Board of Directors Meeting - 29 March 2012 - Devon Partnership ...

ASSURANCE FRAMEWORK AND CORPORATE RISK REGISTER - March 2012 - Board of Directors (16 & over)Board of Directors Meeting, 29 March 2012Agenda Item 12IDActivity/Objective/Risk Description Contributory issue Source of risk ExecSafe1. This will be definedaccording to circumstancesbut likely to be moresignificant than a single SUI& where all governancearrangements are calledinto question.HS(JR)KPIRefCQCOutcomesRiskTypePrevMonth'sRiskActionPlanprogressCurrentRiskResidualRiskCurrent AssuranceAction Plan(Evidence of effective actions) Committee (Evidence of action to address control/assurance gaps)1. Strengthened & recognised SUIprocesses.2. Historic evidence of managing theseincidents both internally & externally.1. Dedicated RCA investigators appointed. Some appointed, furtherappointments to take place. Target date: May 2011 (completed)13/9/11 - all RCA investigators appointed. One yet to start.2. Incident occurred - highlights potential issue relating to environmental& practice factors - immediate action plan in place monitored throughExec.3. Commissioned four part review (2 RCA, system review & model ofcare). Target date: 31 Jul 2011. Review completed & with SHA. (Allcompleted). Paper prepared for Directorates to consider whether theywant to maintain the Dedicated RCA investigator team (funding availabletill mid 12) or develop another investigatory process.S10Catastrophic clinical adverse 2. Improvement in practice 1. Team dashboards &event occurs.is limited as a result of lack composite risk scores.of delayed & sustained 2. Serious incidentimprovement in CTL reports.leadership.HS4 S/OHigh(5x4=20)High(5x4=20)Moderate 1. Quality/performance matrix in place(4x2=8) for teams not meeting requiredquality/practice standards.2. Composite risk scoring.(i)Q&S1. Exec approval for sustainable improvement academy - pilot to beundertaken. Target date: Dec 2012. 10/1/12 pilot work with teams hastaken place, paper to exec on 16/1/12. (completed)2. Consultant - support & coaching where necessary - ongoing.3. Rapid improvement work - ongoing.4. Prompt list to be developed to identify high risk people & teams fromMDT discussion. Target date: Sept 2011, revised target date: Dec2011, revised target date: Apr 2012.5. Draft risk guidance drafted by Co-Medical Director, awaiting commentsfrom Senior Management Teams within Directorates, then forimplementation. Target date: Feb 2012. Currently being piloted in somecommunity teams. Revised target date: Mar, Apr 2012 followingDirector review.6. Monthly performance meetings with Directorates.**Timescale to achieve residual risk level: to remain at higher risklevel until assurance rec'd thro Clinical Directorate reporting thatquality & safety issues have been addressed. (Apr 2012, revised toJul 2012)SU1SustainableEXTERNAL RISK1. Public spendingenvironment & near levelNHS spending required tomeet continuing increaseddemand.2. Public spending reductions& effect on local authoritysocial care budgets mayresult in Health Servicesincluding DPT having toabsorb some social carecosts.1. Spending on mentalhealth & learning disabilityservices is squeezed due toblock contractarrangements.2. Sub set risk (4x4=16)3. Commissioner overspendon IPPs in 2011/12.4. National CommissioningBoard assessment of MHservices being 10% aboveachievable cost.1. Trust wide riskassessment of externaleconomic environment.IFH 6, 26 S/FHigh(5x4=20)High(5x4=20)1. Active participation in NHS SW &NHS Devon QIPP programmes with lowexpectations of cost savings from MH &LD services which have now beenconfirmed with QIPP financial planningforecasts & corresponding impact onprovider income.2. Board receive regular reports &Significant additional informal discussion.(4x3=12) 3. Monthly review by FIC/BE.4. Current joint managementarrangements.(i)BE(ii)FICSU1 & SU5 combined as at Dec 20111. Main action is ongoing revision & review of financial plans as newinformation comes to light. No specific project is required & the situationis reviewed regularly at FIC.2. IPP Remediation Strategy being developed in conjunction withCommissioners. Target Date: Oct 2011 (completed)3. The Trust is monitoring closely any emerging potential impact.4. The Trust has produced a prudent LTFM.5. Further mitigated plans have been developed & will be approved byMar 2012.**Timescale to achieve residual risk level: Mar 2012Red indicates movement in original timescaleDefinitionsRisk Type S - Strategic, C - Corporate level operational risk due to material impact, O - Operational, F- Financial, IMT- Information Management & TechnologyPrev Month's Risk Risk status - February 2012 (consequence x likelihood)In Month Movement Change (reduction, improvement or no change) in risk status from February 2012 to March 2012Current Risk Risk status - March 2012 (consequence x likelihood)Residual Risk Risk status - once all actions have been implemented / remaining inherent riskResponsible Committee(s)Q&S Quality & Safety Committee BEFICFinance & Investment CommitteeBusiness ExecutiveRef: Combined Assurance Framework Corporate Risk Register Page 1 of 1Page 107 of 156