TB2012.63
Trust Board Meeting: Thursday 5 July 2012
TB2012.63
Title
Status
History
Development of Strategies for Risk, Assurance and Quality
A paper for discussion
Board Strategy Workshop 16 May 2012
Audit Committee Workshop 25 June 2012
Quality Committee 26 June 2012
Trust Management Executive 28 June 2012
Board Lead(s)
Ms Eileen Walsh, Director of Assurance
Mrs. Elaine Strachan-Hall, Chief Nurse
Professor Edward Baker, Medical Director
Key purpose
Strategy
Assurance
TB2012.63_Development of Strategies for Risk, Assurance and Quality
Policy
Performance
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Oxford University Hospitals
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Summary
The paper presents the proposed strategies to support the Trust’s business, through
improved arrangements for the management of risk, quality, and assurance.
1
The development of the strategies underpins the delivery of safe services and
managing the Trust’s business efficiently.
2
Implementation plans for each strategy have been developed, subject to
approval, which will be overseen by the relevant Executive Director.
3
The strategies were presented for review by the, Audit Committee, Quality
Committee and Trust Management Executive meetings in June for discussion.
4
Feedback has been collated from the respective meetings and is presented to the
Board to review.
5
Based on the decisions agreed by the Board the updated strategies will be
approved and circulated.
6.
Recommendations
The Board is asked to:

review the proposed amendments and points where feedback has differed

agree delegated authority to the Chair and Chief Executive to approve the
amended strategies
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Introduction
1.
The purpose of this paper is to present the collated feedback given on the proposed
three strategies which underpin the Trust’s risk management, quality, and assurance
agendas.
2.
The draft documents were considered by the full Quality Committee, Executive and
Non-Executive Directors at the Audit Committee Seminar, and Trust Management
Executive during June. Members were invited to discuss the drafts in detail to inform
further development of the strategies. Individual Directors have also provided
feedback outside of the meetings.
3.
This paper summarises the key points raised during discussion. These will be
incorporated into the amendments for the final versions. However where points
which were raised but views differed, these are presented in this paper for final
decision by the Board.
4.
The drafts of the strategies discussed at previous meetings have been circulated
separately to all Board members.
5.
Notwithstanding the Trust’s own objective to have interlinked strategies to support
the development of these important agendas, there are a number of external
demands on the Trust to have supporting strategies in place in the identified areas.
These include Strategic Health Authority development support as part of the
Foundation Trust authorisation process, regulatory requirements including Care
Quality Commission Essential Standards of Quality & Safety, and NHS Litigation
Authority criteria.
6.
The strategies will form an important part of developing risk, quality and assurance
in the Trust, as a means to support continuous quality improvement, improved
management of risk, and assurance provided to the Board on the effectiveness of the
system for internal control.
Key points across strategies
7.
Details of the comments received on each individual strategy have been collated into
Appendix 1. A number of common issues were identified across the strategies,
namely:
7.1. The strategies should set a clear vision for the next five years, defining clear and
measurable goals;
7.2. Implementation plans will need to include timescales which are achievable and
realistic with consideration given to resource requirements, including the
provision of training for staff;
7.3. The inter-relationship of the strategies should be better described within the
documents;
7.4. The strategies should be written in a way that gives context and set out clearly
how they are relevant to each staff group;
7.5. The final documents should be of the highest quality in terms of style, format,
and content;
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Oxford University Hospitals
8.
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However, a small number of comments were not in agreement and the Board is
asked to discuss the individual comments and confirm their decision on each
amendment.
8.1. Risk Proximity:
The Audit Committee Seminar and the Quality Committee discussed the
addition to the risk register of a column noting the proximity of a risk
occurring. Both committees agreed that using another colour grading scale
would not be appropriate and this will be removed. However, different views
on the timescales for noting the proximity of a risk occurring were discussed.
The Audit Committee Seminar considered that timescales should be longer and
more strategically focussed, while the Quality Committee suggested a more
operational approach to the risk occurring:
Audit Seminar
12
–
months
18 18 months
years
Quality Committee
within
months
3 3 - 6 months
–
3 3 years or more
6 – 12 months
The Trust Management Executive discussed the two differing approaches. It
was suggested that to reflect the new performance framework three months
would be a more appropriate measure as in terms of performance reporting
externally, a serious risk not resolved within three months would result in
intervention.
8.2. High Impact / Low Likelihood Risks:
The Audit Committee Seminar and Quality Committee both discussed the
value of reviewing risks assessed as being of high consequence, but low impact.
These risks would not necessarily be escalated to the level that would be
reviewed by the committees. The Board is asked to consider whether including
this as a separate item within risk register reports would be of value in future,
or whether other options should be explored.
9.
The Board is asked to discuss the detail of Appendix 1 and to confirm their decisions
regarding the issues marked for discussions.
Implementing the Risk Strategy
10.
The management of risk underpins the delivery of safe services and managing the
Trust’s business efficiently. An important part of revising systems will be developing
the capacity at all levels to manage risk through education and training.
11.
An assessment of the Trust’s risk maturity has been undertaken which was used to
inform the Board session considering the Trust’s capacity to manage risk,
appropriate tolerances and methods of escalation. These will be supported by
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guidance and tools for staff at each level and published in a Risk Management
Handbook for staff.
12.
Further work will be undertaken with the Board to set its risk appetite for key areas
for the financial year.
13.
The supporting documentation will be developed by the Director of Assurance’s
team in consultation with specialist staff in Health & Safety and Clinical Governance,
and will link into the Trust’s revised performance management framework and
reporting.
Implementing the Quality Strategy
14.
It is vital that the Trust clearly defines its goals in relation to clinical quality such that
a consistent message can be articulated both within and outside the organisation.
15.
The Quality Strategy has been developed by bringing together existing work streams
that relate to safety and quality, whilst articulating the aspirations of the organisation
going forward.
16.
The development of the Quality Strategy has been managed as a project by the
Medical Director and Chief Nurse, together with the supporting frameworks for
outcomes, effectiveness and experience.
17.
Key members of staff have been engaged in the process of development.
18.
The Quality Strategy has been developed to support the maintenance and
improvement of clinical quality. An associated implementation plan will be further
developed subject to approval of the strategy.
Assurance Strategy
19.
Building on existing work programmes to strengthen assurance, the assurance
strategy has been developed to complement the risk and quality strategies.
20.
In addition to the Board Assurance Framework, supporting assurance processes
around the management of risk and quality will be incorporated. This will ensure
that the Trust is delivering services safely and efficiently and has sufficient means to
identify any gaps and monitor the effectiveness of controls.
21.
In a similar approach to Internal Audit functions, this includes responsive reviews
where further assurance is required or problem areas are identified. Additional tools
and supporting processes are described and defined, and how these provide
assurance to different audiences.
Plan to implement the strategies
22.
Overseen by the Executive Directors, senior staff from the teams will be responsible
for implementation of the strategies. Each strategy has a supporting plan for
implementation.
23.
As these three strategies underpin a significant objective for the Trust, it is
anticipated that they will be implemented as soon as possible following approval at
the July Trust Board meeting. This in turn will support other key objectives such as
FT authorisation which requires formal external assessment against the Quality
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Governance Framework, Board Governance Assurance Framework, and an exercise
of historical due diligence..
Strategy Approval
24.
Based on the decisions reached by the Board in response to the points presented for
discussion, the strategies will be finalised and approved.
25.
The final strategies will be circulated for the Board Seminar to be held on 19 July
2012.
26.
Given timescales, the Board is asked to grant delegated authority to the Chair and
Chief Executive to approve the final strategies following amendment.
Recommendations
27.
The Board of Directors is asked to:
27.1. review and discuss the proposed strategy documents
27.2. agree the points marked for decision in Appendix 1.
27.3. grant delegated authority to the Chair and Chief Executive to approve the
strategies
Ms. Eileen Walsh, Director of Assurance
28 June 2012
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Appendix 1: Feedback received on strategy development
X
The link between the three strategies and how each interrelates needs to be improved
X
The long term vision is not as clear as that defined in the Quality Strategy
X
X
X
X
X
X
X
X
Audit
Committee
Trust
Management
Executive
The final strategy needs to be of publishable standard, in terms of presentation, format, and writing style.
A one page visual summary should accompany the strategy.
Quality
Committee
Issues to be addressed by amendments
Individual
Feedback
Strategy: Risk Management
How the impact of the strategy will be measured needs to be included
X
The individual and committee responsibilities need to be clarified, including the differentiation between
front line staff and management at each level
X
X
The statements on risk and horizon scanning should be stronger, and include definition around positive
opportunities and a positive approach to horizon scanning
X
X
It was noted that further work needed to occur with the Board to agree the risk appetite against individual
strategic objectives
X
X
The common currency for risk registers should be service level rather than clinical directorate level
X
X
X
Strategies refer to Divisional General Managers which should read Clinical Directors
X
X
X
Mechanisms need to be clearly described for how risks across the organisation are aggregated, and the
process for de-escalation
X
X
X
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X
X
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An overview needs to be provided on how risks are captured at ward level and how the system fits
together, i.e. through schematic diagrams included in the document
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X
Training requirements need further review and planning
Implementation plans and associated timescales need to be achievable and realistic with consideration
given to resource requirements, including the provision of training for staff
Implementation plans should describe how the transition from old to new risk registers will take place
X
X
X
X
X
X
X
Issues for agreement by the Board
1. Risk Proximity: The Audit Committee Workshop and the Quality Committee discussed the addition to the risk register of a column noting the
proximity of a risk occurring. Both committees agreed that using another colour grading scale would not be appropriate and this will be
removed. However, different views on the timescales for noting the proximity of a risk occurring were discussed. The Audit Committee
Workshop considered that timescales should be longer and more strategically focussed, while the Quality Committee suggested a more
operational approach to the risk occurring:
Audit Committee:
1) 12 – 18 months 2) 18 months – 3 years 3) 3 years or more
Quality Committee: 1) within 3 months 2) 3 - 6 months
3) 6 – 12 months
2. High Impact / Low Likelihood Risks: The Audit Committee Seminar and Quality Committees both discussed the value of reviewing risks
assessed as being of high consequence, but low impact. These risks would not necessarily be escalated to the level that would be reviewed by the
committees. The Board is asked to consider whether including this as a separate item within risk register reports would be of value in future, or
whether other options should be explored.
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Quality
Committee
Audit
Committee
Trust
Management
Executive
Issues to be addressed by amendments
Individual
Feedback
Strategy: Assurance
The final strategy needs to be of publishable standard, in terms of presentation, format, and writing style.
A one page visual summary should accompany the strategy.
X
The link between the three strategies and how each interrelates needs to be improved
X
X
X
X
The long term vision is not as clear as that defined in the Quality Strategy
X
X
X
X
X
How the impact of the strategy will be measured needs to be included
The staff and committee responsibilities need to be clarified, including how assurance relates to different
levels of staff
The strategy should clarify further how assurances will be used and how they can be used for different
audiences, e.g. Patient Groups, or how Governors are assured once FT Membership arrangements are in
place
X
X
X
X
X
How assurances will link back to risk registers should be explained
The assurance level definitions should be reviewed in comparison to similar measures, e.g. internal /
external audit terminology; data quality definitions
Distinction should be made between assurance for targets, and assurance of quality, and how this relates
to assurance across the totality of the business
The Assurance Tools section needs further explanation of how sources of assurance and assurance tools link
together and enable the delivery of the strategy
TB2012.63_Development of Strategies for Risk, Assurance and Quality
X
X
X
X
X
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Within the healthcare setting an additional mechanism of assurance was defined encompassing the
various mechanisms for capturing patient assurance, i.e. through the patients’ experience framework,
reactive processes such as complaints and PALS contacts, and surveys
The Sources of Assurance examples should include simple, relevant examples such as the assurance level of
integrated performance reporting, or how different sources of assurance are brought together through a
topic example (Cancer Waits; Delayed Transfers of Care)
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X
X
X
Issues for agreement by the Board
No areas requiring further discussion were identified through by the various committees/contributors.
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Quality
Committee
Audit
Committee
The final strategy needs to be of publishable standard, in terms of presentation, format, and writing style.
A one page visual summary should accompany the strategy.
X
The link between the three strategies and how each interrelates needs to be improved
X
X
X
The vision should be further defined in terms of will be the year on year improvement
X
X
X
X
How the impact of the strategy will be measured needs to be included
X
The strategy objectives and goals should include how these fit with other agencies, e.g. SHA or PCT
priorities
X
How the Trust aims to deliver an enhanced quality of care through specialist services and the relationship
to DGH services should be described
X
How the impact of the strategy will be measured needs to be included; this should include how the vision
translates into actual goals and quality measures
Greater emphasis should be included on the Trust’s leadership of quality and interfaces with partners
within an Academic Health Sciences Network
Trust
Management
Executive
Issues to be addressed by amendments
Individual
Feedback
Strategy: Quality
X
X
X
X
X
The breadth of the strategy could be wider, e.g. considering research, or education
X
X
Improvements are required to diagrams showing committee reporting linkages
X
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Before approval the strategy should be checked against the Quality Governance Framework
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X
Issues for agreement by the Board
No areas requiring further discussion were identified through by the various committees/contributors.
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