
April
May
June
July
August
September
October
November
December
January
February
March
Each complaint is assigned to the relevant Directorate it is regarding and the chart below
demonstrates the percentage of total complaints received for each Directorate.
21%
10%
2%
33%
C.D.T
Corporate Non Clinical
Medical
Surgical
Women And Children
34%
4

3.2 Acknowledgement Time
The Complaints Regulations (2009), state that all complainants should receive an
acknowledgement from the Trust within 3 working days.
During the year, 99.6% of complainants received an acknowledgement within 3 working
days.
3.3 Response Time
During the year the Trust’s target for percentage of complainants receiving a response
within the agreed timescale was 80%. Unfortunately, the Trust did not meet this target.
The chart below outlines the actual monthly percentages achieved:
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
April
May
June
July
August
September
October
November
December
January
February
March
3.4 Outcome
Of the 1096 complaints received and investigated by the Trust, 604 were upheld.
The table below reflects the status of all complaints received during this period. 85% of
complaints received were resolved after a first written response or a first response meeting
with the complainant, even though this may not have been within the agreed timeframe.
Stage
No of Complaints
Open 44
Open - reactivated complaint 32
Closed - no consent 15
Closed after first response/first meeting 930
Closed after additional response/ local resolution
75
meeting
Total 1096
5

3.5 Themes
General care issues and communication were the two main themes of complaints received
during the year accounting for 92% of complaints received, and as outlined above, this is in
line with the outcome of the CQC investigation. These two main themes are common
across all Directorates.
General Care Issues
General care issues received during the past year related to:
Delay in diagnosis
Wrong diagnosis
Failure to respond to patients’ buzzers in a timely manner and/or leaving buzzers
out of reach of patient
Failure to respond to a patient needing help with getting to the toilet/personal
hygiene
Failure to provide assistance to patients needing help to eat
Food and water being left out of the reach of patients
Failure to supervise the taking of medication
Communication Issues
Communication issues received during this period included:
Staff interaction with patients and families - a lack of basic courtesy to visitors or
telephone callers
Patients and visitors being spoken to in an abrupt manner on the ward or in the
clinic environment
Failure to keep patients and visitors informed as to developments whilst they are in
hospital
Failure to document fully in medical and nursing records, which then leads to
problems for other staff to determine the up-to-date position.
Difficulties in being able to contact the Appointments Call Centre, particularly as
there was no queuing facility resulting in patients often hearing an engaged tone
Overall, the Trust received complaints about the following:
Category
No. of
Complaints
Category
No. of
Complaints
Care general -
316 Wait - in out-patient
4
nurse/midwife
department
Care general - treatment 290 Care process - in
3
department
Communication 160 Safety - other, accident 3
Care general - diagnosis 145 Safety - other, assault etc 3
Communication - staff
54 Security - general 3
attitude
Care process - cross
department
19 Wait - for tests/scans etc
out-patient
2
6

Category
Communication -
privacy/dignity/
discrimination
Care process -
transfer/discharge
Wait - for out-patient
appointment
No. of
Category
Complaints
17 Facilities/equipment - hotel
services
No. of
Complaints
2
13 Care process - attendance 2
etc
13 Care procedure - other 1
Wait- in A&E 12 Communication - patient 1
property/ expenses
Care general - patient
10 Facilities/equipment -
1
event
availability
Care procedure -
7 Facilities/equipment -
1
medication
maintenance
Care procedure -
7 Safety - patient, accident 1
documentation
Wait - for in-patient
5 Safety – patient, accident 1
admission
fall from height
Total 1096
The categories for each Directorate are outlined in the tables below.
Specialist Medicine
Category
Number of Complaints
Communication 46
Care general - treatment 23
Communication - staff attitude 10
Care general - diagnosis 6
Care process - cross department 5
Care general - nurse/midwife 4
Communication - privacy/dignity/discrimination 3
Wait - in out-patient department 3
Care procedure - medication 2
Care process - transfer/discharge 2
Wait - for tests/scans etc (out-patient) 2
Care procedure - documentation 1
Facilities/Equipment - hotel services 1
Wait - for out-patient appointment 1
Total 109
7

Corporate Non Clinical
Category
Number of Complaints
Communication 6
Communication - staff attitude 3
Care process - cross department 1
Care general - nurse/midwife 1
Facilities/equipment - availability 1
Safety - other, accident 1
Safety - other, assault etc 1
Security - general 3
Total 17
Medical
Surgical
Category
Number of Complaints
Communication 58
Care general - treatment 121
Communication - staff attitude 19
Care general - diagnosis 43
Care process - cross department 3
Care general - nurse/midwife 100
Communication - privacy/dignity/discrimination 2
Care procedure - medication 1
Care process - transfer/discharge 6
Care procedure - documentation 2
Wait - for out-patient appointment 1
Communication - patient property/expenses 1
Safety - other, assault etc 2
Safety - patient, accident 1
Safety - patient, accident fall from height 1
Wait - in A&E 12
Total 373
Category
Number of Complaints
Communication 36
Care general - treatment 120
Communication - staff attitude 10
Care general - diagnosis 70
Care process - cross department 9
Care general - nurse/midwife 75
Communication - privacy/dignity/discrimination 7
Wait - in out-patient department 1
Care procedure - medication 3
Care process - transfer/discharge 5
Care procedure - documentation 1
Facilities/equipment - hotel services 1
8

Category
Number of Complaints
Wait - for out-patient appointment 11
Care general - patient event 8
Care procedure - other 1
Care process - attendance etc 2
Care process - in department 2
Facilities/equipment - maintenance 1
Safety - other, accident 1
Wait - for in-patient admission 5
Total 369
Women & Children
Category
Number of Complaints
Communication 14
Care general - treatment 26
Communication - staff attitude 12
Care general - diagnosis 26
Care process - cross department 1
Care general - nurse/midwife 136
Communication - privacy/dignity/discrimination 5
Care procedure - medication 1
Care procedure - documentation 3
Care general - patient event 2
Care process - in department 1
Safety - other, accident 1
Total 228
3.6 Reactivated Complaints
During the year the Trust received 75 new requests from complainants to re-open their
complaint.
By Directorates these were:
Directorates
Specialist Medicine 9
Medical 36
Surgical 13
Women and Children 15
Corporate non-clinical 2
No of Reactivated
The majority of reactivated complaints related to complex medical cases where the
complainant was seeking further clarification of the response or where they did not agree
with the Trust’s response. A number of complaints were reactivated as following a written
response the complainant had requested financial recompense.
Where complaints were reactivated, complainants were offered a further written response
or the opportunity to have a local resolution meeting with relevant Trust representatives in
9

order to resolve concerns. Particularly where there are complex medical issues which
require explanation, it is often more helpful for the complainant if this is achieved through a
face-to-face meeting as it allows the complainant to ask questions and to raise any
outstanding concerns.
3.7 Parliamentary and Health Service Ombudsman (PHSO)
Once the local resolution process has been concluded between the Trust and the
complainant, if they are dissatisfied with the way in which the complaint has been handled
or if it is not possible to resolve the complaint, they can ask the PHSO to review the case.
Sometimes, complainants do not wait until the local resolution process has concluded
before approaching the PHSO and the case is then returned to the Trust to continue with
local resolution. Where local resolution has concluded, the PHSO reviews the case and
either upholds the complaint, often suggesting the resolution that needs to take place, or
rejecting the complaint and no further action is required.
During the last year the Trust were advised of 38 complaints which were referred by
complainants to the PHSO.
Of this number, the status of the cases were:
Still being considered 5
Local resolution 17
Upheld 3
Rejected 13
Although a number of cases were referred to the PHSO, it is encouraging to note that only
8% of these cases were upheld. The remainder were either rejected, returned to the Trust
to conclude local resolution or are still awaiting PHSO consideration.
The PHSO are unable to provide the Trust with details as to why a complaint has been
referred to them without the consent of the complainant. It is therefore sometimes difficult
to determine the specific reasons why complainants refer their complaint to the PHSO.
However, during this period, delays in the Trust complaint handling process has led to
some referrals being made to the PHSO prior to conclusion of local resolution.
According to the PHSO findings and recommendations, the large majority of cases referred
to them during 2011-12 were as a result of failures and/or delays in care and treatment and
this is in line with the overall themes from complaints.
Of the 38 cases referred to the PHSO during 2011-12, 3 referred to Specialist Medicine, 1
to Corporate Non-clinical, 20 to Medical, 10 to Surgical, 4 to Women & Children.
Of the cases that the PHSO upheld against the Trust, 2 related to Surgical Division and 1
related to Medical Division.
4. Actions Taken in Response to Complaints
BHRUT is keen to learn from all patient feedback including complaints. Any complaint
which identifies shortcomings in services provided to patients is supported by an individual
action plan which details learning and actions required to prevent a recurrence of the
events which led to the complaint.
10

The following improvements / actions were implemented during the year:
Additional pain management capacity identified to ensure patients are seen as
quickly as possible
Every patient admitted to a ward is seen within 24 hours by a consultant even if their
own consultant is not available
Introduction of 1 - 2 hourly comfort ward rounds ensure patients needs are regularly
identified
A communication book is now available on all wards to assist patients with
communication difficulties. This is a pictorial book and allows patients who cannot
verbalise to point out their needs
The Trust senior nursing team undertake a rolling programme of weekly audits that
concentrate on a topic of the week. The process of audit allows the senior nursing
team to monitor documentation and feedback to staff any issues with inappropriate
or inadequate documentation. This then identifies the gaps and support if given to
that ward area. During these audits the senior nursing team speak to patients about
their experience, particularly around issues of privacy and dignity, access to nurse
call buzzers, nutrition, quality of food, use of ‘red tray’ and water jug system that is
in place for patients who require assistance
Within the Care of the Elderly Unit, the Matrons are introducing a twice weekly
Matron’s surgery. This will be publicised to families and patients in the ward areas.
This will allow patients and next-of-kin to have direct access to a Matron to discuss
any concerns they may have. This will promote and improve communication. It is
anticipated that following a review period, if successful, it will be rolled out across
the Trust
Introduction of a parents advice leaflet within paediatrics
Redesign of emergency department to include a dedicated room for mothers to use
to breast-feed their babies
Introduction of enhanced telephony system for Appointment Call Centre
Medical Director led communication forums for junior medical staff
Complaints discussed in consultant governance meetings, learning identified and
shared
5. Service Developments
Review of Complaints Handling
Following the publication of the CQC investigation report into issues at the Trust, in January
2012, NHS London provided a resource to the Trust to undertake a review into the reasons
for the decline in the Trust meeting its own targets for providing responses to complainants.
The review took place throughout January 2012 and all aspects of the complaints handling
process were considered.
11

The findings of the review were that there were two main areas of concern relating to
process issues and systems issues. Along with the review report, the project lead also
submitted a proposed action plan to address the issues raised.
At the time of this report progress on delivering the actions in the plan are being regularly
reviewed at the Trust’s Quality & Safety Committee.
Handling Complaints Policy & Procedure
During the later part of the year, the Trust’s Handling Complaints Policy and Procedure was
reviewed to bring the Trust in line with the Complaint Regulations 2009. The draft policy
includes all aspects of the 2009 regulations and places greater emphasis on getting it right
for the complainant. It aims to ensure a flexible, proportionate approach is implemented in
order that the process be as easy to understand and as un-bureaucratic as possible.
The draft policy and procedure has been widely circulated to internal and external
stakeholders for comment, prior to being presented at the Trust’s Policy Ratification
Committee.
New Complaints Leaflets
A new Trust complaints leaflet has been designed and is currently in the process of being
printed. The new leaflet is completely different to the old version and provides much more
information for patients and relatives on making a complaint and other services and
organisations who can help. Once printed, the new leaflet will be available in all patient
areas across the two main hospital sites.
The leaflet is available for download on the Trust’s website.
6. The Year Ahead - Future Plans
Development/Goal
Date Due
Implementation of a complaints annual workplan 2012-2013 Summer 2012
Distribution of a new complaints leaflet Summer 2012
Production of easy-read complaints leaflet Summer 2012
Develop complaints induction material Summer 2012
Moving core complaints team onto one site Summer 2012
Service review of processes and procedures Autumn 2013
Gary Etheridge
Deputy Director of Nursing
Victoria Wallen
Interim Head of Complaints & PALS
12

TITLE:
EXECUTIVE SUMMARY
BOARD/GROUP/COMMITTEE:
Single Operating Model – Self certification template
Trust Board
1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:
Delivering the NHS Foundation Trust Pipeline: Single
Operating Model (SOM) sets out the requirement for
□ PEQ……….…...……. □ STRATEGY……….….…….
Trusts to complete a self-assessment.
□ FINANCE ……..……… □ AUDIT ………….……..….
The SOM requires NHS Trusts to regularly self-certify
governance and financial risk ratings on a monthly basis.
They are also required to submit a template of quality and
contractual information and provide an accurate selfassessment
against a series of Board statements drawn
from the Monitor Compliance Framework.
□ CLINICAL GOVERNANCE …………..………….....……
□ CHARITABLE FUNDS ………………………………...…
TRUST BOARD – Oct 2012
□ REMUNERATION ………………………………….…...
□ OTHER …………………………..……. (please specify)
All declarations and self-certification should have been
robustly discussed and approved by the Trust Board with
the discussion minuted. Where an issue of non-compliance
is identified the Trust should submit the relevant Board
approved action plan to rectify the issue. In line with the
principle of avoiding duplication this would normally be the
same level of detail that has been presented to the Board
to provide them with assurance that an issue can be
rectified.
2. DECISION REQUIRED: CATEGORY:
The Trust Board is asked to discuss and approve the
contents of the Trust Self-Assessment
NATIONAL TARGET
□ CQC REGISTRATION
□ CNST
□ HEALTH & SAFETY
3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:
Not applicable.
4. DELIVERABLES
□ ASSURANCE FRAMEWORK
□ CQUIN/TARGET FROM COMMISSIONERS
□ CORPORATE OBJECTIVE ……………………………....
□ OTHER …NHS Operating Framework
AUTHOR: Claire Burns, Head of Planning, Commissioning
and Information
PRESENTER: Neill Moloney, Director of Delivery
DATE: Oct 2012
Meeting the Delivering the NHS Foundation Trust Pipeline: Single Operating Model (SOM) requirement for Trusts to
complete a self-assessment
5. KEY PERFORMANCE INDICATORS
Please see attached self-assessment which includes indicators
AGREED AT ______________________ MEETING
OR
REFERRED TO: __________________________
DATE: ____________________________
DATE: ____________________________
REVIEW DATE (if applicable) ___________________________

SELF-CERTIFICATION RETURNS
Organisation Name:
BHR University Hospitals NHS Trust
Monitoring Period:
September 12
NHS Trust Over-sight self certification template

TFA Progress
BHR University Hospitals NHS Trust
Sep‐12
Select the Performance from the drop‐down list
TFA Milestone (All including those delivered)
Milestone
Date
Performance
Comments where milestones are not delivered or where a risk to
delivery has been identified
Mar
1 AA - TFA governance agreed by Trust / Cluster / SHA Aug-12 On track to deliver
2 AA - Trust Transformation Programme Plan developed Sep-12
3 AA - Transformation plan approved by Board Oct-12
High risk to delivery
within timescale
High risk to delivery
within timescale
4 AA - All Trust Board and Executive Director positions filled Oct-12 On track to deliver
complete
plan developed to go to Joint Transformation board in October and
board in November
Transformation plan to be developed by Dec 12 following approval of the
LTFM
Chairman and Director of Nursing commenced post. Chief Information
Office appointed , due to commence in Nov 12
Fully On track
achieved to deliver
in time
ll h High k risk d l h l
to
delivery
Not fully
achieved
5 AA - OD plan agreed with deliverables/milestones Dec-12 On track to deliver
OD plans were submitted to gain funding ‐ awaiting feedback from DoH
6 AA - Quality Governance self assessment agreed by Trust Board Jan-13 On track to deliver
7 AA - BGAF self assessment agreed by Trust Board Jan-13 On track to deliver
Recruited Director of Governance who is taking the lead on this
requirement
Recruited Director of Governance who is taking the lead on this
requirement
8 AA - Formal review of Transformation Programme Jan-13 On track to deliver `12/13 review in Oct 12 , 13/14 plan being developed
9 AA - Workforce strategy/education/training plan approved May-13 On track to deliver New Head of HR recruited and taking the lead on this development
10 AA - A&E target achieved at KGH Aug-12 On track to deliver KGH meeting 95% target since June 12
11 AA - A&E target achieved at Queen’s Oct-12
High risk to delivery
within timescale
To meet this standard the following actions are being put in place
Implement redesigned medical rotas – pilot on 7 day a week consultant
cover commencing in November
Bed Management review ensuring defined roles and responsibilities that
support and focus on flow from ED to Assessment and then with focus
on the delivery of bed availability from the inpatient areas to deliver
seamless use of the bed capacity to meet demand and ensure timely
patient flow.
Ward reviews to commence
7 day working across the Trust including support services
Reducing Length of Stay by working with partner organisations and
families to reduce length of stay
Improved communication with partner organisation to expedite
discharges and forward planning to meet demand

12 AA - Quality Improvement Strategy approved by Trust Board Jan-13 On track to deliver
13 AA - March 2012 CQC compliance actions addressed Dec-12 On track to deliver
Trust wide areas agreed in July 12. Each of the 11 Directorates to come
up with up to 3 Directorate Quality indicators to be reported regularly in
their performance meetings alongside progress with the Trust wide
areas. These will be confirmed and discussed when each Directorate
presents plans to the Quality and Safety Committee (sub committee of
the Board chaired by Non‐ execs).
the stratgic actions have now been incorporporated as business as usual.
Mock CQC inspections are being undertaken ahead of the CQC
inspections.
14 AA - 12/13 monthly CIP plan re-profiled Sep-12 On track to deliver completed in August 2012
15 AA - Plan to deliver £23m Recurrent CIP by Mar 13 agreed by Trust
Board
Oct-12
High risk to delivery
within timescale
full year effects of current plan £17.7M
16
AA - Plan to deliver additional in year non recurrent CIP to deliver 12/13
control total agreed by Trust Board
Oct-12
High risk to delivery
within timescale
Plans in place for 17m , to go to Joint Transformation board in October
and board in November
17 AA - 2012/13 £23.2m CIP target delivered Oct-12
18 AA - 2012/13 Plan deficit no greater than £39.2m Apr-13
High risk to delivery
within timescale
High risk to delivery
within timescale
Current forecast to deliver £17.7M CIPs. In additon to this the detail is
included in the Trust FIMS return
as of month 6 FOT is £46.8M
19 AA - 5 year Trust productivity programme developed Sep-12 On track to deliver
baseline LTFM with 5 yr productivity programme complete with report to
Trust Board
20
AA - LTFM base case assumptions and options to bridge gap agreed by
commissioners
Oct-12
On track to deliver
baseline LTFM complete and activity assumptions agreed with
commissioners
21
AA - SHA review 5 year Trust productivity programme and LTFM
baseline and options to bridge gap
Oct-12
On track to deliver
amendments being made to final report following trust board and on
track to deliver against timeframe
22 AA - Clinical & Financial Viability Plan approved by Trust Board Dec-12 On track to deliver baseline LTFM complete. Awaiting completion of out of hospital LTFM
23 AA - OBC (inc commissioner support) approved by Trust Board Date for OBC to be confirmed
24 AA - SHA approval of OBC at CIC Date for OBC to be confirmed
25 AA - FBC approved by Trust Board Date for FBC to be confirmed
26 AA - SHA approval of FBC Date for FBC to be confirmed
27 AA - BHR transition plan for closure KGH maternity (intrapartum care) Oct-12 On track to deliver approved at the October Trust Board MeetingMeeting
28 AA - BHR system readiness assurance gateway Dec-12 On track to deliver this is a commissioner led process on track to deliver
29 AA - BHR birth numbers < 8000 per annum (@660 pcm) Feb-13 On track to deliver
arrangements now agreed with commissioners on how birth numbers
will be reduced and escaltion policy in place for varriation in activity

30 AA - KGH maternity closed Mar-13 On track to deliver progress being monitored by Maternity Strategy Board
31
32

TFA Progress
BHR University Hospitals NHS Trust
Sep‐12
Select the Performance from the drop‐down list
TFA Milestone (All including those delivered)
Milestone
Date
Performance
Comments where milestones are not delivered or where a risk to
delivery has been identified
1
TFA - Agreement reached on BHRUT assuming reasonability for
integrated elderly pathway with transfer of staffing and assets during
2011/12 (RED)
Jun-11
Not fully achieved
No agreement reached with commissioners on the transfer of these
services. Out of Hospital review currently being undertaken and due to
report by December
2
TFA - BHRUT achieving 95th percentile standard for all A&E departmentsthen
sustained to year end. (RED)
Jun-11
Not fully achieved
A&E target not sustained
3
TFA - BHRUT achieving all Cancer targets- then sustained to year end
(GREEN)
Jun-11
Fully achieved in time
In 2011/12 this milestone was achieved although performance has
deteriorated in the first quarter of 2012/13
4
TFA - Agreement of volumes and value of transfer of elective work from
Whipps Cross and tertiary providers during 2011/12 and 2012/13 (RED)
Jun-11
Not fully achieved
No agreement on the transfer of these services has been agreed.
5
TFA - Financial return at month 2 on target against plan YTD and yearend
projection in control (RED)
Jun-11
Not fully achieved
Financial commitments in 2011/12 not achieved.
6 TFA - SHA financial challenges and productivity opportunities
assessment (RED)
Jun-11 Fully achieved in time complete
7 TFA - Q1 review of finance, CIPs and quality and performance (including
achievement and trajectory of CIPs)
Jun-11 Fully achieved in time complete
8
TFA - Board to Board (20 Sept) on financial challenge and productivity
opportunity
Sep-11 Fully achieved in time complete
9
TFA - Financial return at month 5 on target to meet £28.8m (including
IFRS) control total(RED)
Sep-11 Not fully achieved Financial commitments in 2011/12 not achieved
10 TFA - Board to Board 18 October 2011 Oct-11 Fully achieved in time complete

11 TFA - Q3 review of finance, quality and performance (including
achievement and trajectory of CIPs) (RED)
Oct-11
Not fully achieved
12
TFA - Financial return at month 7 on target to meet £35.6m (including
IFRS) control total(RED)
Oct-11 Not fully achieved Financial commitments in 2011/12 not achieved
13
TFA - Establishment of Clinical Productivity Programme - year 1 of full
delivery 2012/13
Nov-11
Fully achieved but late
Business Plans were constructed such that first draft plans were available
in January 2012.
14 TFA - Application to CQC for removal of conditions (RED) Nov-11 Fully achieved but late Final removal of conditions achieved in Q1 of 2012/13
15
TFA - Financial return at month 8 on target to meet £28.8m (including
IFRS) control total (RED)
Nov-11 Not fully achieved Financial commitments in 2011/12 not achieved.
16 TFA - Q3 review of finance, quality and performance (including
achievement and trajectory of CIPs) (RED)
Jan-12
Not fully achieved
17 TFA - £41.0m deficit control total for 2011/12 projected to be met (RED) Feb-12 Not fully achieved Financial commitments in 2011/12 not achieved.
18 TFA - No CQC conditions (RED) Mar-12 Fully achieved but late Final removal of conditions achieved in Q1 of 2012/13
19
TFA - Q4 review of finance, quality & performance (including
achievement and trajectory of CIPs) (RED)
Apr-12
Not fully achieved
20 TFA - Submit IBP & LTFM (RED) Jun-12 Not fully achieved
Baseline LTFM completed in June 2012 which is being updated using 4
options for clinical productivity and reconfiguration by October 2012
21 TFA - Q1 review of finance, CIPs and quality and performance (including
achievement and trajectory of CIPs)
Jul-12 Fully achieved in time complete
22 TFA - Undertake public consultation (RED) Jul-12 Not fully achieved Revised tracjectory to be agreed.
23 TFA - Safety & Quality Assurance Gateway Review Aug-12
Will not be delivered on
time
Revised trajectory to be agreed
24
TFA - Q2 review of finance. CIPs and Quality & performance (including
achievement and trajectory of CIPs)
Oct-12
On track to deliver

25 TFA - Final IBP /; LTFM Dec-12
High risk to delivery
within timescale
Revised trajectory for IBP to be agreed
26
TFA - Q3 review of finance, CIPs and Quality & Performance (including
achievement and trajectory of CIPs)
Jan-13
High risk to delivery
within timescale
27 TFA - Board to Board Meeting Jan-13
28 TFA - Trust Board formal approval of FT Application Feb-13
29 TFA - SHA Board Approval of FT Application Mar-13
30 TFA - Submission of FT Application to DH Apr-13
Will not be delivered on
time
Will not be delivered on
time
Will not be delivered on
time
Will not be delivered on
time
Revised trajectory to be agreed
Revised trajectory to be agreed
Revised trajectory to be agreed
31
32

NHS Trust Governance Declarations : 2012/13 In-Year Reporting
Name of Organisation: BHR University Hospitals NHS Trust Period: August 2012
Organisational risk rating
Each organisation is required to calculate their risk score and RAG rate their current performance, in addition to providing comment with regard to any contractual issues
and compliance with CQC essential standards:
Key Area for rating / comment by Provider
Governance Risk Rating (RAG as per SOM guidance)
Financial Risk Rating (Assign number as per SOM guidance)
Contractual Position (RAG as per SOM guidance)
Score / RAG rating*
R
R
g
* Please type in R, A or G
Governance Declarations
NHS Trusts must ensure that plans in place are sufficient to ensure compliance in relation to all national targets and including ongoing compliance with the Code of
Practice for the Prevention and Control of Healthcare Associated Infections, CQC Essential standards and declare any contractual issues.
Supporting detail is required where compliance cannot be confirmed.
Please complete sign one of the two declarations below. If you sign declaration 2, provide supporting detail using the form below. Signature may be either hand written
or electronic, you are required to print your name.
Governance declaration 1
The Board is satisfied that plans in place are sufficient to ensure continuing compliance with all existing targets (after the application of thresholds), and with all known
targets going forward. The board is satisfied that plans in place are sufficient to ensure ongoing compliance with the Code of Practice for the Prevention and Control of
Healthcare Associated Infections (including the Hygiene Code) and CQC Essential standards. The board also confirms that there are no material contractual disputes.
Signed by:
Print Name:
on behalf of the Trust Board
Acting in capacity as:
Signed by:
Print Name:
on behalf of the Trust Board
Acting in capacity as:
Governance declaration 2
For one or some of the following declarations Governance, Finance, Service Provision, Quality and Safety, CQC essential standards or the Code of Practice for the
Prevention and Control of Healthcare Associated Infections the Board cannot make Declaration 1 and has provided relevant details below.
The board is suggesting that at the current time there is insufficient assurance available to ensure continuing compliance with all existing targets (after the application
of thresholds) and/or that it may have material contractual disputes.
Signed by : Print Name :
Sir Peter Dixon
on behalf of the Trust Board
Acting in capacity as:
Chairman
Signed by : Print Name :
Averil Dongworth
on behalf of the Trust Board
Acting in capacity as:
Chief Executive
If Declaration 2 has been signed:
Please identify which targets have led to the Board being unable to sign declaration 1. For each area such as Governance, Finance, Contractual, CQC Essential
Standards, where the board is declaring insufficient assurance please state the reason for being unable to sign the declaration, and explain briefly what steps are being
taken to resolve the issue. Please provide an appropriate level of detail.
Target/Standard:
The Issue :
Goverance
A&E performance, MRSA & Cdiff performance, CQC warning notices non compliance
MRSA & Cdiff:
New Director of Infection Prevention and Control is now in post. There is a change of focus to Infection prevention
and the current action plan is being reviewed to identify the high impact actions, one of which is ANTT. ANTT has
been introduced across the Trust and to date 60% of Matrons and 72% of senior sisters have achieved Train the
Trainer competencies. These staff will now roll out the training across the wards. New hand washing campaigns and
training programmes have been introduced. Training for doctors has commenced for FY1/2s Consultants and is
being planned for staff grades.
Action :
CQC:
Trust-wide action plan in place that captures all outstanding CQC requirements that has been comprehensively
shared with the SHA and local Commissioners, is being implemented with Trust Board and is subjected to external
monitoring.
A&E target
Implement redesigned medical rotas – pilot on 7 day a week consultant cover commencing in November
Bed Management review ensuring defined roles and responsibilities that support and focus on flow from ED to
Assessment and then with focus on the delivery of bed availability from the inpatient areas to deliver seamless use of th
Ward reviews to commence
7 day working across the Trust including support services
Reducing Length of Stay by working with partner organisations and families to reduce length of stay
Improved communication with partner organisation to expedite discharges and forward planning to meet demand
Target/Standard:
The Issue :
Action :
Finance
Financial risk rating of 1
In-year savings programme developed with support from external consultancy. Programme Management Office established
to support delivery of cost improvement plans. Long term financial model developed along with 5 year productivity and
efficiency programme for review at October 2012 Trust Board

Effectiveness
GOVERNANCE RISK RATINGS
BHR University Hospitals NHS
Trust
See 'Notes' for further detail of each of the below indicators
Area Ref Indicator Sub Sections
Threshold
Referral to treatment information 50%
1a
Data completeness: Community services
comprising:
Referral information 50%
Treatment activity information 50%
Weighting
Historic Data
Qtr to Dec- Qtr to
11 Mar-12
1.0 N/a
Insert YES (target met in month), NO (not met in month) or N/A (as
appropriate)
See separate rule for A&E
Qtr to
Jun-12
N/a N/a N/a
Current Data
Jul 12 Aug-12 Sep-12
Patient identifier information 50% N/a N/a N/a N/a N/a N/a Yes
Data completeness, community services:
1b
(may be introduced later)
Patients dying at home / care
50% N/a N/a N/a N/a N/a N/a Yes
home
1c Data completeness: identifiers MHMDS 97% 0.5 N/a N/a N/a N/a N/a N/a Yes
N/a
N/a
Qtr to
Sep-12
Yes
Comments where target
not achieved
1c
2a
Data completeness: outcomes for patients
on CPA
From point of referral to treatment in
aggregate (RTT) – admitted
50% 0.5 N/a N/a N/a N/a N/a N/a Yes
Maximum time of 18 weeks 90% 1.0 N/a N/a Yes Yes Yes yes Yes
Patient Experience
2b
2c
2d
3a
From point of referral to treatment in
aggregate (RTT) – non-admitted
From point of referral to treatment in
aggregate (RTT) – patients on an
incomplete pathway
Certification against compliance with
requirements regarding access to
healthcare for people with a learning
disability
All cancers: 31-day wait for second or
subsequent treatment, comprising :
Maximum time of 18 weeks 95% 1.0 Yes Yes Yes Yes yes yes Yes
Maximum time of 18 weeks 92% 1.0 Yes Yes Yes Yes yes yes Yes
Surgery 94%
Anti cancer drug treatments 98%
Radiotherapy 94%
From urgent GP referral for
suspected cancer
85%
3b All cancers: 62-day wait for first treatment: 1.0 yes
From NHS Cancer Screening
90%
Service referral
N/A 0.5 no no no no no no No
1.0 yes
yes yes yes yes yes
yes
no
Yes
No yes yes No
the Trust is meeting meeting 5 of the 6
requirements . The area not yet fully
compliant 'audit of practice' against policy.
Business Units will review casenote for
patients with LD treated in the service during
October to meet this requirement
This measure was not met in July. The
underachievement was due to complex
pathways, endoscopy capacity and lack of
escalation across the pathways. The annual
trajectory was approved by the Trust
Executive Committee (TEC) with action plans
being provided by each specialty. In addition
the NHS Intensive Support Team provided
the Service with advice. Weekly specialtylevel
patient target list (PTL) meetings with
each Service Manager have been
introduced; a more robust escalation process
for delays in radiological and pathology
reporting has been implemented together
with a review of endoscopy capacity. The
Service is also recruiting additional MDT coordinators
a senior MDT coordinator and a
float MDT coordinator to provide cover for
leave. The target has been achieved since
August 2012.

3c
3d
All Cancers: 31-day wait from diagnosis to
first treatment
Cancer: 2 week wait from referral to date
first seen, comprising:
all urgent referrals 93%
for symptomatic breast patients
(cancer not initially suspected)
93%
96% 0.5 yes yes yes yes yes yes Yes
0.5 yes yes yes yes yes yes Yes
Quality
3e
3f
3g
3h
A&E: From arrival to
admission/transfer/discharge
Care Programme Approach (CPA) patients,
comprising:
Minimising mental health delayed transfers
of care
Admissions to inpatients services had
access to Crisis Resolution/Home
Treatment teams
Maximum waiting time of four
hours
Receiving follow-up contact within
7 days of discharge
Having formal review
within 12 months
95% 1.0 No No No No no no No
95%
1.0 N/a N/a N/a N/a n/a n/a Yes
95%
≤7.5% 1.0 yes yes Yes Yes yes yes Yes
95% 1.0 N/a N/a N/a n/a n/a n/a Yes
Implement redesigned medical rotas – pilot
on 7 day a week consultant cover
commencing in November
Bed Management review ensuring defined
roles and responsibilities that support and
focus on flow from ED to Assessment and
then with focus on the delivery of bed
availability from the inpatient areas to deliver
seamless use of the bed capacity to meet
demand and ensure timely patient flow.
Ward reviews to commence
7 day working across the Trust including
support services
Reducing Length of Stay by working with
partner organisations and families to reduce
length of stay
Improved communication with partner
organisation to expedite discharges and
forward planning to meet demand
3i
Meeting commitment to serve new
psychosis cases by early intervention
teams
95% 0.5 N/a N/a N/a N/a n/a n/a Yes
3j
Category A call – emergency response
within 8 minutes
75% 1.0 N/a N/a N/a N/a n/a n/a Yes
3k
Category A call – ambulance vehicle
arrives within 19 minutes
95% 1.0 N/a N/a N/a N/a n/a n/a Yes
There were 7 cases of infection reported
during September, none of the patients
acquiring the infection was as the result of
cross contamination.
4a
Clostridium Difficile
Enter
Are you below the ceiling for your
contractual
monthly trajectory
ceiling
1.0 yes yes no no no no No
Exception reporting occurred in all 7 cases
against the standardised 17 criteria. 6 wards
scored 100%, one ward (heather) scored
less than 100% and has been required to
produce an action plan to address the issues
highlighted by the infection control exception
report. No primary cause was identified for
this case. The issues identified were practice
related. The Infection Control Committee
monitors the wards progress against their
action plans

Safety
4b
MRSA
Enter
Are you below the ceiling for your
contractual
monthly trajectory
ceiling
1.0 yes yes no no No No No
2 cases Q1 , 2 cases in September. 6 YTD
against ceiling 7 per year New Director of
Infection Prevention and Control is now in
post.There is a change of focus to Infection
prevention and the current action plan is
being reviewed to identify the high impact
actions, one of which is ANTT. ANTT has
been introduced across the Trust and to date
60% of Matrons and 72% of senior sisters
have achieved Train the Trainer
competencies. These staff will now roll out
the training across the wards. New hand
washing campaigns and training
programmes introduced. Training for doctors
has commenced for FY1/2s Consultants and
is being planned for staff grades.
A
CQC Registration
Non-Compliance with CQC Essential
Standards resulting in a Major Impact on
Patients
0 2.0 yes yes Yes No No No No
B
Non-Compliance with CQC Essential
Standards resulting in Enforcement Action
0 4.0 yes yes Yes Yes Yes Yes
Trust-wide action plan in place that captures
all outstanding CQC requirements that has
been comprehensively shared with the SHA
and local Commissioners, is being
implemented with Trust Board and is
subjected to external monitoring.
C
NHS Litigation Authority – Failure to
maintain, or certify a minimum published
CNST level of 1.0 or have in place
appropriate alternative arrangements
0 2.0 no no No No No No No
RAG RATING :
GREEN = Score of 1 or under
TOTAL 5.5 5.5 8.5 8.5 7.5 3.5 8.5
AMBER/GREEN = Score between 1 and 1.9
AMBER / RED = Score between 2 and 3.9
RED = Score of 4 or above
Overriding Rules - Nature and Duration of Override at SHA's Discretion
Greater than six cases in the year to date, and either:
i) Meeting the MRSA Objective
Breaches the cumulative year-to-date trajectory for three
successive quarters
no no no No No no No
Breaches its full year objective
Greater than 12 cases in the year to date, and either:
Breaches the cumulative year-to-date trajectory for three
ii) Meeting the C-Diff Objective
successive quarters
Breaches its full year objective
no no no no No No No
Reports important or signficant outbreaks of C.difficile, as
defined by the Health Protection Agency.
Breaches:
The admitted patients 18 weeks waiting time measure for a
third successive quarter

iii) RTT Waiting Times The non-admitted patients 18 weeks waiting time measure
for a third successive quarter
The incomplete pathway 18 weeks waiting time measure for
a third successive quarter
no
no
no no No
No
No
Fails to meet the A&E target twice in any two quarters over
iv) A&E Clinical Quality Indicator a 12-month period and fails the indicator in a quarter during yes yes yes yes Yes Yes Yes
the subsequent nine-month period or the full year.
v) Cancer Wait Times
Breaches either:
the 31-day cancer waiting time target for a third successive
quarter
the 62-day cancer waiting time target for a third successive
quarter
no no no no No
No
No
vi)
Ambulance Response Times
Breaches either:
the category A 8-minute response time target for a third
successive quarter
the category A 19-minute response time target for a third
successive quarter
N/a
n/a n/a n/a N/a N/a
Yes
vii)
Community Services data completeness
Fails to maintain the threshold for data completeness for:
referral to treatment information for a third successive
quarter;
service referral information for a third successive quarter,
or;
treatment activity information for a third successive quarter
n/a
n/a
n/a n/a N/a
N/a
Yes
viii) Any Indicator weighted 1.0 Breaches the indicator for three successive quarters.
yes yes yes yes Yes
Number of Overrides Triggered 2.0 2.0 2.0 2.0 1.0 1.0 4.0
A&E target

FINANCIAL RISK RATING
BHR University Hospitals NHS Trust
Insert the Score (1-5) Achieved for each
Criteria Per Month
Risk Ratings
Reported
Position
Normalised
Position*
Criteria Indicator Weight 5 4 3 2 1
Year to
Date
Forecast
Outturn
Year to
Date
Forecast
Outturn
Underlying
performance
EBITDA margin % 25% 11 9 5 1

FINANCIAL RISK TRIGGERS
BHR University Hospitals NHS Trust
Insert "Yes" / "No" Assessment for the Month
Historic Data
Current Data
Criteria
Qtr to
Dec-11
Qtr to
Mar-12
Qtr to
Jun-12
Jul 12 Aug-12 Sep-12
Qtr to
Sep-12
Comments where risks are triggered
1
Unplanned decrease in EBITDA margin in two
consecutive quarters
yes yes yes no No Yes Yes
11/12 figures influenced by position against Plan where
agreed Control total with SHA adjusted £10m. Ytd at Sep
2012/13 EBITDA -2.2% against plan of -1.6%
2
Quarterly self-certification by trust that the financial risk
rating (FRR) may be less than 3 in the next 12 months
yes yes yes yes Yes Yes Yes
Driven by deficit position both planned and actual
3
Working capital facility (WCF) agreement includes default
clause
4
Debtors > 90 days past due account for more than 5% of
total debtor balances
yes yes yes yes Yes Yes Yes
Taken from AR ledger, after application of bad debt provision.
Debtors > 90 days account for 9% of total debt. Overseas
patients forms a particular risk. Some debt written off in
September
5
Creditors > 90 days past due account for more than 5% of
total creditor balances
yes yes yes yes Yes Yes Yes
Taken from AP ledger, creditors over 90 days form 14% of
total creditors. Heavily influenced by cash-flow consequences
of running a deficit, plus planning for October's PFI payment.
6
7
8
Two or more changes in Finance Director in a twelve
month period
Interim Finance Director in place over more than one
quarter end
Quarter end cash balance

CONTRACTUAL DATA
BHR University Hospitals NHS Trust
Insert "Yes" / "No" Assessment for the Month
Historic Data
Current Data
Criteria #REF! #REF! #REF! #REF! #REF! #REF! #REF! Comments where reds are triggered
Are the prior year contracts* closed? yes yes yes yes yes yes Yes
Are all current year contracts* agreed and
signed?
Are both the NHS Trust and commissioner
fulfilling the terms of the contract?
yes yes yes yes yes yes Yes
yes yes no no no no No
CDIFF Targets, A&E admissions, Activity
reductions and Readmissions reinvestment
are currently all under review
on a weekly basis to ensure acheivement
by the end of the Financial year.
Are there any disputes over the terms of the
contract?
Might the dispute require SHA intervention or
arbitration?
no no no no no no No
no no no no No no No
no
Are the parties already in arbitration? no no no no no no No
no
Have any performance notices been issued? yes yes no no no no No
Sexual health notice was issued in 2011/12
and has now been resolved and removed.
Have any penalties been applied? no no no no no no No

QUALITY
#REF!
Insert Performance in Month
Criteria
Unit Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12
Septemb
er 12
Comments on Performance in Month
1 SHMI - latest data Ratio 95.6
2
Venous Thromboembolism (VTE)
Screening
% 92 92 90 90 91 91 94 94 93 94 94 95
To improve performance to ensure delivery of this
standard the following actions have been taken
A review of the pathway for patients who go straight to a
procedure without attending a pre‐admission clinic to
ensure that these patients are swabbed prior to admission.
This pathway will be implemented from October
3a Elective MRSA Screening % no data 71 61 67 81 78 78 78 74 78 79 84
A review of data capture to ensure that all swabs are
matched correctly to admissions – this will be completed in
September
Training of Admissions Team Leader on data accuracy,
which will improve data quality when patients are added to
waiting list and thereby improve coverage of data for MRSA
elective screening; this will be completed in September
To improve performance to ensure delivery of this
standard the following actions have been taken
3b Non Elective MRSA Screening % no data 76 72 71 70 69 69 74 83 77 75 79
• A change of process in emergency day unit (EMDU) to
screen patients who currently do not qualify for screening
has been implemented in September
• Using the ward board rounds to check if patents have
been screened. The Ward Sponsors will work with the
wards to ensure that screening takes place.
• Staff to be reminded to write legibly on test requests to
ensure that the Lab is able to identify which patient the
swabs have come from. This error will be addressed by the
roll out of order communications for Pathology in
December 2012,
• Review of the data to ensure patients who do not require
screening are excluded from the data this will be
completed in September

4
Single Sex Accommodation
Breaches
Number 39 34 14 17 21 30 30 21 10 12 19 13
These occurred within the High Dependency Unit (9),
Intensive Therapy Unit (3), and Coronary Care Unit (1) at
Queen’s Hospital. All of the breaches occurred due to
delays in the transfer out of patients who had been
‘stepped down’ to general care. This was due to constraints
on the availability of suitable beds for ‘step down’ due to
patient flow delays across the organisation. A root cause
analysis on all patients who breach will commence on the
1st October 2012.The Deputy Director of Nursing during
September randomly spoke to a number of patients who
breached during September and they confirmed that the
reason for the breach was explained to them and that their
privacy and dignity was maintained during this period of
their care.
5
Open Serious Incidents Requiring
Investigation (SIRI)
Number 320 318 274 274 274 270 216 105 91 68 46 35
6 "Never Events" in month Number 0 1 0 0 0 0 0 0 0 0 0 0
7 CQC Conditions or Warning Notices Number 3 3 3 3 2 2 2 2 2 2 2 2
8
Open Central Alert System (CAS)
Alerts
Number 0 0 0 0 0 0 0 0 0 0 0 0
Trust‐wide action plan in place that captures all
outstanding CQC requirements that has been
comprehensively shared with the SHA and local
Commissioners, is being implemented with Trust Board and
is subjected to external monitoring.
9
10
RED rated areas on your maternity
dashboard?
Falls resulting in severe injury or
death
Number 16 13 10 6 7 5 8 10 9 7 5
Number 4 1 1 1 3 3 3 2 8 2 3 0
11 Grade 3 or 4 pressure ulcers Number 12 5 8 11 6 5 5 4 6 5 2 1
one grade 3 pressure ulcer occurred in Sept 12. The trust is
now focussing on reducing the number of grade 2 PU by
50%
12
100% compliance with WHO
surgical checklist
Y/N n y y n y y
13 Formal complaints received Number 85 111 78 121 120 128 101 98 85 100 85 67
14
Agency as a % of Employee Benefit
Expenditure
% 5.3 6.5 4.7 5.3 4.8 4.65
15 Sickness absence rate % 5.46 5.13 6 5.15 5.81 4.41 4.29 4.51 4 4.59 4.68 4.88
16
Consultants which, at their last
appraisal, had fully completed their
previous years PDP
% this data is not collected

Board Statements
BHR University Hospitals NHS Trust
September 12
For each statement, the Board is asked to confirm the following:
For CLINICAL QUALITY, that: Response Comments
The Board is satisfied that, to the best of its knowledge and using its own processes and having had regard to the
SHA's Provider Management Regime (supported by Care Quality Commission information, its own information on
1 serious incidents, patterns of complaints, and including any further metrics it chooses to adopt), the trust has, and will Yes
keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare
provided to its patients.
2
The board is satisfied that plans in place are sufficient to ensure ongoing compliance with the Care Quality
Commission’s registration requirements.
Yes
3
The board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care on
behalf of the trust have met the relevant registration and revalidation requirements.
Yes
For FINANCE, that: Response Comments
4 The board anticipates that the trust will continue to maintain a financial risk rating of at least 3 over the next 12 months. No
The board is satisfied that the trust shall at all times remain a going concern, as defined by relevant accounting
5 Yes
standards in force from time to time.
For GOVERNANCE, that: Response Comments
6 The board will ensure that the trust remains at all times compliant with has regard to the NHS Constitution.
Yes
All current key risks have been identified (raised either internally or by external audit and assessment bodies) and
7 Yes
addressed – or there are appropriate action plans in place to address the issues – in a timely manner.
8
The board has considered all likely future risks and has reviewed appropriate evidence regarding the level of severity,
likelihood of it occurring and the plans for mitigation of these risks.
Yes
The necessary planning, performance management and corporate and clinical risk management processes and
9 mitigation plans are in place to deliver the annual operating plan, including that all audit committee recommendations Yes
accepted by the board are implemented satisfactorily.
An Annual Governance Statement is in place, and the trust is compliant with the risk management and assurance
10 framework requirements that support the Statement pursuant to the most up to date guidance from HM Treasury
Yes
(www.hm-treasury.gov.uk).
The board is satisfied that plans in place are sufficient to ensure ongoing compliance with all existing targets (after the
11 application of thresholds) as set out in the relevant GRR; and a commitment to comply with all known targets going No
forwards.
12
The trust has achieved a minimum of Level 2 performance against the requirements of the Information Governance
Toolkit.
No
Details are included in previous on the GRR commentary
Last year 10/45 requirements at level 1
Action plans agreed to ensure level 2 reached for all
standards
Majority of actions will be complete by Dec 12 although
evidence will not be available for a small number until
Feb 13
The board will ensure that the trust will at all times operate effectively. This includes maintaining its register of interests,
13 ensuring that there are no material conflicts of interest in the board of directors; and that all board positions are filled, or Yes
plans are in place to fill any vacancies.
The board is satisfied that all executive and non-executive directors have the appropriate qualifications, experience and
14 skills to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks, Yes
and ensuring management capacity and capability.
15
The board is satisfied that: the management team has the capacity, capability and experience necessary to deliver the
annual operating plan; and the management structure in place is adequate to deliver the annual operating plan.
Yes
Signed on behalf of the Trust: Print name Date
CEO Averil Dongworth 18/09/2012
Chair Sir Peter Dixon 18/09/2012

TITLE:
EXECUTIVE SUMMARY
BOARD/GROUP/COMMITTEE:
Workforce Key Performance Indicators
Trust Board & TEC
1. KEY ISSUES: REVIEWED BY (BOARD/COMMITTEE) and DATE:
• For the month of September 2012 the overall
number of FTE's in post across the Trust
decreased by 2.52 FTE's on the August position
but has increased overall by 67.18 FTE's across
the 12 month period.
• The number of starters in month was 53.78
FTE's compared to 47.92 FTE's in the previous
month, September saw an increase in the
number of leavers with 71.42 fte leavers
compared to 57.75 fte's in August. Following a
period of focussed recruitment activity, a total of
582.93 FTE's have started in the Trust since
October 11 whilst 556.14 fte's have left.
• Starters & leavers data analysis over the same
period differs from the staff in post growth for the
same 3 reasons as in previous reports.
1. If new starters commence employment or leave
after the payroll cut off date (midmonth) they will not
be entered or removed onto/off ESR until month end
– therefore they will not appear on the staff in post
report generated from ESR until the following month.
2. Staff who increase or decrease their hours will
affect the reported FTE’s in post but not the starters
and leavers
3. Timliness of managers completing and submitting
the appropriate forms to HR - for entering onto ESR.
• Overall Trust Bank & Agency spend decreased
by £32,847 in month. The bank and agency
spend continues to account for 11.9% of the pay
bill despite a 2.68% decrease over the 12 month
period. Bank & Agency spend is provided by the
Finance department and relates to paid invoices
in month. The YTD figure reported on the
dashboard relates to the rolling 12 month period
spend ( Oct 11 to Sept 12) rather than the fiscal
year measurement which may be reported
elsewhere.
• Overall Trust bookings of Bank & Agency
decreased on the August position with a
reduction of 31.65 FTE. The number of agency
bookings decreased by 16.96 FTE's in month -
bank bookings decreased by 14.70 FTE's in the
same period.
1. Midwifery bank and agency FTE bookings
decreased in September by 0.14 FTE's on
the August position
2. Registered nursing temporary staff bookings
increased in September by 0.59 FTE's on
the August position.
• For the month of September, Trust annualised DATE:
√ TEC October
□ FINANCE ……………
□ EPB ………..…….
□ AUDIT ………..….
□ CLINICAL GOVERNANCE …………..…...……
□ CHARITABLE FUNDS ………………………...…
√ TRUST BOARD November 2012
□ REMUNERATION ………………………….…...
□ OTHER ………………………. (please specify)
CATEGORY:
□ NATIONAL TARGET
□ CNST
□ STANDARDS FOR BETTER HEALTH
□ HEALTH & SAFETY
□ ASSURANCE FRAMEWORK
□ TARGET FROM COMMISSIONERS
□ CORPORATE OBJECTIVE …………………..
……………………………………………………..
□ OTHER …………………….. (please specify)
AUTHOR/PRESENTER:
Author – Linda Baker – Head of workforce
Planning
Presenter – Dorothy Hosein – Director of
Transformation
1

turnover increased by 0.34% to 11.57% -
despite the increase this remains 0.43% below
the current average of other large Acute Trusts.
• The reported sickness absence rate for the
month of September has decreased slightly by
0.13% on the August position, reducing from
4.68% to 4.55% across the month. The sickness
absence rate has decreased by 0.25% when
compared to the same period last year.
• The pan London benchmarking exercise against
other acute Large London Trusts has been
repeated which shows that the combined
average sickness absence rate for this group is
3.59% - as such the graph has been revised to
reflect this. Based upon this revised information
BHRUT's benchmarked position shows us as
currently sitting 0.94% above the 3.59% average
of all other large acute London Trusts. The
Trust's target remains at 3.6%
• Part of the increase in reported sickness
absence rates is related to improve recording
through the roll out of electronic systems such as
e-rostering. This has minimised the effort in
recording and reporting of all types of staff
absence, including sickness through
managers/supervisors especially in the clinical
areas no longer having to complete and submit
weekly absence returns.
• It is acknowledged that key to achieving a
significant reduction in rates is: reviewing &
updating our existing sickness absence policy,
sickness absence management training and
working with proactively managers to understand
the support they require to manage sickness
absence.
• These actions have been initiated and additional
schemes such as staff MOT days continue in
order to encourage staff to proactively manage
their own health & wellbeing at work.
• Occupational Health have implemented monthly
case meetings with Directorates to discuss the
management and progress of individual cases
• The estimated costs associated with sickness
absence have increased this month. It is
estimated that the cost to the Trust for
September was £878,995. This figure has risen
by an estimated £259,997 on the same period
last year despite the sickness rate reducing by
0.25%. The rise in the estimated costs of
sickness absence is attributed to the banding
and roles of those staff taking sick absence
compared to the same period last year, the
higher the band or more senior the role the
higher the associated cost.
• When the number of FTE's lost due to sickness
absence is analysed by reason for absence, the
highest loss remains 'Unknown causes - not
specified' with 39.40 fte lost.
• To counteract this as previously presented to the
Trust Board, the Trust as part of their contract
review and renewal process with McKesson
have requested that this reason be removed
from the reporting options. Therefore 'unknown
2

causes/ Not specified' will be removed from the
option list from November providing greater
clarity on the reasons for absence allowing for a
review of potential proactive measures to be
taken in reducing sickness absence.
• Compliance to Statutory & Mandatory training
programmes has been included within the KPI
report for the first time. Currently this information
will continue to be reported to the Board on a
quarterly basis, however, a new system, WIRED
which has been successful within other NHS
Organisations for reporting mandatory training is
in the process of being commissioned to provide
clear, real time information in regards to
Statutory & Mandatory training.
2. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:
3. ALTERNATIVES CONSIDERED/REASONS FOR REJECTION:
N/A
4. DELIVERABLES:
Continuous measurement and monitoring of workforce performance against NHS and local agreed
targets
5. EVIDENCE :
ESR data
IView Data
NHSIE data
6. RECOMMENDATION/ACTION REQUIRED:
No action for information only
AGREED AT ______________________ MEETING
OR
REFERRED TO: __________________________
DATE: ____________________________
DATE: ____________________________
REVIEW DATE ___________________________
(if applicable)
3

TRUST - WORKFORCE KEY PERFORMANCE INDICATORS - SEPTEMBER 2012
Indicator Target Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 YTD
Staff In Post 5263.48 5313.23 5363.19 5353.99 5355.45 5350.71 5366.64 5366.82 5397.95 5397.08 5392.02 5382.93 5380.41 5368.37
Starters *¹ 70.57 78.23 55.37 31.24 44.46 38.74 58.25 50.44 50.53 29.00 44.97 47.92 53.78 582.93
Leavers *¹ 49.75 38.32 40.87 42.38 39.15 41.19 52.31 46.83 32.93 34.59 58.39 57.75 71.42 556.14
Turnover (Annualised)
*¹
12.0% 10.69% 10.60% 10.70% 10.78% 10.82% 11.0% 10.9% 10.9% 10.9% 10.8% 10.9% 11.2% 11.57%
Trust Sickness
Absence % for month
4.5% 4.80 5.46 5.13 6.00 5.15 5.81 4.41 4.29 4.51 4.00 4.59 4.68 4.55
Trust Sickness
Absence Rolling 12
Month Period
Trust Estimated Cost
of Sickness Absence
(Month)
3.6% 4.49 4.63 4.31 4.77 4.76 4.87 4.92 4.99 5.09 5.00 4.96 4.90 4.88
£618,998 £760,710 £707,395 £903,771 £756,866 £764,730 £594,960 £582,757 £645,566 £511,345 £750,024 £824,139 £878,995 £8,681,258
Appraisals 80.0% 76.03% 76.42% 72.25% 73.74% 77.80% 79.3% 74.3% 77.9% 78.49% 76.40% 72.69% 68.49% 67.96%
Resus 80.0% 69.04% 68.22% 68.26% 72.15% 75.69% 77.8% 78.6% 76.3% 77.86% 77.89% 77.50% 75.09% 75.09%
Paybill Budget £21,393,649 £21,806,873 £22,000,988 £21,907,263 £22,422,582 £22,276,976 £25,028,069 £23,895,905 £23,701,154 £23,492,904 £23,179,203 £25,711,256 £24,350,165 £279,773,338
Paybill £24,012,335 £24,085,519 £24,357,038 £24,267,150 £24,857,841 £24,430,745 £24,518,224 £24,282,126 £24,950,935 £24,441,456 £24,764,208 £24,607,757 £24,508,722 £294,071,722
Bank/Agency Spend £3,259,189 £3,179,473 £3,176,222 £3,079,296 £3,527,427 £3,053,265 £3,584,109 £3,155,363 £3,326,525 £2,988,710 £3,011,923 £2,929,439 £2,896,592 £37,908,344
% Paybill Budget spent
on bank & Agency staff
15.23% 14.58% 14.44% 14.06% 15.73% 13.71% 14.32% 13.20% 14.04% 12.72% 12.99% 11.39% 11.90% 13.55%
Overtime Spend (£) £116,637 £67,772 £65,940 £58,911 £69,768 £70,658 £62,666 £53,941 £61,881 £57,877 £54,076 £56,638 £49,581 £729,709
IHB FTE Bookings 646.05 663.25 661.31 600.15 667.76 672.17 714.77 587.37 586.98 592.32 578.73 565.82 534.17 7424.80
IHB FTE Booked as a
% of Substantive SIP
12.27% 12.48% 12.33% 11.21% 12.47% 12.56% 13.32% 10.94% 10.87% 10.97% 10.73% 10.51% 9.93% 11.53%
*¹ Starters, Leavers & Turnover figures excludes junior doctors on rotation
Financial value in month of February 2012 for Bank/Agency spend has been adjusted by a £353,356 reduction relating to prior period accruals. This has come about from: an improved system between IHB and Finance creating a more accurate base
resulting in an downward adjustment of £182,354 for agency; a further reduction to the agency accrual due to writing off of old year agency accruals from the system of £51,186 as part of an aged analysis; and as a reduction for ageing to the Bank
Accrual of £119,816.
1

Staff In Post
Starters & Leavers
FTE's
5500.00
5400.00
5300.00
5200.00
5100.00
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
Month
May-12
Jun-12
Jul-12
Aug-12
Sep-12
FTE's
90.00
80.00
70.00
60.00
50.00
40.00
30.00
20.00
10.00
0.00
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Month
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Staff In Post
Starters *¹ Leavers *¹
Staff in Post ( SIP )
For the month of September 2012 the overall number of FTE's in post across the Trust decreased by 2.52 FTE's on the August position but has increased overall by 67.18 FTE's
across the 12 month period.
Starters & leavers
The number of starters in month was 53.78 FTE's compared to 47.92 FTE's in the previous month, September saw an increase in the number of leavers with 71.42 fte leavers
compared to 57.75 fte's in August. Following a period of focussed recruitment activity , a total of 582.93 FTE's have started in the Trust since October 11 whilst 556.14 fte's have left
Supported by the HR Advisors, Divisions have been tasked to actively promote Exit interviews so that 'reasons for leaving' can be truly understood.
Starters & leavers data analysis over the same period differs from the staff in post growth for the same 3 reasons as in previous reports.
1. If new starters commence employment or leave after the payroll cut off date (mid month) they will not be entered or removed onto/off ESR until month end – therefore they will not
appear on the staff in post report generated from ESR until the following month. Starters and leavers numbers are refreshed each month to capture any late input to ESR.
2. Staff who increase or decrease their hours will affect the reported FTE’s in post but not the starters and leavers
3.Timliness of managers completing and submitting the appropriate forms to HR - for entering onto ESR.
Trust Overall Scorecard - September 2012 - Workforce Information Department

Temporary staff Use and Spend
4500000
Bank/Agency Spend ( Provided by Finance)
800
IHB Bookings - FTE
3750000
700
Spend (£'s)
3000000
2250000
1500000
750000
FTE
600
500
400
300
200
100
Agency
Bank
0
Sep-11
Oct-11
Nov-11
Bank/Agency Spend
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
Month
May-12
Jun-12
Jul-12
Aug-12
Sep-12
0
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Date
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Bank & Agency Spend
Overall Trust Bank & Agency spend decreased by £32,847 in month. The bank and agency spend continues to account for 11.9% of the pay bill despite a 2.68% decrease over the 12
month period. Data relating to Bank & Agency spend is provided by the Finance department and relates to paid invoices in month. The YTD figure reported on the dashboard relates to
the rolling 12 month period spend ( Oct 11 to Sept 12) rather than the fiscal year measurement which may be reported elsewhere.
Bank & Agency Usage
Overall Trust bookings of Bank & Agency decreased on the August position with a reduction of 31.65 FTE. The number of agency bookings decreased by 16.96 FTE's in month - bank
bookings decreased by 14.70 FTE's in the same period.
Midwifery bank and agency FTE bookings decreased in September by 0.14 FTE's on the August position.
Registered Nursing temporary staff bookings increased in September by 0.59 FTE's on the August position.
Trust Overall Scorecard - September 2012 - Workforce Information Department

TURNOVER
Actual Versus Target Annualised Turnover
14.0
Turnover %
12.0
10.0
Turnover
For the month of September, Trust annualised turnover increased by 0.34% to
11.57% - despite the increase this remains 0.43% below the current average of
other large Acute Trusts.
8.0
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Actual Turnover
SICKNESS ABSENCE
Percentage (%)
6.50
6.00
5.50
5.00
4.50
4.00
3.50
3.00
2.50
2.00
1.50
1.00
0.50
0.00
Sep-11
Oct-11
Nov-11
Month
Target Turnover
Real - Time Sickness Absence
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
Month
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Sickness Absence
Reported sickness absence rates for the month of September has decreased
slightly by 0.13% on the August position, reducing from 4.68% to 4.55% across
the month. The sickness absence rate has decreased by 0.25% when
compared to the same period last year. The pan London benchmarking
exercise against other acute Large London Trusts has been repeated which
shows that the combined average sickness absence rate for this group is
3.59% - as such the graph has been revised to reflect this. Based upon this
revised information BHRUT's benchmarked position shows us as currently
sitting 0.94% above the 3.59% average of all other large acute London Trusts.
The Trust's target remains at 3.6%
Driving down our sickness absence rates is a key focus for the trust for 12/13
Part of the increase in reported sickness absence rates is related to improve
recording through the introduction of electronic systems such as e-rostering.
This has minimised the effort in recording and reporting of all types of staff
absence, including sickness through managers/supervisors especially in the
clinical areas no longer having to complete and submit weekly absence returns.
It is acknowledged that key to achieving a significant reduction in rates is:
reviewing & updating our existing sickness absence policy, sickness absence
management training and working with proactively managers to understand the
support they require to manage sickness absence. These actions have been
initiated and additional schemes such as staff MOT days continue in order to
encourage staff to proactively manage their own health & wellbeing at work.
BHRUT Target Other Large Acute London
Occupational Health have implemented monthly case meetings with
Directorates to discuss the management and progress of individual cases
Trust Overall Scorecard - September 2012 - Workforce Information Department

Trust Estimated Cost of Sickness Absence (Month)
£1,000,000
Estimated Cost (£'s)
£900,000
£800,000
£700,000
£600,000
£500,000
£400,000
£300,000
£200,000
Estimated costs of sickness absence
The estimated costs associated with sickness absence has increased this
month. It is estimated that the cost to the Trust for September was £878,995.
This figure has risen by an estimated £259,997 on the same period last year
despite the sickness rate reducing by 0.25%. The rise in the estimated costs of
sickness absence is attributed to the banding and roles of those staff taking sick
absence compared to the same period last year, the higher the band or more
senior the role the higher the associated cost.
£100,000
£0
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Month
Trust Overall Scorecard - September 2012 - Workforce Information Department

FTE Lost due to Sickness Absence by Absence Reason
S10 Anxiety/stress/depression/other psychiatric illnesses
S11 Back Problems
Absence Reason
S12 Other musculoskeletal problems
S13 Cold, Cough, Flu - Influenza
S14 Asthma
S15 Chest & respiratory problems
S16 Headache / migraine
S17 Benign and malignant tumours, cancers
S19 Heart, cardiac & circulatory problems
S20 Burns, poisoning, frostbite, hypothermia
S21 Ear, nose, throat (ENT)
S22 Dental and oral problems
S23 Eye problems
S24 Endocrine / glandular problems
S25 Gastrointestinal problems
S26 Genitourinary & gynaecological disorders
S27 Infectious diseases
S28 Injury, fracture
S29 Nervous system disorders
S30 Pregnancy related disorders
S31 Skin disorders
S98 Other known causes - not elsewhere classified
S99 Unknown causes / Not specified
0 5 10 15 20 25 30 35 40 45
FTE Lost
Reasons for Sickness Absence v FTE's
lost
When the number of FTE's lost due to
sickness absence is analysed by reason for
absence, the highest loss remains 'Unknown
causes - not specified' with 39.40 fte lost. HR
acknowledge this creates concern as it
means that staff are not providing their
absence reason or it isn't being recorded by
their manager / supervisor. • To counteract
this as previously presented to the Trust
Board, the Trust as part of their contract
review and renewal process with McKesson
have requested that this reason be removed
from the reporting options. Therefore
'unknown •causes/ Not specified' will be
removed from the option list from November
providing greater clarity on the reasons for
absence allowing for a review of potential
proactive measures to be taken in reducing
sickness absence.
In order to further improve the accuracy of
sickness absence reporting and recording, HR
have incorporated 'effective recording
processes' in their ' Essential Skills for
Managers ' training programme. The effects
of this training on the actual reported data may
take time to show a demonstrable change.
Directorates must not only ensure that
managers record absence correctly within the
weekly absence returns but also that returns
are submitted in a timely way.
STATUTORY & MANDATORY TRAINING COMPLIANCE
Trust Overall Scorecard - September 2012 - Workforce Information Department

The table below provides a quarterly Trust-wide perspective of compliance to identified statutory & mandatory training programmes for monitoring purposes . This data is run and
analysed by the workforce information department on a quarterly basis via ESR for the Education Board, with the education department providing the commentary to the data (located
on the following page). At the current time due to the method of recording and inputting attendance to training data onto ESR analysis by the workforce information team takes 3 days
per course, as such this data can only be provided quarterly. However, a national solution called WIRED will revolutionise recording and reporting allowing the Trust to increase its
frequency and complexity of reporting in the medium term and participate in an employee 'passport' scheme where compliance to training requirements moves with the employee as
they change jobs . A Business case is currently being developed with funding identified, for presentation to TEC, in the meanwhile the workforce information and education departments
will continue to report to the Board quarterly.
Statutory and Mandatatory Training Monitoring as at 30th September 2012
Reporting Period - Compliance Rate
Course Name Frequency 31-Dec-10 28-Feb-11 30-Jun-11 30-Sep-11 31-Dec-11 31-Mar-12 30-Jun-12 30-Sep-12
Conflict Resolution 3 yearly 11.61%
Equality, Diversity & Human Rights 3 yearly 55.92%
Fire Training Annual 52.46% 39.49% 36.33% 28.63% 33.57% 21.63% 35.10% 45.46%
Health & Safety Annual 41.31%
Infection Control Annual 41.61%
Information Governance Annual 37.42% 36.22% 36.92% 37.98% 17.43% 21.45% 21.35% 28.23%
Manual Handling (Loads) 2 yearly 12.77% 18.76% 20.37% 22.77% 33.00% 39.54% 33.53% 38.28%
Manual Handling (People - Refresher) 2 yearly 55.97% 63.50% 68.83% 69.22% 85.12% 73.84% 76.19% 71.16%
Manual Handling (People + Loads) Once 14.23% 46.60% 41.62% 40.90% 40.55% 40.77% 65.95% 63.80%
Resuscitation Yearly 93.32% 89.72% 78.42% 69.04% 72.15% 78.61% 77.89% 75.09%
Safeguarding Adults 3 Yearly 65.84%
Safeguarding Children Level 1 3 yearly 67.86% 62.61% 70.50% 56.61% 67.79% 69.72% 71.15% 71.12%
Safeguarding Children Level 2 3 yearly 32.37% 26.87% 37.50% 10.76% 53.25% 58.29% 30.08% 42.93%
Safeguarding Children Level 3 3 Yearly 54.98% 54.49% 50.97% 34.78% 67.68% 80.82% 72.14% 71.29%
Trust Overall Scorecard - September 2012 - Workforce Information Department

The data on the previous page has been presented by training subject, to reflect the Skills for Health National Training Framework. This sets minimum training standards and
frequency and promotes consistency and avoids duplication between organisations. Therefore Conflict Resolution, Equality, Diversity and Human Rights are now included.
This format also reflects previous discussion and agreement to not report by programme but to report by subject.
Detailed reports for Resuscitation, RN, HCA and ODP Mandatory are still provided.
Subject Matter Experts (SME) are aware of their responsibilities to drive up compliance in their area, this is dependent on them being provided with robust data
Fire and Health and Safety have now been separated into specific Subject Matter to reflect the national requirements.
Infection Control figures now include the Risk Management Standard (RMS) requirements for Hand Hygiene training which is now included on Trust Induction and on
Mandatory programmes.
Conflict Resolution training has not been regarded as a mandatory priority. However in view of the CQC findings this will need to be mapped into the ongoing work on cultural
change which will improve compliance. to complete this successfully there will need to be a resource review.
Did Not Attend (DNA) data is shown on the next page to reflect requirements of internal audit, and this is followed up by the SME.
The data demonstrates that release and uptake remains the biggest challenge as the amount of places offered for most subjects exceeds the amount required. Low compliance
rates for Information Governance are reflective of the change of frequency from 3yearly to annual. Safeguarding children level 2 uptake saw a drop as nursing staff are now
required to do this and not level 1 as was previously the case.
In April 2012 the Trust launched new Mandatory programmes specifically designed to improve compliance for other clinical staff groups and for admin and clerical staff.
It is anticipated that should the Board endorse the proposal to implement the WIRED system, compliance will rise across subjects as data will be timely, transparent, accurate
and align to the Training Needs Analysis and available to all Managers.
CONFLICT RESOLUTION
HEALTH & SAFETY
2012 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2012 Q2 2012 Q3 2012 Q4
Number of Staff
Requiring Training 447 470 472
Number of Staff
Requiring Training 1408
Actual Number Trained 131 135 147 Actual Number Trained 915
Trust Overall Scorecard - September 2012 - Workforce Information Department

Places Offered 184 163 196 Places Offered 2051
DNAs 31 30 28 DNAs 173
EQUALITY, DIVERSITY & HUMAN RIGHTS
INFECTION CONTROL
2012 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2012 Q2 2012 Q3 2012 Q4
Number of Staff
Requiring Training 469
Number of Staff
Requiring Training 1408
Actual Number Trained 517 Actual Number Trained 908
Places Offered 1316 Places Offered 2051
DNAs 89 DNAs 173
FIRE
INFORMATION GOVERNANCE
2012 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2012 Q2 2012 Q3 2012 Q4
Number of Staff
Requiring Training 1408
Number of Staff
Requiring Training 1400 1408 1408
Actual Number Trained 728 Actual Number Trained 286 307 713
Places Offered 728 Places Offered 1550 1912 2012
DNAs 0 DNAs 25 53 52
MANUAL HANDLING - LOADS
MANUAL HANDLING - PEOPLE & LOADS 1 DAY
2012 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2012 Q2 2012 Q3 2012 Q4
Number of Staff
Requiring Training 200 293 317
Number of Staff
Requiring Training 163 92 83
Actual Number Trained 160 182 96 Actual Number Trained 49 67 52
Places Offered 664 852 647 Places Offered 127 185 156
DNAs 44 62 13 DNAs 6 1 6
MANUAL HANDLING - PEOPLE REFRESHER SAFEGUARDING LEVEL 1
2012 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2012 Q2 2012 Q3 2012 Q4
Number of Staff
Requiring Training 480 319 327
Number of Staff
Requiring Training 364 214 211
Actual Number Trained 216 381 355 Actual Number Trained 283 393 186
Places Offered 772 775 704 Places Offered 1059 815 950
DNAs 31 8 77 DNAs 38 26 34
RESUS SAFEGUARDING LEVEL 2
2012 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2012 Q2 2012 Q3 2012 Q4
Number of Staff
Requiring Training 996 1000 995
Number of Staff
Requiring Training 53 208 207
Actual Number Trained 613 574 895 Actual Number Trained 0 333 366
Places Offered 1661 1791 1711 Places Offered 240 318 923
DNAs 154 186 166 DNAs 11 38 156
SAFEGUARDING ADULTS SAFEGUARDING LEVEL 3
2012 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2012 Q2 2012 Q3 2012 Q4
Number of Staff
Number of Staff
Requiring Training 467 469 472
Requiring Training 51 52 51
Actual Number Trained 277 517 831 Actual Number Trained 26 20 19
Places Offered 956 1394 2031 Places Offered 189 318 328
DNAs 31 77 164 DNAs 27 15 28
DIRECTORATE WORKFORCE KPI REPORTS
DIAGNOSTICS & SPECIAL MEDICINE DIRECTORATE -
WORKFORCE KEY PERFORMANCE INDICATORS - SEPTEMBER 2012
Trust Overall Scorecard - September 2012 - Workforce Information Department

Indicator Target Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 YTD
Staff In Post 1094.28 1104.66 1104.97 1104.66 1101.17 1102.35 1102.02
Starters *¹ 9.43 12.66 6.00 10.91 8.43 11.15 58.58
Leavers *¹ 6.12 4.46 12.20 12.00 7.70 10.77 53.25
Turnover (Annualised) *¹ 12.0% 9.1% 8.6% 9.1% 9.1% 9.4% 9.6%
Trust Sickness Absence %
for month
3.6% 4.29% 4.51% 4.00% 4.59% 4.68% 4.55%
Directorate Sickness
Absence For Month
Directorate Sickness
Absence Rolling 12 Month
Period
Directorate Estimated Cost
of Sickness Absence
(Month) *²
3.6% 5.11% 5.03% 4.50% 5.36% 5.64% 5.43%
3.6% 5.11% 5.07% 4.88% 5.00% 5.13% 5.18%
£151,450 £162,189 £116,008 £151,225 £164,939 £194,557 £940,368
Appraisals Compliance 80.0% 71.95% 71.96% 69.55% 61.65% 57.28% 61.49%
Resus Compliance 80.0% 77.57% 77.13% 77.83% 78.15% 78.77% 75.09%
Paybill Budget
£4,719,045 £4,655,044 £4,745,751 £4,659,061 £4,669,833 £4,582,046 £28,030,779
Paybill £4,763,991 £4,859,576 £4,799,919 £4,957,346 £4,879,298 £4,778,114 £29,038,245
Bank/Agency Spend £496,296 £517,013 £461,899 £569,332 £562,077 £477,070 £3,083,687
% Paybill Budget spent on
bank & Agency staff
10.52% 11.11% 9.73% 12.22% 12.04% 10.41% 11.00%
Overtime Spend (£) £15,913 £22,366 £21,338 £29,976 £21,885 £16,800 £128,278
IHB FTE Bookings 77.34 75.64 73.15 85.37 83.02 72.12 466.64
IHB FTE Booked as a % of
Substantive SIP
7.07% 6.85% 6.62% 7.73% 7.54% 6.54% 7.06%
*¹ Starters, Leavers & Turnover figures excludes junior doctors on rotation
EMERGENCY, GEN. MEDICINE & NEUROSCIENCES DIRECTORATE -
WORKFORCE KEY PERFORMANCE INDICATORS - SEPTEMBER 2012
Indicator Target Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 YTD
Trust Overall Scorecard - September 2012 - Workforce Information Department

Staff In Post 1497.50 1488.89 1537.40 1532.03 1480.44 1481.43 1502.95
Starters *¹ 24.47 16.73 8.40 15.40 20.43 12.80 98.23
Leavers *¹ 17.71 5.00 10.99 19.20 23.27 20.97 97.14
Turnover (Annualised)
*¹
12.0% 12.3% 12.4% 12.6% 12.7% 13.6% 14.2%
Trust Sickness
Absence % for month
3.6% 4.29% 4.51% 4.00% 4.59% 4.68% 4.55%
Directorate Sickness
Absence For Month
3.6% 3.71% 3.88% 3.46% 3.58% 3.85% 3.75%
Directorate Sickness
Absence Rolling 12
Month Period
3.6% 3.71% 3.80% 3.68% 3.66% 3.70% 3.71%
Directorate Estimated
Cost of Sickness
Absence (Month) *²
Appraisals
Compliance
£128,632 £143,589 £119,511 £169,367 £202,747 £214,494 £978,340
80.0% 74.07% 75.21% 75.82% 73.91% 68.83% 66.33%
Resus Compliance 80.0% 76.26% 78.64% 79.23% 77.88% 72.52% 73.68%
Paybill Budget
£6,897,802 £6,887,836 £6,900,253 £6,626,925 £7,353,490 £6,655,213 £41,321,519
Paybill £6,945,598 £7,283,477 £7,305,661 £7,090,481 £6,856,072 £6,752,570 £42,233,860
Bank/Agency Spend £1,351,514 £1,514,580 £1,455,228 £1,412,147 £1,171,550 £1,063,376 £7,968,395
% Paybill Budget
spent on bank &
Agency staff
19.59% 21.99% 21.09% 21.31% 15.93% 15.98% 19.28%
Overtime Spend (£) £4,331 £6,229 £6,057 £3,546 £6,139 £5,823 £32,125
IHB FTE Bookings 247.95 261.02 256.04 247.01 224.43 210.39 1446.84
IHB FTE Booked as a
% of Substantive SIP
16.56% 17.53% 16.65% 16.12% 15.16% 14.20% 16.04%
SURGICAL DIRECTORATE - WORKFORCE KEY PERFORMANCE INDICATORS - SEPTEMBER 2012
Indicator Target Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 YTD
Staff In Post 1122.50 1151.10 1094.11 1094.93 1100.01 1099.09 1110.29
Trust Overall Scorecard - September 2012 - Workforce Information Department

Starters *¹ 7.00 3.60 5.00 7.43 6.21 7.00 36.24
Leavers *¹ 10.67 7.43 6.20 7.00 7.31 10.61 49.22
Turnover (Annualised)
*¹
12.0% 8.5% 8.9% 8.7% 8.9% 9.3% 10.0%
Trust Sickness
Absence % for month
3.6% 4.29% 4.51% 4.00% 4.59% 4.68% 4.55%
Directorate Sickness
Absence For Month
3.6% 3.44% 3.90% 3.65% 4.45% 3.58% 3.98%
Directorate Sickness
Absence Rolling 12
Month Period
3.6% 3.44% 3.67% 3.66% 3.86% 3.80% 3.83%
Directorate Estimated
Cost of Sickness
Absence (Month) *²
£99,908 £120,250 £109,709 £178,309 £151,067 £171,684 £830,927
Appraisals Compliance 80.0% 85.65% 86.14% 83.32% 82.55% 79.02% 77.86%
Resus Compliance 80.0% 76.42% 78.59% 78.65% 77.18% 74.18% 73.87%
Paybill Budget
£5,182,485 £5,288,767 £5,177,341 £5,149,402 £5,857,824 £5,332,322 £31,988,141
Paybill £5,501,762 £5,495,357 £5,380,580 £5,434,785 £5,471,086 £5,497,975 £32,781,545
Bank/Agency Spend £753,584 £655,882 £629,230 £647,069 £659,381 £711,319 £4,056,465
% Paybill Budget spent
on bank & Agency staff
14.54% 12.40% 12.15% 12.57% 11.26% 13.34% 12.68%
Overtime Spend (£) £25,315 £22,791 £20,505 £11,955 £19,845 £17,212 £117,623
IHB FTE Bookings 137.79 112.35 121.92 111.77 116.02 116.41 716.26
IHB FTE Booked as a %
of Substantive SIP
12.28% 9.76% 11.14% 10.21% 10.55% 10.59% 10.75%
*¹ Starters, Leavers & Turnover figures excludes junior doctors on rotation
WOMEN, CHILDREN & SUPPORT SERVICES DIRECTORATE -
WORKFORCE KEY PERFORMANCE INDICATORS - SEPTEMBER 2012
Indicator Target Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 YTD
Staff In Post 1181.94 1180.51 1181.31 1181.78 1171.20 1163.20 1176.66
Starters *¹ 3.40 10.80 7.60 5.01 7.00 6.83 40.64
Trust Overall Scorecard - September 2012 - Workforce Information Department

Leavers *¹ 13.33 12.60 5.20 12.59 16.87 12.54 73.13
Turnover (Annualised)
*¹
12.0% 11.4% 11.7% 11.4% 10.9% 11.7% 12.0%
Trust Sickness
Absence % for month
3.6% 4.29% 4.51% 4.00% 4.59% 4.68% 4.55%
Directorate Sickness
Absence For Month
3.6% 5.24% 5.57% 4.83% 5.04% 5.41% 5.02%
Directorate Sickness
Absence Rolling 12
Month Period
3.6% 5.24% 5.41% 5.21% 5.17% 5.22% 5.19%
Directorate Estimated
Cost of Sickness
Absence (Month) *²
£140,926 £149,545 £125,186 £183,603 £206,326 £193,995 £999,581
Appraisals Compliance 80.0% 85.03% 86.20% 82.43% 77.28% 75.18% 72.89%
Resus Compliance 80.0% 76.40% 77.79% 76.66% 78.35% 79.04% 78.43%
Paybill Budget
£4,559,907 £4,562,188 £4,567,601 £4,542,598 £4,537,970 £4,600,939 £27,371,203
Paybill £4,627,315 £4,640,770 £4,569,944 £4,597,102 £4,585,629 £4,576,345 £27,597,106
Bank/Agency Spend £444,148 £422,884 £420,487 £385,261 £401,752 £423,014 £2,497,546
% Paybill Budget spent
on bank & Agency staff
9.74% 9.27% 9.21% 8.48% 8.85% 9.19% 9.12%
Overtime Spend (£) £2,542 £3,422 £3,818 £2,275 £2,864 £2,266 £17,187
IHB FTE Bookings 103.68 108.89 110.33 98.74 101.42 100.52 623.58
IHB FTE Booked as a %
of Substantive SIP
8.77% 9.22% 9.34% 8.36% 8.66% 8.64% 8.83%
*¹ Starters, Leavers & Turnover figures excludes junior doctors on rotation
Trust Overall Scorecard - September 2012 - Workforce Information Department

EXECUTIVE SUMMARY
TITLE:
COST IMPROVEMENT UPDATE
BOARD/GROUP/COMMITTEE:
TRUST BOARD
1. PURPOSE: REVIEWED BY (BOARD/COMMITTEE) and DATE:
TO UPDATE THE TRUST BOARD ON PROGRESS AND
CURRENT STATUS OF THE COST IMPROVEMENT
PROGRAMME – MONTH 6 (SEPT 2012)
□ TEC ……………..….. □ STRATEGY……….….…….
□ FINANCE ……..……… □ AUDIT ………….……..….
□ QUALITY & SAFETY …………..………….....……
□ WORKFORCE
□ CHARITABLE FUNDS ………………………………...…
X TRUST BOARD ……………………………….………….
□ REMUNERATION ………………………………….…...
□ OTHER …………………………..……. (please specify)
2. DECISION REQUIRED: CATEGORY:
TO NOTE PROGRESS, RISKS AND MITIGATIONS
□ NATIONAL TARGET □ CNST
□ CQC REGISTRATION □ HEALTH & SAFETY
□ ASSURANCE FRAMEWORK
X CQUIN/TARGET FROM COMMISSIONERS
□ CORPORATE OBJECTIVE ……………………………....
□ OTHER …………………….. (please specify)
3. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:
AUTHOR/PRESENTER: Dorothy Hosein
DATE: 29/10/2012
The CIP position shows year to date delivery of £4.3m against a period target of £6.5m. This is a shortfall of £2.2m.
The forecast delivery is £17.7m of which £8.4m is considered to be at high risk, this is however and improvement on the
£6.2m of high risk schemes reported at Month 5 (August 2012)
4. DELIVERABLES
5. KEY PERFORMANCE INDICATORS
Cost Improvement Tracker
AGREED AT ______________________ MEETING
OR
REFERRED TO: __________________________
DATE: ____________________________
DATE: ____________________________
REVIEW DATE (if applicable) ___________________________

Cost Improvement Programme Update September 2012
Summary
The CIP position shows year to date delivery of £4.3m against a target for the period of
£6.5m, a shortfall of £2.2m. The forecast delivery is £17.7m of which £4.8m is
considered to be at high risk as compared to £6.2m of schemes identified in Month 6;
CIP mitigation plans to achieve the £17.7m forecast are now as follows:
Blue Green Amber Red Total
£000 £000 £000 £000 £000
Draft Forecast Outturn Workstream 7,090 2,270 2,190 2,998 14,548
Add/(Deduct):
Repatriation JAK 2 tests ‐ Path; Non recurrent Diagnostics 10 10
Further opportunities identified post ‐ M6 Diagnostics 66 66
Medicines Management ‐ various Medicines Management ‐121 182 166 227
Lucentis ‐ pass back 65% of income to commissioners Medicines Management ‐152 ‐152
VAT on Utilities ‐ b/f start by 1 month to December Estates 30 30
Rates assessment Estates 100 100
Emergency Care Non‐pay 24 100 124
Outpatients ‐ 140k deducted in Tracker; replaced by Outpatients 36 300 16 352
Outpatients ‐ FURTHER POSTS Outpatients 37 37
Theatres ‐ ITU skill mix Theatres 62 62
AHP's Workforce ‐ AHP ‐26 100 74
Neurosciences Workforce ‐ Medical 16 94 20 130
Nursing ‐ Bed & Site team Workforce ‐nursing 8 8
Annual Leave accrual Corporate 750 750
Medicines Management Medicines Management 400 400
Stroke Consultant release 5 PA's Workforce ‐ Medical 20 20
Medical locums ‐ VAT Corporate 600 600
Other ‐ Salary sacrifice (Car parking), Pharmacy VAT Corporate 66 ‐49 297 314
Final M6 Forecast Outturn 7,090 2,365 3,453 4,792 17,700
Key areas to focus to maximise run rate and in year delivery and turn red schemes
green:
• Continue to implement mechanisms for monitoring, and challenging budget
holders against agreed plans
• Provide strong project management and delivery support to Directorates and
Work streams
• Validate Bank and Agency reductions as real cost containment, supporting the
achievements of the control total
• Ensure rapid escalation of risks and issues relating to CIP delivery.
• Embed recently developed Executive SRO roles
1

Month 6 CIP Performance
Workstream progress
Admin& Clerical: Approximately 30% of the A&C workforce spend relates to bank and
agency. There has been an improvement of £
Medical Efficiency: The Job planning process has commenced with CDs arranging
formal meetings with Consultants and Managers. Completion of 1st level sign off
November 2012 with final JPA sign off December 2012. Directorates agreeing bank and
agency spend in line with budgets. Benchmarking with pan-London Bank rates being
undertaken.
Allied Health Professionals: There is a cost pressure of circa £300k relating to length
of Stay. On-call payment analysis is underway. Further investigation of opportunities for
CIPs in pharmacy production.
Workforce Reduction: In terms of established vacancies throughout the Trust, a
reduction of 30 vacancies has attracted savings. A further 14 vacancies identified and
associated savings are anticipated by December 2012. The Head of Workforce
Transformation has established a project plan for further potential vacancies where
savings are anticipated at the end of this financial year. Agreement was reached at the
Transformation Board to take forward a 3 year pay protection policy to the Joint Staff
Committee for ratification. PAUL
Beds & Length of Stay – Bed Reduction: A further saving of equivalent costs for 30
beds in year is required to achieve the CIP. Plans are currently being worked up with
options to provide ‘winter’ contingency beds.
2

Diagnostics – Introduction of ‘Hot’ Reporting of CT & MRI Scans: To support the
A&E four hour target and to ensure maximum efficient use of Trust ward beds ‘hot’
reporting on a five day week with a view to extend to seven day week has commenced.
Continued progress is being monitored. Additional schemes are under review.
Diagnostics - Interventional Radiology (non clinical): To date a review of current
activity is being undertaken by Radiology and will be completed in three main phases;
1. A review of recorded and reported activity with cross referencing to income,
audit data and PAS/RIS information
2. A cross referencing of this analysis with the current Contractual (Device)
exclusions
3. A cross referencing with Procurement colleagues to assess cost saving
opportunities.
This work is in progress. Data from the Trust Information department has now been
received and analysis has commenced.
Outpatients - Reduction in DNA and Cancellations: Key metrics have been
developed and are being monitored and action taken as required with the General
Managers. All specialties have developed action plans to reduce the need for additional
activity and capacity, and ensure that efficient use of resources is optimised.
Outpatients – e.Choose and Book and administration: Efficiency and Clinical
governance assurance has now been achieved with E Choose & Book now compliant
(71%). Turnaround times for referral validation have reduced further. The review of PAS
clinic letter volumes reducing from 7000 to 900.
Outpatients – Demand & Capacity: Action plan for the delivery of a reduction in New to
Follow Up attendances is now at the implementation stage. All specialities have
developed action plans to reduce the need for additional activity and capacity.
Outpatients – Printing & Postage Services (non-clinical): Work is about to
commence on the outsourcing of printing and postage services and resultant potential
savings. Implementation is likely to commence in Q4.
Theatres – Theatre Utilisation: Theatre utilisation has been reviewed to encompass
start times and rescheduling of theatre lists. Workstream programmes have been ratified.
Audits are underway which have and will inform the work programme for the next month.
Theatre – Consumables (non-clinical): Procurement analysis on key consumables
have been completed outcomes to be implemented.
Facilities & Estates: Work is on going to identify new opportunities.
Medicine Management – Drugs: Full uptake of homecare services has taken place.
PbR exclusion drug reimbursement and the reduction in FP10 issues still to be
addressed.
3

Governance
The Cost Improvement Programme Governance Framework has now been ratified by
The Transformation Board (October 2012). A specific change to the framework is the
inclusion of the Executive Workstream Sponsor who will provide executive level
oversight, support and direction to the individual CIP workstream, ensuring an
appropriate escalation route for risks and non delivery of schemes.
Weekly Workstream Accountability meetings are held to ensure the ongoing delivery and
progress of existing directorate schemes. Identified Executive SROs are identified below.
Quality Assurance
A Clinical Quality assurance panel has been set up and has reviewed the process and
documentation to assess and monitor the risks associated with each work stream within
the Cost Improvement Programme. The group is chaired by Dr Maureen Dalziel the Non
Executive Director and supported by a number of executive and clinical staff.
The framework includes impact assessments on clinical outcomes, safety and patient
experience in addition to parameters measured by the Quality and Safety board. The
Quality Assurance panel meets monthly and will provide assurance to both the
Transformation and Quality and Safety Boards. Focused work using this framework is
now taking place to carry out quality impact assessments on any schemes previously
assessed as high or moderate risk.
4

CIP Project Governance – Approval Flowchart
New CIP scheme generated
Work stream steering group
Operational/ directorate
Agree work stream
Complete a Quality Impact Assessment
Directorates add to their risk register
Director/ divisional
review meetings
All schemes‐
Complete a Risk Assessment
CD review of risk assessment
Does the risk assessment contain any
Moderate (M) or High (H) risks after mitigation?
CIP delivery ( as per tracker)
Clinical risk assessment
Blue Green Amber Red
1 2 3 4
Low 1 1 2 3 4
Medium 2 2 4 6 8
High 3 3 6 9 12
PMO add to CIP risk register
Service
Transformation
Office
Complete a Project Mandate
for schemes over £50,000
Transformation
Board
(Monthly)
Ongoing monitoring of operational and clinical indictors via directorates dash boards
Patient satisfaction, Length of stay
HCAI’s, Hospital readmission rates, Staff satisfaction
Clinical Quality Assurance
Panel (Monthly)
Quality and Safety
Board (Bi‐monthly)
Version 3- JM 19/10/12
Status to be tracked in both CIP and departmental risk register and the Q&S board
5

1
REPORT TO:
REPORT FROM:
Trust Board
Chief Executive
DATE: 11 October 2012
SUBJECT:
FOR:
CHAIRMAN & CHIEF EXECUTIVE’S REPORT
Information
______________________________________________________________
1. INTRODUCTION
This report contains a summary of:
• Actions taken under emergency powers
• Executive decisions
• National Issues/News
• Local Issues/News
2. RECOMMENDATION
The Board is asked to note this report.
3. ACTIONS TAKEN UNDER EMERGENCY POWERS
No actions have been taken by the Chairman, or Chief Executive acting under
emergency powers.
4. EXECUTIVE DECISIONS
The Trust Executive Committee has been meeting on a monthly basis and have
reviewed and inputted into several reports prior to their submission to the Trust
Board, such as the Board Assurance Framework, Information Governance
Strategy 2012/13, Complaints Annual Report 2011/12 and the Single Operating
Model. .
1.
Chairman & Chief Executive’s Report – November 2012

2
NATIONAL ISSUES/NEWS:
New health ministerial team:
Jeremy Hunt has been appointed Secretary of State for Health following the
Government’s reshuffle. He is MP for South West Surrey and was previously
Secretary of State for Culture, Olympics, Media and Sport. His team consists of
three new health ministers, joining Lord Howe who remains as Health Minister in
the Lords. They are Norman Lamb, Minister of State, Dr Daniel Poulter,
Parliamentary Under Secretary of State and Anna Soubry, also Parliamentary
Under Secretary of State.
For further information, go to: http://www.dh.gov.uk/health/aboutus/people/ministers
Fund will boost digital innovation:
The Department has announced that local NHS organisations could now be
awarded funding to develop new digital services that improve patient care and
can be used to share information more easily across the NHS. Funded projects
are expected to lead to a successful deployment and use, in an NHS
environment, of solutions based on the NHS Interoperability Toolkit.
For further information, go to:
http://www.connectingforhealth.nhs.uk/systemsandservices/interop
Join the conversation on how to strengthen the NHS Constitution:
The NHS Future Forum, which is advising the Government on how the NHS
Constitution might be strengthened, is talking about what the NHS Constitution
means to them and is keen to hear your views. On a newly-launched blog,
members of the NHS Future Forum will explain what the NHS Constitution
means to them and discuss ways of strengthening it.
For further information, go to: http://www.dh.gov.uk/health/2012/09/constitutionblog
Cancer drugs fund – National Cancer Action Team bulletin:
The National Cancer Action Team has published a bulletin providing an update
on drugs that were funded through the cancer drugs fund (CDF) in 2011/12,
highlighting the current systems and processes in place and focusing on the work
that is underway for the second and third year of the fund’s operation.
Link:
http://ncat.nhs.uk/sites/default/files/uploaded/CDF%20National%20Bulletin%20S
ummer%202012.pdf
The Foundation Trust Non-Executive role - meeting the challenges:
On 15 November 2012, Monitor, in partnership with the King’s Fund, is holding a
one-day conference in London to support FT Non-Executive Directors. It will
provide a forum for learning, discussion and debate on how Non-Executives can
best meet specific challenges facing Foundation Trusts and those of the
changing health landscape, including regulation.
Link: http://www.kingsfund.org.uk/events/ft_nonexecutive_rol.html#tab_2
Preventing suicide in England – a cross-government outcomes strategy:
A new suicide prevention strategy has been launched, with the objectives of
reducing the suicide rate and providing better support for those bereaved, or
affected by suicide. Much of the work to prevent suicides is carried out locally
and the strategy outlines evidence-based approaches to inform this work. NHS
and Local Authority Chief Executives will consider the strategy in preparing joint
strategic needs assessments and joint health and wellbeing strategies.
For further information, go to: www.dh.gov.uk/health/2012/09/suicide-prevention
Chairman & Chief Executive’s Report – November 2012

3
Preparations for winter planning and reporting:
A letter from David Flory, Deputy NHS Chief Executive and Shaun Gallagher,
Acting Director General, Social Care, Local Government and Care Partnerships,
sets out preparations for winter planning and reporting, which will run from 6
November 2012 to the end of February 2013. SHA Cluster Chief Executives
have been asked to ensure preparations are in place and encourage local NHS
organisations to review local winter plans and observe the timetable for daily
SITREP reporting.
For further information, go to: http://www.dh.gov.uk/health/2012/09/winterreporting-2012-13
Commissioning specialised services nationally – new proposals:
The Clinical Advisory Group for prescribed services (CAG) has made
recommendations about which specialised services for people with rare
conditions should be commissioned in England. The services listed on its latest
report will be commissioned by the NHS Commissioning Board from April 2013,
rather than by Clinical Commissioning Groups. The list will be agreed by
Ministers and the Commissioning Board in the Autumn.
For further information, go to: http://www.dg.gov.uk/health/2012/09/cagreport
New National Equalities Lead for NHS:
The NHS Commissioning Board Authority has appointed Paula Vasco-Knight as
National Equality Lead. Reporting to Jim Easton, National Director
Transformation, Paula will lead the equalities work at the Board, whilst continuing
her full time role as CEO at the South Devon Healthcare NHS Foundation Trust
and Senior Responsible Officer for the equality delivery system.
Link: http://www.commissioningboard.nhs.uk/2012/09/07/national-equalities-leadappointed-to-the-nhs-commissioning-board
Safeguarding children and adults in the future NHS – interim advice:
The NHS Commissioning Board Authority has published interim advice on
arrangements to secure children’s and adult safeguarding, which provides
additional information, in particular to emerging Clinical Commissioning Groups.
A covering letter from Jane Cummings, Chief Nursing Officer, and Shaun
Gallagher, Acting Director General, Social Care, Local Government and Care
Partnerships, reminds PCTs and SHAs of the vital importance of maintaining
appropriate arrangements, as the health system goes through transition.
Link: http://www.commissioningboard.nhs.uk/2012/09/12/safeguarding
Publication of organisation patient safety incident data:
The NHS Commissioning Board Authority has released the latest organisation
patient safety incident data. High levels of incident reporting provide an
indication of an increased safety culture within the organisation.
Link: http://www.nrls.npsa.nhs.uk/patient-safety-data/organisation-patient-safetyincident-reports
Doctors urged to encourage staff immunisation against flu:
In an open letter to Doctors, Professor Dame Sally Davies, the Chief Medical
Officer and Dr Mark Porter, Chair of Council at the British Medical Association,
have stressed the vital role that Doctors can play in ensuring that as many
frontline staff are vaccinated against flu as possible. The letter also includes
supporting evidence on the importance of the influenza vaccine. NHS
organisations are urged to use this letter locally to encourage Doctors to have
their flu jabs.
For further information, go to: http://www.dh.gov.uk/health/2012/09/get-flu-jab
Chairman & Chief Executive’s Report – November 2012

4
Nurses and midwives have vital role in flu vaccination:
In an open letter to nurses and midwives, Professor Viv Bennett, Director of
Nursing, Department of Health, and the Government’s principal advisor on public
health nursing, has stressed the vital role that nurses and midwives play in
making sure frontline staff are vaccinated against flu and patients are protected.
This drive is supported by the Royal College of Nursing (RCN) and the Royal
College of Midwives (RCM).
Frontline healthcare workers are more likely to be exposed to the influenza virus,
particularly during winter months, when some of the people in their care will be
infected. It has been estimated that up to 1 in 4 healthcare workers may catch
flu during a mild influenza season, a much higher incidence than expected in the
general population.
For further information, go to:
http://www.nhsemployers,org/HealthyWorkplaces/SeasonalFluCampaign/Latestnews/pages/DepatmentOfHealthIssueLetterToNursesAndMidwivesFluVaccinatio
n.aspx
Hospital patients need high quality food and drink:
Principles outlining what patients should expect from hospital food were
announced recently by Health Secretary, Jeremy Hunt. These include the
provision of high quality and healthy hospital food and drink, and patients being
given a choice from a varied menu. A particular focus will be on the most
vulnerable, such as older people, which is a top priority for the Secretary of State.
These principles will be a feature of new patient-led assessments covering areas
such as hospital food, cleanliness, privacy and dignity.
For further information, go to: http://www.dh.gov.uk/health/2012/10/hospital-food
Equality duty to make reasonable adjustments:
Although the duty to make reasonable adjustments for disabled service users is
not new, the Department of Health wants to make sure all service providers are
aware of their responsibilities. Where a provider does not comply with the duty
to make reasonable adjustments in the provision of services of a public nature, it
will be committing an act of unlawful discrimination. Further guidance is
available in chapter 7 of the Equality and Human Rights Commission’s Statutory
Code of Practice for Services, Public Functions and Associations.
Link: http://www.equalityhumanrights.com/uploaded_files/EqualityAct/services
code.pdf
NHS Leadership Recognition Awards 2012 finalists:
The NHS Leadership Academy’s short-listed finalists for these awards represent
outstanding leadership across nine categories and exemplify the quality,
dedication and innovation of staff working in the system today. The winners will
be announced at the awards ceremony at Barts Great Hall on 10 December
2012.
Link: http://www.nhsleadershipawards.nhs.uk/about-the-awards/awards-
2012.aspx
Managing nursing performance and supporting nurses in difficulty:
With an opening presentation from Professor Juliet Beal, Director of Nursing
Quality, Improvement and Care at the NHS Commissioning Board Authority, this
Conference in London on 6 December 2012 is for all nurse managers and
leaders. It offers practical guidance for managing nursing performance and
supporting nurses in difficulty to ensure safe, high quality patient care.
Link: http://www.healthcareconferencesuk.co.uk/managing-poor-performancesupporting-nurses
Chairman & Chief Executive’s Report – November 2012

5
Preparing the Payment by Results package for 2012/13:
A letter from David Flory updates the NHS on work to prepare the payment by
results (PbR) package for 2012/13 and outlines a provisional timetable for the
rest of the process. NHS Chief Executives will discuss planning for the road test
of the PbR package with relevant colleagues and subsequent implementation
from 1 April 2013.
For further information, go to: http://www.dh.gov.uk/health/2012/09/pbr-2012-14
Views sought on vision for nursing:
A proposed new vision for nursing, midwifery and care given sets out the values
of compassionate care and asks how they can be developed further across
health and social care. Over recent months, Viv Bennett, Director of Nursing,
Department of Health and Jane Cummings, Chief Nursing Officer for England,
have been talking to care givers across the Country to start to develop what the
new vision looks like and what values unite the profession. They now want to
hear your views on the ideas contained in the draft vision.
For more information, go to: www.dh.gov.uk/health/2012/09/views-vision-nursing
Equality, diversity and inclusion in the NHS Board recruitment process:
Two guides have been developed to build equality, diversity and inclusion into
the NHS Board recruitment process for both Executives and Non-Executives.
These practical resources help ensure selection panels and appointed board
members demonstrate confidence, commitment and competency in these areas
and are able to apply these to core board level business.
Link: www.leadershipacademy.nhs.uk/board-recruitment-guides
NICE Fellowships:
Chief Executives and other senior professionals can now apply for Fellowships
provided by NICE. These are unique opportunities to engage in the Institute’s
work more strategically, participate in high level discussions and support NICE in
the implementation of its guidance. Appointments start in April 2013 and run for
three years.
Link: www.nice.org.uk/fellowsandscholars
Healthwatch England launched:
Healthwatch England, the new independent consumer champion for health and
social care in England, has been launched. A key milestone in achieving the
Government’s vision set out in the White paper ‘Equity and Excellence:
Liberating the NHS’, Healthwatch England’s role is to give a national voice to the
key issues affecting people who use health and care services.
For further information, go to: http://www.dh.gov.uk/health/2012/10/healthwatchengland-launched
NHS friends and family test – National implementation guidance:
This guidance is now available and aims to support those who will be
implementing this work, initially providers of NHS funded acute services for
inpatients, and patients discharged from A&E, from April 2013.
Link: http://www.dh.gov.uk/health/2012/10/guidance-nhs-fft
Information flows and personal information in the new commissioning
landscape:
Robust information governance enables us to safeguard the privacy and
confidentiality of personal confidential information. In the new commissioning
environment, information governance remains vitally important. Liability for
information governance rests with the legal entity responsible for the processing
Chairman & Chief Executive’s Report – November 2012

6
of data, even where this is contracted out, and organisations need to ensure they
comply with their legal obligations.
Link: http://www.nigb.nhs.uk/igplgflows
Consensus statement supporting the Liverpool Care Pathway:
Over 200 organisations have signed a consensus statement in support of the
Liverpool Care Pathway for the dying patient, including professional bodies, third
sector organisations, disease specific charities and organisations representing
care homes, hospices, social services and palliative care specialists.
Link: http://www.endoflifecareforadults.nhs.uk/tools/core-tools/liverpool-carepathway
Radiotherapy treatment to be rolled out across the NHS:
Almost 8,000 more cancer patients a year could benefit from the roll-out of an
advanced radiotherapy technique with fewer side effects, thanks to a £15m
investment announced by the Department of Health. The Cancer Radiotherapy
Innovation Fund will expand NHS capacity to deliver life-saving advanced
radiotherapy techniques by April 2013. The money will be used to speed up the
use of Intensity Modulated Radiotherapy (IMRT) building on the success of the
Cancer Drugs Fund, which has already benefited over 21,000 patients. The
£15m Radiotherapy Innovation Fund will cover the remainder of 2012/13.
For further information, go to: http://mediacentre.dh.gov.uk/2012/10/08/eightthousand-patients-to-benefit-from-advanced-cancer-treatment
The Quarter shows continued strong NHS Performance:
David Flory’s quarterly report for Quarter 1 (April to June) 2012/13, published
recently, provides a summary of the NHS financial position and performance
against National priorities set out in the NHS Operating Framework 2012/13. It
shows the NHS has continued to perform strongly against key performance
measures in the first quarter of this important year for the NHS. The NHS also
continues to make progress with system transformation and the financial savings
required to deliver the quality, innovation, productivity and prevention (QIPP) and
reform challenge.
For further information, go to: http://www.dh.gov.uk/health/2012/10/quarter-1-
2012-13
Medical revalidation of doctors to start in December:
Medical revalidation, the process by which all doctors who are licensed with
the General Medical Council (GMC) regularly demonstrate they are up-todate
and fit to practice, will start in December 2012.
The new system will help doctors maintain the standard expected of them by
making sure they keep pace with the latest techniques, technologies and
research. Revalidation will also require a doctor to tackle any concerns about
skills such as communication and maintaining trust with patients.
A joint letter from Sir David Nicholson and Sir Bruce Keogh provides more
detail.
To read the letter go to: http://www.dh.gov.uk/health/2012/10/medicalrevalidation-uk/
Chairman & Chief Executive’s Report – November 2012

7
People with dementia to receive more support:
The Department of Health is providing dedicated funding to create care
environments for people with dementia that help reduce anxiety and distress,
and make them feel safer.
Up to £50 million will be available to NHS trusts and local authorities, working
in partnership with care providers, to help tailor hospitals and care homes to
the needs of people with dementia. The care providers involved will need to
sign up to the Dementia Care and Support Compact, which commits them to
providing first-rate care and support for people with dementia and their
families.
For further information go to :
http://www.dh.gov.uk/health/2012/10/dementiaenvironments
National Self Care week 12-18 November 2012:
(Gateway reference number: 18251)
This campaign to be launched by Health Minister Norman Lamb, raises
awareness of the support available to help people, especially those with longterm
conditions, to grow older healthily. This year's theme, which builds on
the European Healthy Ageing Initiative, focuses on supporting people to take
control of their own health and wellbeing, and play a more active role in
decisions about their care.
Link: http://www.dh.gov.uk/health/2012/10/self-care-week-2012/
Pricing of NHS services:
(Gateway reference number: 18128)
From April 2014, Monitor and the NHS Commissioning Board will take over
responsibility for pricing NHS services from the Department of Health. They
will do this through the national tariff. The consultation seeks views on which
providers can formally object to Monitor’s way of calculating prices, and what
level of objection from commissioners and/or providers would require Monitor
to reconsider how it calculates prices.
Link: http://healthandcare.dh.gov.uk/pricing-consultation/
Latest wave of NHS staff survey launched:
(Gateway reference number: 18280)
The Department of Health has commissioned GFK NOP, an independent
research agency, to conduct a survey among NHS staff of their awareness of
a range of important issues, including major NHS policy initiatives and
attitudes towards them. Fieldwork will begin on 2 November 2012 and will
run through December and possibly into early January 2013. The survey will
be conducted across all SHA clusters, to make sure staff views are
represented across the country. The link below takes you to the results of last
year's NHS staff attitudes survey.
Link: http://www.dh.gov.uk/health/2012/06/public-perception/
Finance transition planning arrangements:
(Gateway reference number: 18269)
The Department of Health, in collaboration with PCT and SHA finance
colleagues, has developed a draft document covering the main year-end
finance transition areas that SHAs and PCTs will need to plan for in 2012/13.
The final document will be issued by the end of November 2012.
Link: http://www.dh.gov.uk/health/2012/10/finance-transition/
Chairman & Chief Executive’s Report – November 2012

8
Handover and closedown: planning for a secure transition:
(Gateway reference number: 18231 and 18228)
The Department of Health Integrated Programme Office is working with
transition leads in SHAs to support and assure handover and closedown
activity. Guidance is being produced by experts in the field, and policy and
business leads, to make sure best practice is followed and there is a
consistent approach across all organisations. The first set of guidance is now
available, covering 'transfer documentation' and 'intellectual property rights'.
Link: http://www.dh.gov.uk/health/2012/10/handover-guidance-transition/
LOCAL NEWS:
Executive Director Appointments:
Recent Executive Director appointments include Flo Panel-Coates, Director of
Nursing, Dr Mike Gill, Medical Director, Steve Huddleston, Chief Information
Officer and Dr Ian Hosein, Director of Infection Prevention and Control.
Staff Engagement Sessions:
A recent initiative has commenced with staff being invited to attend face to
face briefings from the Chief Executive and the Senior Team on
developments around the Trust. This is an opportunity for staff to put their
questions and suggestions forward and to get involved in the Trust’s plans for
the future.
HSJ Award Nomination:
The Chief Executive, Director of Estates and several other representatives
from the Trust recently attended an award ceremony sponsored by the Health
Service Journal, where BHRUT had been nominated in the Category of
Efficiency in Clinical Support Services. Although the Trust was not successful
in winning the Award, the Directorate should be congratulated for reaching
the shortlist and being nominated for this prestigious Award.
World Health Organisation Hand Hygiene Compliance Education
Programme:
Through the Infection Control Committee, BHRUT has agreed to a fantastic
opportunity to become only the third NHS Trust in the UK to participate in the
World Health Organisation Hand Hygiene Compliance Education Programme.
Representatives who have been trained by the World Health Organisation will
undertake this Programme.
This is a one year Programme, which will involve four wards at Queen’s and
three wards at King George Hospital (a cross section of specialties have been
selected). Preliminary Audits will be carried out on the seven wards and
customised Education Programme Tools will be designed for the specific
needs of each ward. Mid-year Audits will also be undertaken to provide an
interim measure of the effectiveness of the Programme. It will cover all
groups of staff and a concise KPI Dashboard will be designed, in order to
track and monitor progress.
Chairman & Chief Executive’s Report – November 2012

9
Clinical Patient Management and Handover System (eHandover):
The e-Handover system developed by Dr Aklak Choudhury, Respiratory
Consultant and Mr John White, Consultant Orthopaedic Surgeon/Clinical IT
Director is an award winning business critical SharePoint Hospital solution
that improves patient safety and staff productivity. It has been running in the
Trust for the past two years and is used by many disciplines, including
Doctors, Nurses, Managers and Performance Teams.
Dr Choudhury and Mr White have been invited by Microsoft to be the first
case study produced as part of the business critical SharePoint Programme
and will attend a Microsoft Conference in Las Vegas in November.
The eHandover solution is the first to identify and successfully manage the
shift gap issue, which results in significant communication failure and patient
risk during nights and weekends. It provides the user with the functionality to
complete their handover tasks safely, efficiently and without duplication and
has the backing of the London Deanery and NHS Innovations. It won the
EHI 2011 Award for “Best use of IT to promote patient safety” and the
Microsoft Partner of the Year for Health Award. It has also been adopted by
three other organisations and they are working with one of the Medical
Education Teams to potentially set the processes as a ‘standard’ for all health
organisations in the UK.
Chairman & Chief Executive’s Report – November 2012

QUALITY & SAFETY COMMITTEE
PART II - OPEN
Minutes of the meeting held on Tuesday 14 th August 2012 at 15.45 hrs in Board Rooms 1&2,
Trust Headquarters, Queen’s Hospital, Romford.
Present:
Prof. Anthony Warrens, Non Executive Director (AW) (Chair)
Caroline Wright, Non Executive Director (CW)
Maureen Dalziel, Non Executive Director (MD)
George Wood, Chairman (GW)
Averil Dongworth, Chief Executive (AD)
Mike Gill, Medical Director (MG)
Magda Smith, Associate Medical Director MS)
Stephen Burgess, Director of Clinical Strategy (SB)
Pam Strange, Clinical Governance Director (PS)
Alison Crombie, Director of Education (AC)
John Alcolado, Director of Medical Education (JA)
Gary Etheridge, Deputy Director of Nursing (GE)
Portia Omo-Bare, Chief Pharmacist (POB)
Andrew Deaner, Clinical Director – Acute Medicine (ADe)
Dele Olorunshola, Clinical Director – Women’s Services (DO)
Derek Hicks, Clinical Director – Emergency Care (DH)
Gabriel Sayer, Clinical Director – Specialist Surgery (GSa)
Dip Mukherjee, Clinical Director – Surgery (DM)
Geraldine Soosay, Clinical Director – Pathology (GS)
Jane Stevens, Clinical Director – Specialist Medicine (JS)
Zoltan Narg, Clinical Director – Radiology (ZN)
Imogen Shillito, Director of Communications (IS)
Cris Robinson, Committee Coordinator (Minutes) (CR)
Rachel Brady, NHS North East London and City (RB)
Elaine Clark, Chair of Improving Patient Experience Group (EC)
In Attendance: Lucy Etheridge, Medical Education
Dr Rull, Emergency Care
Dr Umo-Etuk, Clinical Lead, Anaesthetics deputising for Remi Odejinmi
Dr Andole, Clinical Lead, Neurosciences deputising for Jonathan Pollock
1

102/2012 Apologies
Apologies were received from:
Ambalika Das, Clinical Director – Children’s Services (ADa)
Remi Odejinmi, Clinical Director – Anaesthetics (RO)
Jonathan Pollock, Clinical Director – Neurosciences (JP)
Cathy Geddes, Chief Operating Officer (CG)
Vanessa Lodge, Deputy Director of Quality & Clinical Governance, NHS
North East London & City
103/2012 Minutes of the Meeting held on the 12 th June 2012
The minutes from the previous meeting were agreed to be a true record.
104/2012 Matters Arising
Action Log
18/2012 - SB advised there had been further discussions with Health UK about
the ISTC that has resulted in the Trust agreeing to support cardiac arrests in
the centre. However, the Trust declined to provide advice to ISTC clinicians,
although a pathway for referring the patient to A&E was agreed.
36/2012 – Information Governance Committee reports would in future be
independent items and not part of the Feeder Committee update.
42/2012 – The infection control items were included as agenda items.
45/2012 – DO advised that the range used for Emergency LSCS performed
within graded times was 30 for grade 1, and 60 for grade 2. The national
figure for grade 2 was 75, but the Trust had agreed an internal ‘stretch’ target.
45/2012 – DO and IS agreed to jointly review the potential for a positive journal
article on the Trust’s experience of meeting NHSL performance indicators for
Emergency LSCS.
54/2012 – The item on patient stories to be deferred to the October meeting.
70/2012 – The update from each CD on NICE compliance was deferred to the
October meeting.
70/2012 – The Deanery/GMC visit was included an agenda item.
72/2012 – POB reported that the missing methadone had been found, so the
issue was due to a lag in reporting and it was not therefore an SI.
74/2012 – The Dr Foster reports had been re-circulated to members.
74/2012 – PS advised the Trust was in the process of introducing CHKS
mortality data and had discontinued the contract with Dr Foster. Further
information would be made available to the next meeting and once the
changeover is complete the presentation will be scheduled into the
Committee’s agenda.
MS explained in relation to the update required on weekend mortality data
relating to elective weekend deaths that she had been reviewing the notes of
these patients and had identified that some were miscoded; some were
attributable to the way cancer was coded. Of the notes reviewed only 8 relate
to true elective surgical deaths, which she needed to discuss further with
neurosurgery to fully understand. There were 3 actions following the review
i.e. 1) work with the coders to review the miscoding of emergency admissions
as planned deaths, 2) further investigate how cancer day unit cases are coded
and 3) review with neuro that the deaths were not inappropriately coded.
IS confirmed that appropriate publicity would be given to ensure mortality data
was transparent.
Action
DO / IS
GE
CDs
PS
2

77/2012 – GE confirmed invitations to the MenCap Charter launch had been
completed.
78/2012 – GE confirmed the letter to the Safeguarding team was completed.
79/2012 – GE confirmed the letter to the Chaplains was completed
81/2012 – SB confirmed the issue from the PALS Annual Report had been
escalated to the Trust Board. However, 50% of the total PALS contacts
continue to be in relation to cancellation of Outpatient appointments and the
often extensive delays in rebooking some patients. SB felt this was an
ongoing problem that was generating high levels of complaints, but was also a
significant cause of concern for clinicians as patient’s individual risks factors
needed closer scrutiny. It was agreed this item should be referred to the
Directorate Manager for Outpatients for urgent resolution and feedback.
GE confirmed that the letter to the PALS team was completed.
Rolling Programme
Members were advised that following discussions aimed at ensuring the
Committee focused on clinical governance outputs, over the next few meetings
the Directorates would be required to provide updates on their progress with
embedding clinical governance. This would by necessity mean some items on
the rolling programme were deferred. It was agreed that MG, SB and PS
would revise the rolling programme and advise Directorates when they would
be required to make their reports. It was also proposed that the presentations
should focus on the 3 top corporate and 3 local priorities.
105/2012 Quality Dashboard
STRATEGY
PS explained the new dashboard was still being developed and future
iterations would include more detail e.g. corporate indicators. The expectation
is that CDs will add to the overall dashboard’s effectiveness by providing
exception reports in future.
AW said the dashboard was moving in the right direction. He asked that the
RAG rating be shown in words as well as in colour.
106/2012 Items for Escalation from Feeder Committees
This report was presented for information.
107/2012 Deanery / GMC Visit Report and Action Plan
JA reported on the annual Deanery visit in May that required the Trust to take
immediate remedial actions in relation to OPD cover, gynae continuity of care,
gynae outpatients, consultant attendance out of hours, triage of patients and
FY2 responsibilities on HDU. JA explained that all mandatory actions had
been completed but further work was needed to address consultant reticence
to attend the Trust when they are called at home.
The GMC Survey of trainees identified there was good core training, but
GPVTS in emergency and obs. and gynae. was poor; paediatrics was
satisfactory. The issues identified are not within the gift of the Education
Department to resolve as they are trustwide issues not specifically educational
ones.
JA also advised there were ongoing patient safety concerns relating to
supervision of junior doctors, the pressure in very busy areas such as obs. and
gynae. and emergency medicine and the poor quality of locums.
Action
AK
MG / SB
/ PS
3

Action
Members were advised that acute services and maternity should expect
similar visits soon. JA summarised the ongoing challenges to be:
• The need for a clinical governance bulletin
• Hospital at Night
• Bleep free time for junior doctors that would also assist in getting the
11am discharge target met.
• Phlebotomy cover at KGH
• Daily Consultant Ward Rounds
• Study Leave
• Obs. and gynae. Middle grade numbers
Most importantly JA felt the issue of clinical supervision of junior doctors must
be focused on.
AD also highlighted the Deanery’s requirement for obs. and gynae. junior
doctors to be withdrawn from King George Hospital and repatriated to Queen’s
within 72 hours of the MLU opening. MG said he would clarify expectations
around this at his meeting with Andy Mitchell next week.
AW felt that the Clinical Directors needed to tackle the issue of clinical
supervision. JA confirmed that the Trust’s Medical & Education Policy for
Supervision was updated in February this year and key performance indicators
are in place. It was agreed that JA would write to the Clinical Directors
requesting that each area should have a written policy that clearly states the
level of clinical supervision expected; it should also clarify the Trust’s
expectation that a Consultant will always attend to support a trainee if
specifically requested to do so by the trainee.
CW suggested that copies of the presentation would have been useful as
would a broader executive summary that included the salient points. Both CW
and AD were concerned that the action plans were not in the Trust’s format.
JA explained the action plan was originally generated by the Deanery.
However, GW felt there were too many action plans and there should be more
consolidation; the action plans should be developed and owned by the Trust
with segments presented to the various audiences that request it.
There was discussion around potential financial costs resulting from these
visits/surveys that the Trust Board will be considering, but they will need to be
added to the deficit.
MG concluded the discussion by stating that other Trusts do provide better
supervision of their juniors and that this leads to safer care. There will be
some challenges but the emergency pathway will be an area to prioritise.
PATIENT SAFETY
108/2012 Care Quality Commission Update
PS explained that the report was for information but did highlight the action
plan was being updated and there was a big drive to sign off as much as
possible.
AW was pleased to note the last Condition had been lifted.
MG
JA
4

109/2012 Infection Control Annual Report
MS reported that the Infection Control Annual Report includes, at Appendix 3,
the Infection Control Annual Plan that has been reviewed by the Infection
Control Committee. The Plan shows there has been a significant rise in the
first 4 months in both MRSA and C.difficile. The Infection Control Committee
is solely focusing on these issues and incidence of MSSA. More positively,
urinary catheter infections are decreasing this year. MS felt there needs to be
a different approach with staff to ensuring that the basic principles of patient
care are implemented.
There have also been significant changes in the Infection Control Team with
the Matron retiring recently and the Infection Control Doctor due to retire
imminently. There are plans for a new Matron and Director of Infection
Prevention and Control (DIPC) to be appointed. It was also important that
aseptic touch technique is focused on.
AW questioned whether there was enough support; MS felt that generally
there was, although more Directorate representation at the Infection Control
Committee was needed. She also felt colleagues had a role in being more
challenging with issues such as hand hygiene and bare below the elbow. An
invitation to Sodexo was being extended to improve environmental control
scrutiny via the Infection Control Committee.
DM commented that in general surgery Matrons and Nurses are empowered
to challenge clinicians; this had resulted from a previous poor hand hygiene
audit. He felt that there had been a view some time ago that infection control
was a ‘nursing’ issue; this attitude is changing.
MS advised that once the Infection Control Committee had completed its
revision of the Annual Plan, it would be brought back to the Committee by the
new DIPC.
PATIENT OUTCOMES
111/2012 Surgical Site Infection Surveillance Update
It was noted that a preliminary report had been reviewed by the Infection
Control Committee relating to infections on fractured neck of femur patients. It
was agreed this would be discussed with the CD and a decision taken on
when and where this data should be presented.
112/2012 Implementing Patient Stories
PATIENT EXPERIENCE
This item to be deferred to the October meeting.
113/2012 Energise for Excellence
This report was submitted for information and was duly noted. MD was
concerned that dirty utensils in ward areas was affecting patient care. MS
confirmed this was a cultural issue that was being monitored through the
Infection Control Committee.
114/2012 Complaints Policy
GE explained that the Complaints Policy required approval. It had been
completely revised to take account of the 2009 Regulations and current best
evidence. It has received wide circulation and comment. Members were
asked to provide any comments to GE within 1 week of this meeting, subject to
which the policy was duly approved.
Action
GSa /
MS
All
5

Action
115/2012 Any Other Business
The Complaints Annual Report for 2011/12 was tabled. The report was based
on the requirements within the NHS Complaints (England) Regulations 2009
providing a summary of complaints received by the Trust in relation to its own
services. Since the Annual Report was required for the September Trust
Board meeting, members were asked to pass any comments to GE within 2
weeks from the date of this meeting.
116/2012 Summary of Issues for Escalation to Trust Board
• Continuing risks to patient care from high levels of cancelled outpatient
appointments and delays with rebooking patients.
117/2012 Date of Next Meeting
The next scheduled meeting will be held in Board Rooms 1&2 at 14.00 hours
on the 16 th October 2012
The dates for 2013 will be circulated.
All
MG
CR
6

ACTION LOG – PART I
104/2012 MATTERS ARISING
45/2012 - Joint review of potential for a positive journal article on the Trust’s
experience of meeting NHSL performance indicators for emergency LSCS.
Responsibility
IS / DO
70/2012 – NICE compliance updates from CDs to be agenda item in October. CDs
74/2012 – Mortality update to the next meeting PS
81/2012 – Continuing risks to patient care from high levels of cancelled outpatient
appointments and delays with rebooking patients to be escalated to the Directorate
General Manager for Outpatients for early resolution and feedback.
104/2012 – Schedule of Directorate presentations on progress with embedding
clinical governance to be developed, circulated and included in Rolling
Programme.
107/2012 DEANERY / GMC VISIT REPORT AND ACTION PLAN
Clarification to be sought concerning repatriation of junior doctors from KGH to
Queen’s within 72 hours of MLU opening.
It was agreed that JA would write to the Clinical Directors requesting that each
area should have a written policy that clearly states the level of clinical supervision
expected
111/2012 SURGICAL SITE INFECTION SURVEILLANCE
Fractured neck of femur infections to be reviewed.
112/2012 IMPLEMENTING PATIENT STORIES
This item to be included in the October meeting agenda.
114/2012 COMPLAINTS POLICY
Any comments on the policy to be submitted to Gary Etheridge within 1 week
115/2012 ANY OTHER BUSINESS
Any comments on the Complaints Annual Report to be submitted to Gary
Etheridge within 2 weeks.
116/2012 ISSUES FOR ESCALATION TO TRUST BOARD
The continuing risks to patient care from high levels of cancelled outpatient
appointments and delays with rebooking patients to be escalated.
117/2012 DATE OF NEXT MEETING
Dates for 2013 to be circulated to members
AK
MG / SB / PS
MG
JA
GS / MS
GE
All
All
CR
CR
7

EXECUTIVE SUMMARY
TITLE:
Finance Report – Month Six (September)
2012/13
BOARD/GROUP/COMMITTEE:
Trust Board
1. KEY ISSUES: REVIEWED BY (BOARD/COMMITTEE) and
DATE:
• In the six month period to the end of September the
trust recorded a year to date deficit of £26.0m
(adjusted for impairments & IFRS reversals), which is
£2.0m worse than plan for the period. This adverse
variance is primarily explained by a £2.2m shortfall
against the CIP target to date.
• The in-month deficit of (£3.5m) was in line with plan.
This represents an improvement on the average monthly
run rate deficit to Month 5 of £4.5m and the deficit in
Month 5 of £5.5m.
• The income position to date is £2.1m ahead of plan.
Some payment for over-performance with ONEL has
now been agreed and £2.7m of this additional income is
reflected in the year to date income position. Underperformance
on non-ONEL SLAs (primarily Essex) has
reduced income during the period by £0.4m.
• The projected income position at the year-end is for
an over-performance of £19.6m on the ONEL contract,
less £0.9m under-performance for non-ONEL. This
represents a significant risk as the commissioners have
not yet agreed to fund £5.0m of these treatments.
• Aside from the CIP shortfall, the expenditure position
shows a £1.7m overspending year to date. This
overspending is largely associated with the activity overperformance.
An appropriate proportion of the income
over-performance is being devolved to business units, to
mitigate the marginal cost of over-performance.
• The CIP position shows year to date delivery of £4.3m
against a target for the period of £6.5m, a shortfall of
£2.2m. The forecast delivery is £17.7m of which
£4.8m is considered to be at high risk, which is an
improvement on the £6.2m of high risk schemes
reported last month. The Trust aims to have plans in
place by the end of the month to deliver all of the £17.7m
forecast.
• This compares to a CIP target of £23.1m for the year.
The PMO/E&Y are leading further work to mitigate the
risks, maximise the savings opportunities and is aiming
to deliver at least £20m CIPs.
□ S&SIB ………………□ EPB…...…………..
□ FINANCE ……………□ AUDIT ….……..….
□ CLINICAL GOVERNANCE …………..…......
□ CHARITABLE FUNDS ……………………….
TRUST BOARD ………………………………
□ REMUNERATION ……………………………
□ OTHER ………………………(please specify)
CATEGORY:
□ NATIONAL TARGET □ CNST
□ STANDARDS FOR BETTER HEALTH
□ ASSURANCE FRAMEWORK
□ TARGET FROM COMMISSIONERS
CORPORATE OBJECTIVE To achieve financial
security for the Trust, with reduced costs, improved
productivity and collecting income due
□ OTHER …………………….. (please specify)
AUTHOR/PRESENTER:
Alan Davies, Deputy Director of Finance / David
Gilburt, Director of Finance
DATE:
• The Trust has significant risks to both income and
CIP delivery. With this level of risk our ability to
deliver the £39.7m year-end control total must be in
doubt.
• We need Commissioners to fund the projected activity
and the Trust has to deliver the CIP savings.
• Discussions continue with the commissions and a
detailed review of the forecast outturn will be
completed and reported to the November Finance
Committee
2. FINANCIAL IMPLICATIONS/IMPACT ON CURRENT FORECAST:
Set out under key issues
3. ALTERNATIVES CONSIDERED/REASONS FOR REJECTION:
1

N/A
4. DELIVERABLES:
N/A
5. EVIDENCE :
N/A
6. RECOMMENDATION/ACTION REQUIRED:
The Trust Board is request to approve the report and note the actions to mitigate risk in achieving
the control total deficit of £39.7m
AGREED AT ______________________
MEETING, OR
REFERRED TO: ______________________
DATE: ____________________________
DATE: ____________________________
REVIEW DATE _________________________
(if applicable)
2

1. EXECUTIVE SUMMARY
Monthly I&E Run rate
m
£
43.0
41.0
39.0
37.0
35.0
33.0
31.0
29.0
Month 6 ‐ Monthly Run Rate Trend
1 2 3 4 5 6 7 8 9 10 11 12
Incom e Exp net of Blue/Green/Amber CIP Expenditure Further red CIPs required to m eet forecast
Trust I&E Summary (+ve variances = favourable, -ve = adverse)
2012/13 In Month (£'000) 2012/13 Year to date (£'000)
2012/13 2012/13 Foreast (£'000)
2011/12
2011/12 YTD Annual
Actual £'000 Var £'000 Var % Actual £'000 Var £'000 Var % Actual £'000 Budget £'000 Actual £'000 Var £'000 Var % Actual
(35,508) 1,296 3.79% Income (209,703) 2,138 1.03% (198,584) (413,055) (420,630) 7,575 -1.83% (419,121)
Expenditure
24,509 (159) -0.65% - Pay 147,555 (571) -0.39% 144,367 292,971 297,334 (4,363) -1.49% 291,010
11,068 (207) -1.90% - Non-pay 67,348 (527) -0.79% 66,700 132,269 133,954 (1,685) -1.27% 138,248
(656) -100.00% - QIPP/Cost Reduction (2,782) (13,710) (8,446) (5,264) 38.40%
(78) -100.00% - Contract adjmt. & reserves (189) (122) 3,088 (3,210) 2635.09%
68 198 74.33% EBITDA 5,200 (1,931) -59.07% 12,482 (1,646) 5,300 (6,946) 10,137
ITDA
1,171 37 3.08% - Depreciation 7,104 143 1.97% 7,003 14,494 14,162 332 2.29% 14,033
355 0.00% - Capital Dividends 2,132 0.00% 1,943 4,263 4,263 0.00% 3,613
1,823 21 1.11% - Net Interest 11,904 22 0.19% 11,488 23,822 23,756 66 0.28% 23,011
3,417 255 6.95% Net position 26,339 (1,766) -7.18% 32,917 40,933 47,481 (6,548) -16.00% 50,794
Impairments (2,005) (5,318) (2,005) (2,005) (1,133)
3,417 255 6.95% Net position 24,334 (1,766) -7.82% 27,599 38,928 45,476 (6,548) -16.82% 49,661
In Month and YTD Performance
Income
• Income of £35.5m in Month Six was £1.3m over the plan and is £2.1m ahead of
plan YTD. The ONEL contract is £4.8m ahead of contract YTD, less transitional
funding not agreed of £2.1m, with a forecast over-performance of £13.0m, less
£4.3m transitional funding. Over-performance has continued to increase,
particularly for non-elective activity, which is only funded at 30% marginal tariff
above 2011/12 baseline, against which the commissioners are applying a 65%
marginal tariff (i.e. net 20% tariff). The forecast expenditure position now
includes £1.8m of non-elective costs not covered by the marginal tariff.
Pay expenditure
• Pay is £159k overspent in the Month, mainly related to Medical staffing £129k
(Radiology £71k and Specialist Surgery £93k) and £78k (Acute Medicine
£128k).
• The YTD position is £571k overspent, mainly related to Medical staff £508k
(Radiology £497k) and Nursing staff £595k (mainly Acute Medicine £640k and
Midwifery £243k, partly offset by under spending in Corporate Nursing
budgets), both partly offset by under spending on Management/Admin staff of
£679k.
Non-pay expenditure
• Non-pay is £207k overspent in the Month, mainly related to Pathology £109k
and Pharmacy £136k
• YTD the overspending is £527k, mainly related to Pathology £355k and
Specialist Medicine (£224k – Oncology and Pharmacy)
EBITDA
• Earnings before Interest, Tax, Depreciation and amortisation (EBITDA) were
£0.1m negative in the Month and £5.2m negative YTD. The improved in month
position was primarily driven by income. The YTD EBITDA of £5.2m negative is
£1.9m adverse against plan YTD but has improved by £7.3m compared with
the same period last year. The forecast is £5.3m negative, £4.8m better than
last year’s outturn..
Net deficit
• The net deficit is £25.7m to date, which is £1.8m worse than plan. The forecast
deficit is £46.8m, primarily related to:
o £4.3m transitional income support not agreed by commissioners
o £1.0m increased income over-performance not agreed by
commissioners
o £1.8m unfunded cost of Non-elective activity
• The forecast assumes full delivery of £4.8m red-rated CIPs (in addition to the
£12.9m CIP rated as blue/green/amber, making a total of £17.7m)
Add back - Impairment 2,005 2,005 2,005 1,133
121 (221) IFRS reversed (380) (221) (1,202) (759) (443) (882)
3,538 34 Net against control 25,960 (1,987) 39,731 46,722 (6,991) 49,912
3

CIP
CIP
• Overall CIP delivery in month and YTD is £1.4m and £4.3m respectively. The forecast outturn is £12.9m for blue/green/amber rated schemes, with a further £4.8m of red-rated schemes,
which are in the process of being validated, with the aim of confirming the full £17.7m before the end of October.
Financial risk rating (per Monitor criteria) KPIs
Criteria Indicator Weight 5 4 3 2 1
Underlying
performance
Achievement of
plan
Financial
efficiency
Risk Ratings
Reported
Position
Year to
Date
Forecas
t
Outturn
Normalised
Position*
Year to
Date
Forecast
Outturn
EBITDA margin % 25% 11 9 5 1

Trust I&E summary by Division/Directorate:
2012/13 In Month 2012/13 In Month 2012/13 Year to date (£'000) 2011/12 2012/13 2012/13 Foreast (£'000)
Actual £'000 Var £'000 Var %
Adj Actual
WTE
Variance
WTE Actual £'000 Var £'000 Var %
Adj Average
Actual WTE
Average
Actual £'000
YTD Actual
£'000
Annual
Budget £'000 Actual £'000 Var £'000
(32,691) 888 2.79% Central Income (193,737) 1,924 1.00% (32,119) (182,812) (381,659) (388,538) 6,879
Surgical Services Division
3,692 (109) -3.04% 662.14 -0.81 Anaesthetics 22,296 (672) -3.11% 613.40 3,507 19,928 42,137 44,268 (2,130)
1,370 (140) -11.38% 224.94 -0.93 Specialist Surgery 8,271 (242) -3.01% 250.26 1,340 7,900 15,600 16,271 (671)
1,475 (73) -5.19% 327.24 -5.18 Surgery 8,678 (203) -2.40% 384.78 1,624 9,614 16,625 17,178 (553)
6,538 (322) -5.17% 1,214.32 -6.92 Total 39,245 (1,117) -2.93% 1,248.44 6,472 37,443 74,363 77,717 (3,354)
Emergency Care, Gen Med & Neurosciences
3,774 (245) -6.95% 957.31 -63.82 Medicine 22,747 (909) -4.16% 1,033.10 3,829 22,837 42,811 44,476 (1,666)
2,371 47 1.95% 523.96 13.12 Emergency Care 15,012 (191) -1.29% 583.37 2,573 14,499 28,732 29,933 (1,201)
1,096 32 2.83% 237.60 -3.74 Neurosciences 6,916 11 0.16% 230.86 1,136 6,927 13,536 13,703 (166)
7,240 (166) -2.35% 1,718.87 -54.44 Total 44,675 (1,089) -2.50% 1,847.33 7,538 44,262 85,079 88,112 (3,032)
Women's, Children & Support Services
1,148 28 2.34% 269.75 -17.84 Children 6,922 117 1.66% 263.71 1,188 7,162 14,093 13,958 135
882 1 0.08% 377.20 -7.52 Support Services 5,380 (119) -2.27% 382.87 887 5,319 10,212 10,685 (473)
2,937 (26) -0.89% 634.61 35.36 Women 17,960 (401) -2.28% 678.97 3,124 18,846 34,907 35,659 (752)
4,967 2 0.05% 1,281.56 10.00 Total 30,262 (403) -1.35% 1,325.55 5,200 31,327 59,212 60,302 (1,090)
Diagnostics & Specialist Medicine
1,884 (158) -9.13% 279.47 7.71 Pathology 11,125 (631) -6.01% 284.06 1,777 10,854 20,519 22,003 (1,484)
1,730 (158) -10.08% 313.05 -21.16 Radiology 10,357 (629) -6.47% 287.38 1,543 9,081 18,869 20,445 (1,576)
3,226 105 3.15% 575.57 7.30 Specialist Medicine 20,354 (349) -1.74% 605.48 3,441 20,440 38,961 40,058 (1,097)
6,840 (211) -3.18% 1,168.09 -6.15 Total 41,836 (1,609) -4.00% 1,176.92 6,762 40,375 78,349 82,506 (4,157)
7,082 504 6.65% 840.00 34.75 Corporate 43,441 1,107 2.49% 728.52 6,777 41,169 87,962 87,437 524
(23) 695 103.46% 6,222.84 -22.76 - Sub-total 5,721 (1,187) -26.18% 6,326.76 630 11,763 3,307 7,536 (4,229)
91 (57) -167.77%
Central adjustment including
provisions & red CIP (520) 725 353.73% 134 764 410 (7,113) 7,523
(440) Contract QIPP adjmt. & reserves (1,465) (5,353) 4,888 (10,241)
1,171 37 3.08% Depreciation 7,104 143 1.97% 1,169 6,958 14,494 14,162 332
2,178 20 0.90% PDC & Net Interest 14,034 18 0.13% 2,209 13,431 28,075 28,008 67
3,417 255 6.95% Total 26,339 (1,766) -7.18% 6,326.76 4,142 32,917 40,933 47,481 (6,548)
Impairments (2,005) (5,318) (2,005) (2,005)
3,417 255 6.95% Net position 24,334 (1,766) -7.82% 6,326.76 4,142 27,599 38,928 45,476 (6,548)
• Central income over-performance primarily driven by over-performance on out-patients (£3.9m), less shortfall of £2.2m transitional funding to be agreed.
• Surgical Services YTD overspending primarily driven by £0.4m CIP shortfall, Medical staffing £0.5m and Theatres non-pay £0.2m.
• Emergency/Medicine/Neuro YTD overspending primarily related to CIP shortfall £0.3m and Nursing in Acute Medicine £0.6m
• Women/Children/Support YTD, primarily in Women, related to Midwifery £0.2m and HIV drugs £0.2m, although run rate has improved in M5.
• Diagnostics & Specialist Medicine primarily related to Pathology consumables £0.4m, pay of £0.8m (mainly Radiology medical staff £0.6m) and CIP shortfall £0.5m
• Corporate under-spending primarily from non-recurrent charitable funds contribution £0.4m and Estates £0.5m
5

2. CLINICAL INCOME
Key points:
• In line with guidance from the SHA, the Trust and Commissioners’
have agreed a monthly profile plan based on Commissioners’ QIPP
schemes; as such the Budget has been re-profiled to reflect this
change.
• Income for Month 6 has been forecast using first cut activity for the
Month. Activity for A&E, OP and IP were all taken at day 31. This
has ensured that activity is more accurate and gives greater
assurance around Income for the current month.
• There was an under- performance of £1.8m in the month, with a year
to date over-performance of £4m, on an ‘activity times price’ basis.
Final Month 5 actual income came in at £30.9m, £1.2m more than
was accrued, and as such, the YTD position reflects the actual activity
for Months 1 – 5 and the current month forecast.
Business Unit
Performance
In Month Year to date Forecast
Actual Var Actual Var Actual Var
(7,223) 919 Acute Medicine (44,732) 3,240 (89,557) 7,894
(1,950) 223 Anaethetics (11,101) (47) (22,180) (197)
(1,781) (127) Children (11,430) (736) (22,709) (1,347)
(2,318) 192 Emergency Care (14,437) (219) (28,853) 331
(2,257) (56) Neurosciences (13,991) (461) (28,034) (817)
(784) 42 Pathology (4,912) 25 (9,945) 27
(1,062) 61 Radiology (6,191) 493 (12,484) 1,088
(2,734) 538
Specialist
Medicine (16,017) 1,825 (32,324) 3,758
(3,546) 457
Specialist
Surgery (21,402) 1,248 (43,127) 2,569
(3,484) 222 Surgery (21,756) 293 (43,835) 965
(4,393) 494 Women (26,601) 1,107 (53,424) 2,693
547 (1,129) Corp (1,168) (2,695) (2,042) (10,108)
(30,984) 1,837 Total (193,737) 4,074 (388,514) 6,855
• The forecast reflects an £8.7m FOT over- performance on the ONEL
contract, with an FOT under-performance of £1.8m on other ‘non-
ONEL’ contracts. The over-performance for the ONEL contract is now
being renegotiated as the likely outturn has increased by c.£2m due
to increased activity. The £8.7m is net of £4.3m shortfall on
transitional funding (i.e. £13m gross over-performance)
• The Trust is currently negotiating for additional income with ONEL for
Best Practice Tariff, Breast Screening and Commissioners’ failure to
move births to other providers. Discussions with the cluster are still
on-going.
• On the East of England Contract, there has been a reduction in the
Non Elective Activity partially offset by an increase in the use of
Devices; the net effect is an FOT under performance of £1.5m.
• A&E activity has grown by 7% year on year, but this is primarily due to
the full-year effect of the Queen’s UCC, which was taken on by
BHRUT in August 2012.
• There is a growth of 4% in Day cases year on year as a result of the
achievement of the 18 weeks targets, coupled with the Trust
undertaking work that went to the ISTC last year.
• Non Elective admissions activity has declined by 3% year on year.
6

Income by POD
In Month Year to date Forecast
Actual Var Actual Var Actual Var
(1,708) 199 AandE (10,595) (9) (21,173) 628
(64) (3) Ambulatory Care (451) 6 (912) 10
(216) 50 Breast Screening (1,026) (77) (2,077) (165)
(217) 0 Challenge Trust Board (1,300) 0 (2,600) 0
(378) 0 CQUIN (2,268) 0 (4,536) 0
(2,419) 295 Critical Care (13,598) 191 (26,971) 117
(2,617) 234 Daycases (16,480) 749 (33,366) 1,380
(945) (11) Devices & Drugs (5,876) 545 (11,880) 1,249
(1,292) 170 Direct Access (7,859) 448 (15,913) 865
(1,798) 36 Elective (11,690) 147 (23,667) 198
(355) 0 HIV Contract (2,132) 0 (4,264) 0
(33) (12) ISTC Contract (211) (59) (412) (128)
(10,931) 767 Non Elective (67,412) 707 (134,441) 3,984
(2,720) 494 OP First Attendances (16,353) 1,557 (33,109) 3,103
(2,875) 528 OP Follow Ups (17,555) 1,989 (35,543) 3,967
(513) 118 OP Procedures (3,040) 428 (6,154) 844
(480) (993) Other (6,972) (1,867) (14,041) (3,637)
Patient Transport
(308) 27 Services (1,762) 78 (3,523) 157
(342) 53 Radiotherapy (2,060) 158 (4,109) 249
496 0 Readmissions 2,976 0 5,953 0
(519) 97 Regular Day Attenders (2,911) 135 (5,806) 173
(92) (147) Road Traffic Accidents (1,168) (264) (2,000) (864)
0 0 Transitional Funding 0 0 0 (4,300)
(659) (65) XBD (3,993) (790) (7,969) (976)
(30,984) 1,837 Total (193,737) 4,074 (388,514) 6,855
Note: Other includes the 65% marginal rate adjustment in respect of ONEL performance (£7.1m)
Activity
POD Group 2011-12 2012-13 Var % Change
AandE 95,652 110,117 14,465 7%
Ambulatory Care 1,458 1,527 69 2%
Breast Screening 10,482 10,360 (122) -1%
Critical Care 13,383 13,857 474 2%
Daycases 20,254 22,110 1,856 4%
Direct Access 2,447,662 2,401,471 (46,191) -1%
Elective 3,827 3,848 21 0%
Non Elective 39,972 37,897 (2,075) -3%
OP First Attendan 85,277 89,951 4,674 3%
OP Follow Ups 201,644 200,710 (934) 0%
OP Procedures 16,201 18,147 1,946 6%
Other 41,071 43,931 2,860 3%
Radiotherapy 8,931 10,806 1,875 9%
Regular Day Atten 6,912 7,221 309 2%
XBD 20,319 15,084 (5,235) -15%
Total 3,013,045 2,987,037 (26,008)
7

Cluster Performance
In Month Year to date Forecast
Actual Var Actual Var Actual Var
(25,605) 2,011 Outer North East London (161,828) 4,832 (324,928) 8,700
(559) 82 Inner North East London (2,881) 9 (5,776) 5
(1,016) 67 London Specialist Commissioning (5,891) 199 (11,610) 227
East Of England Specialist
(3,027) (134) Commissioning (18,288) (787) (36,843) (1,516)
(427) (63) Non Contract Activity (2,297) 127 (4,596) 397
(95) 32 North Central London (383) 3 (768) 5
(255) (158) Trust (2,169) (308) (3,992) (963)
(30,984) 1,837 (193,737) 4,074 (388,514) 6,855
8

Devolved income
Annual
Budget
Forecast
Variance
Forecast
Income overperformance
against plan
Income
attibuted to
Directorate
Net variance
after income
attribution
9
Difference
between
forecast
income overperformance
and income
attributed
Comment
Surgical Services
Anaesthetics 44,614 (2,476) (197) 479 (1,997) 676
Includes allocation from Surgical Business Units for
over/(under) performance
Specialist Surgery 16,166 (566) 2,569 439 (127) (2,130) Over‐performance primarily related to Out‐patient
Surgery 16,977 (351) 965 29 (322) (936) QiPP non‐delivery
Surgical Services Total 77,757 (3,393) 3,337 948 (2,445) (2,389)
Emergency Care, Gen Med & Neurosciences
Emergency Care 30,208 (1,476) 331 (162) (1,638) (493)
Neurosciences 13,724 (188) (817) (62) (250) 755 Adjustment for Drugs/devices & NEL activity
Medicine 44,561 (1,751) 7,894 1,438 (313)
Most of over‐performance associated with nondelivery
of QiPP as opposed to increase in activity
(6,456) from 2011/12
Emergency Care, Gen Med & Neuroscie 88,493 (3,415) 7,408 1,214 (2,201) (6,194)
Women's, Children & Support Services
Most of under‐performance associated with reclassification
of PAU activity from NEL to Outpatients,
Children 13,858 236 (1,347) 134 370 1,481
not reflected in contract
Support Services 10,779 (567) 172 (395) 172
Most of over‐performance associated with lower
Women 35,567 (660) 2,963 (170) (830) (3,133) reductions in births than planned
Women's, Children & Support Services 60,204 (991) 1,616 136 (855) (1,480)
Diagnostics & Specialist Medicine
Pathology 21,974 (1,455) 27 179 (1,276) 152
Radiology 19,509 (640) 1,088 832 192 (256) Includes allocation from other Business Units for
Specialist Medicine 41,488 (2,527) 3,758 1,259 (1,268) (2,499) support services
Diagnostics & Specialist Medicine Tota 82,971 (4,622) 4,873 2,270 (2,352) (2,603)
Total of above 309,425 (12,421) 17,234 4,569 (7,852)
Most of difference associated with non‐delivery of
(12,665) circa £10m QiPP reductions in contract
• The table above, gives a summary of the forecast outturn position for each business unit, and then builds in an appropriate share of over-performance income, as mitigation against the
increased marginal cost of the over-performance for each area.
• Business Unit budgets are funded to 2011/12 outturn levels (as forecast at Month 8), so the principle applied is as follows:
o Take the increase (or decrease) in activity from the 2011/12 outturn (as at Month 8 forecast) to the 2012/13 forecast outturn (as at Month 6)
o Apply 65% of the full tariff, as a proxy for marginal costs (this is also the level that commissioners are paying for over-performance and is commensurate with the average level
of direct & indirect costs, as calculated through SLR)
o Apply 50% of the 65% to Business Units in respect of direct costs, with the other 15% apportioned to clinical support services (e.g. Pathology, Radiology)
o Of the 50%, a proportion is then allocated to Operating Theatres, in respect of the surgical specialties.
o
• It is proposed to allocate budgets through the ledger on this basis for Month 7 and to review the allocation again at Q3 (Month 9) and Month 12.

3. COST IMPROVEMENT PROGRAMME
Commentary
Forecast outturn
The Month 6 forecast is £17.7m - at the same level as at Month 5. A new “Blue” rating is used to denote schemes that have been fully implemented, e.g. a post has been removed.
£1.5m has moved in the RAG profile from Red to Blue, Green and Amber which are forecast at £12.9m.
This includes:
Reversal of Annual Leave Provision 750
Outpatients schemes 330
Emergency Care 120
Neurosciences 110
Rates Assessment 100
Other 90
Total new BAG schemes £1,500k
CIP mitigation schemes (Red rated currently) include:
Short Term Controls 2,350
VAT on Medical Locum spend 600
Medicines Management 560
VAT on Pharmacy 250
Length of Stay 200
Workforce – AHP’s 200
Salary sacrifice 50
Other 580
Total CIP mitigation £4,790k
YTD position
The Trust has achieved savings of £4.3m against a target of £6.5m, a shortfall of £2.2m (34%). This is mainly due to the Unidentified CIP gap of £1.4m. In addition there are
material adverse variances in Diagnostics - £200k - and Nursing - £400k - relating to workforce and temporary pay reduction schemes.
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4. BALANCE SHEET
Balance Sheet Current Previous Last
(£m) Period Period Yr End
Aug-12 Jul-12 Mar-11
Non-current assets £390.4 £390.3 £389.1
Current assets
Inventories £5.8 £5.8 £7.0
Trade and other receivables £35.1 £40.2 £29.5
Cash and cash equivalents £1.4 £5.4 £2.8
£42.4 £51.4 £39.3
Current liabilities
Trade and other payables (£67.2) (£69.1) (£48.2)
PFI \ Borrow ings (£6.3) (£6.3) (£5.5)
Provisions (£1.9) (£2.1) (£1.8)
Net current assets/(liabilities) (£33.1) (£26.1) (£16.2)
Non-current liabilities:
PFI \ Borrow ings (£255.8) (£255.8) (£259.9)
Trade and other payables (£4.9) (£4.9) (£4.9)
Provisions (£4.2) (£5.6) (£5.0)
Total assets employed £92.4 £98.1 £103.0
Financed by taxpayers' equity:
Public dividend capital £365.7 £365.7 £307.3
Retained Earnings - P&L (£284.7) (£279.1) (£216.4)
Retained Earnings - Donated Assets - - -
Revaluation reserve £11.5 £11.5 £11.3
Donated asset reserve £0.0 £0.0 £0.8
Total taxpayers' equity £92.4 £98.1 £103.0
Current Prior Last
KPIs Period Period Yr End
Aug-12 Jul-12 Mar-12
Average Debtors days 16 17 21
Debtors >90 days (£'000s) £1,240 £1,261 £592
Debtors >180 days (£'000s) £466 £495 £1,536
Debtors >365 days (£'000s) £2,089 £2,034 £2,825
Total Bad Debt Provision (£'000s) £2,412 £2,413 £1,926
>365 days provided (£'000s) £1,822 £1,782 £1,293
Average creditor days 50 53 58
Current ratio 53% 62% 71%
Better payment practice code performance:
- Non-NHS
- Volume - paid on time 1,569 1,781 2,773
- Volume - % paid on time 52.35% 52.41% 27.96%
- Value - paid on time (£'000s) £5,874 £20,475.00 £5,150
- Value - % paid on time 68.33% 78.85% 35.85%
- NHS
- Volume - paid on time 39 185 316
- Volume - % paid on time 33.91% 58.36% 34.39%
- Value - paid on time (£'000s) £169 £904 £1,630
- Value - % paid on time 10.82% 26.25% 30.52%
Key points:
• Overall balance sheet position shows a reduction of £5.7m,
related to the in month I&E deficit The cash position shows a
reduction of £4.0m, compared with July.
Key points:
• Average creditor days reduced from 53 in June to 50 in August whilst
average debtor days reduced from 17 to 16. Value of Non-NHS invoices
paid on time reduced from £20.4m to £5.9m in August this was due to PFI
unitary payment in July of £13.3m.
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5. CAPITAL AND CASHFLOW
Summary Cashflow - Year to date
£000's
Operating Deficit (9,601)
Interest Paid (12,266)
PDC Dividend Paid 0
Interest received 204
Impairments (1,728)
Transfers -
Net I&E deficit (cash impact) (23,390)
Depreciation and Amortisation 5,933
Movements in w orking balances:
Decrease in Inventories (5)
Increase in Trade and Other Receivables 2,126
Increase in Trade and Other Payables 23,159
Decrease in Provisions (1,622)
- sub-total 6,201
Capital expenditure (6,646)
Revenue Rental Income 546
Net cashflow before financing 101
Capital Element of Finance Leases and PFI (3,002)
Loans repaid -
Public Dividend Capital Received -
Net Increase/(Decrease) in Cash and
Cash Equivalents
(2,901)
Opening cash balance 4,343
Closing cash balance 1,442
Capital Programme Summary Aug-12
Total
Approved
Total
Proposed
Total
Funding
YTD
Expenditure
2012-13 2012-13 2012-13
Internally Funded Assets
Medical Equipment 1,926 1,848 3,774 1,609
IT - Hardware 1,429 299 1,728 737
IT - Software 482 0 482 88
Other Plant & Machinery 500 0 500 0
Estates 3,372 382 3,754 962
sub-Total 7,709 2,529 10,238 3,395
Externally Funded Assets
Pathology 4,342 900 5,242 525
SAN 967 0 967 711
MLU 2,396 0 2,396 217
Access Funded Assets 117 0 117 49
sub-Total 7,822 900 8,722 1,503
Trust Variation Enquiries 3,380 0 3,380 225
Total Trust - Funded 18,911 3,429 22,340 5,123
Subject to External Approval & Funding
Cardiac Cath Lab 0 1,700 1,700 0
CT Scanners 0 2,000 2,000 0
A&E Reconfiguration 0 3,000 3,000 0
Digital Mammography 0 1,548 1,548 0
PAS Replacement 0 10,000 10,000 0
sub-Total 0 18,248 18,248 0
Total Capital Plan to Date 18,911 21,677 40,588 5,123
Total Trust Submitted Plan 40,011
Balance to Submitted Plan (577)
Assets to be Considered via Charitable Funds
Da Vinci Robot 0 2,400 2,400
Cashflow - Key points:
• The net cash position decreased from £5.4 to £1.4
in August.
Capital - Key points:
• Against the total Trust Capital Plan of £40.9m, £18.3m of externally
funded schemes have yet to be fully approved (including PAS). Of
the remaining £22.6m, £19.2m of projects have been approved, with
a further £3.4m awaiting business case approval.
• Against this position, year to date capital expenditure is £5.1m, an increase
of £1.3m compared with July.
• The Trust has frozen all non-essential capital schemes, pending mitigation
of risk in achieving the £40m revenue control total
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6. Business Unit Summaries
Attached are the summary financial reports for each of the Clinical Business Units. These show:
1. A graphical dashboard summary of the key financial indicators
2. Key financial variances with mitigating actions, including leads and timescales
3. CIP report for the Business Unit
4. Income and Expenditure statement for each Business Unit. This shows each Business Unit’s share of the Central Income position and their local Income and
Expenditure position, giving an overall Net Deficit (+) / Surplus (‐) position. All Income is shown as a credit (‐) and all variances are expressed as Adverse (‐) or
Favourable (+). It should be noted is not a true SLR report, as none of the central income has been apportioned out to the services that are supporting it (e.g.
Diagnostics, Therapies), rather it represents where the income is coded to. They do show, however, the movement in the relationship between coded
income and expenditure between current year to date and prior year average for expenditure and actual reported income.
5. Forecast outturn, with a reconciliation to the previous month’s forecast.
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