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Agenda Item: 10
TRUST BOARD – 29 FEBRUARY 2012
RISK & QUALITY COMMITTEE - 24 FEBRUARY 2012
EXECUTIVE SUMMARY REPORT
PURPOSE:
To present to the Trust Board the report from the Risk and Quality
Committee (RAQC) meeting of 24th February 2012
PREVIOUSLY
CONSIDERED BY:
N/A
IMPLICATIONS:
Objective(s) to
which issue relates:
Spans all objectives.
Risk Issues:
Key assurance committee reporting to the Board
Financial:
Any major financial implications of matters considered by the RAQC are
always referred to the FPC
HR:
A number of items relate to the workforce
Healthcare/
National Policy:
In line with Standing Orders and best practice in corporate governance
Legal Issues:
None identified
Equality Issues:
None identified
RECOMMENDATIONS:
The Board is asked to review the report from the RAQC
DIRECTOR:
Chair of RAQC
PRESENTED BY:
Chair of RAQC
AUTHOR:
Trust Secretary / Company Secretary
DATE:
24 February 2012
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RISK & QUALITY COMMITTEE (RAQC) – 24 February 2012
EXECUTIVE SUMMARY REPORT TO BOARD – 29 February 2012
Clinical Audit
The Audit Committee has asked the RAQC to look at the assurances that it requires on clinical
audit in order to take these into consideration when considering the Annual Governance
Statement, formerly known as the Statement on Internal Control, as part of the annual reporting
process. The RAQC has asked for a report at the next meeting, benchmarking the Trust’s clinical
audit processes and outcomes against a specific set of assurances, and will then report back to
the Audit Committee.
Annual Objectives 2012/13
The RAQC considered the proposed annual objectives for the Trust for 2012/13, focusing
particularly on objectives 3 and 4. The RAQC agreed that the objectives were specific and
measurable, but decided upon a number of amendments to their wording and presentation. An
additional annual objective relating to the delivery of the Learning Disability Improvement Plan
was also agreed.
Annual Plan 2012/13
The RAQC received an update on the process and timetable for the development of the Annual
Plan, and signalled its intention of devoting a significant amount of time to discussing the priorities
for 2012/13 when it considers the draft plan at its next meeting.
Floodlight indicators 2012/13
The RAQC reviewed the proposed floodlight indicators for 2012/13, focusing on those areas that
fall within its remit. It discussed these at some length and made a number of amendments to the
proposed indicators, as well as requesting further review by the relevant director in certain cases.
It also decided that some key metrics for health and safety should be included.
On the broader issue of where the Trust’s internal targets should be pitched, the Committee
agreed that the default position should be to aim to be achieving upper quartile performance
consistently within three to five years (to allow for the period of substantial change facing the
Trust) with the thresholds based on trajectories to achieve that aim. However, in certain areas the
Trust should aim to be an exemplar and in others to achieve upper quartile performance in the first
year. While these areas will need to be identified, the RAQC made a firm decision that one area
where the Trust must aim to achieve upper quartile performance in 2012/13 is culture, since this is
critical to its performance in other areas.
Once the targets and trajectories are established, the RAQC decided that there should be a
reference document setting out the rationale for each indicator.
Learning Disability Improvement Plan
The RAQC considered a Learning Disability Improvement Plan, which is part of a national initiative
and is based on a comprehensive self assessment of the Trust’s current position against a Quality
Assurance Framework. The improvement plan demonstrates that a substantial amount of work
will be required to achieve the expected levels for 2012, and beyond that to move to a position
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where the Trust is rated green in all areas. The plan will also require extra resource. The RAQC
decided that achievement of the improvement plan should become one of the Trust’s annual
objectives. This will ensure that it is not only supported at Board level but that its progress and
resourcing can be monitored.
Ian Morfett, Vice Chairman (Chair of RAQC)
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Agenda Item: 10a
BOARD – 29 FEBRUARY 2012
Board Assurance Framework 2011-12, Quarter 3
PURPOSE:
To present to the Trust Board the Board Assurance Framework for
2011/12, this includes the quarter 3 reviews for consideration
PREVIOUSLY
CONSIDERED BY:
All Executive Directors
RAQC, January 2012: New risk added and action plans reviewed as per
discussions at RAQC.
IMPLICATIONS:
Objective(s) to
which issue relates:
Relates to all assurance objectives. Key component of the Trust’s
governance arrangements
Risk Issues:
Key to providing the Board with assurance on the management of the risks
to delivery of the Trust’s corporate objectives and statement of internal
control
Financial:
Potential risks identified within the framework
HR:
Potential risks identified within the framework
Healthcare/
National Policy:
Key to the Trust’s governance arrangements, Healthcare regulation and
FT application
Legal Issues:
Legislative risks will identified in the framework
Equality Issues:
None identified
RECOMMENDATIONS:
The Committee is asked to consider the Board Assurance Framework for 2011/12 alongside the
quarter 3 reviews and note the new risk to reflect the potential clinical risks of the delay to phase
four element of the consolidation programme.
DIRECTOR:
Chief Executive
PRESENTED BY:
Company Secretary
AUTHOR:
Company Secretary
DATE:
February 2012
Board Assurance Framework 2011-12, Quarter 3
- Trust Board – February 2012
Introduction
The Board Assurance Framework contains the principal risks associated to the achievement
and delivery of the Trust Annual and Strategic Objectives. The Strategic Objectives, from which
the 2011/12 annual objectives have been framed, build on the current annual objectives and the
Trust’s vision: To deliver quality local healthcare that is valued and trusted.
Strategic objectives
1. To consolidate acute services for complex or serious conditions onto a single site.
2. To work with colleagues in primary care to expand local access to specialist acute
services.
3. To maintain the pre-eminence of Mount Vernon as a tertiary Cancer Centre, and to
provide more cancer care locally
4. To improve continuously the quality of all aspects of our services.
The Board Assurance Framework remains a live document and work is ongoing to ensure to
strengthen the links to known future sources of internal and independent assurance, the
identification of key actions and the review of the key controls used to monitor the delivery of the
objectives.
February 2012:
The Risk and Quality Committee reviewed the BAF alongside the quarter 3 reviews at its
meeting in January 2012.
Following consideration at RAQC:
 A new risk was added onto the BAF; the potential clinical risks posed through
delays in approval of the Phase 4 FBC, specifically risk of sustainability of QEII
as an acute site until final consolidation and the risk of increased emergency
activity through the Lister site prior to completion of infrastructure, see page 29.
 some of the action plans have been and continue to be reviewed to ensure that
they more clearly demonstrate how risk is being mitigated and the end of year
position will be achieved.
Other key changes for Trust Board to note this quarter are:
 the achievement of some of the annual objectives on page 2; a final review of all
of the achievement annual objectives will be completed at year end.
 the one ‘red’ risk relating to the risk of delay to consolidation programme on
page 6
 the quarter 3 progress reports on pages 9, 14, 18, 31 and 32.
 the changes to the end of year forecasting for Patient Experience and Staff
culture as the action taken will take longer than 1 year to embed fully.
 the new risk of the potential clinical risks of the delay to phase four (page 29)
See the full BAF within the Trust Board data pack. The most recent changes are noted in a
different colour text. Any changes made to the risk assessment are also noted in the document.
Conclusion:
The Trust Board is asked to consider this report and state is any further assurances are
required.