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									                                                                                           6-ERC (09)12                                                                     Agenda Item: 8.2.2
                                                                                                                                                                           Paper No: TB(09)45

ASSURANCE FRAMEWORK - 09/10

ASSESSMENT OF STRATEGIC AIMS & CORPORATE OBJECTIVES, RISKS AND KEY CONTROLS 2009 - 2010

Objective 1: To maintain and further improve clinical safety and outcomes and reduce HCAIs using evidence based practice

Objective 2: To ensure achievement of National targets, priorities and requirements

Objective 3: Make positive patient involvement and experience a key focus of the organisation

Objective 4: Substantive establishment of the St George's Acute Stroke Services

Objective 5: To be recognised trauma & emergency centre

Objective 6: To support the development of consultant led services into community settings

Objective 7: To ensure all research complies with statutory requirements and best practice

Objective 8: Promote the best interests of patients and the community through co-ordinated planning & development of clinical teaching, training & research to improve care & clinical outcomes

Objective 9: To achieve financial targets and improve financial risk rating

Objective 10: To take necessary steps to position the organisation for FT status

Objective 11: Ensure we meet statutory employment duties, workforce targets and comply with external assessments

Objective 12: To support our workforce through a challenging year

Objective 13: Ensure compliance with statutory and mandatory duties, regulations and external assessments

Objective 14: To continually improve the hospital environment through capital investment

Objective 15: Develop an outline business case for redevelopment of the Tooting campus
6-ERC (09)12    Agenda Item: 8.2.2
               Paper No: TB(09)45
                                                                          6-ERC (09)12                                                    Agenda Item: 8.2.2
                                                                                                                                         Paper No: TB(09)45
      1 -3          Low risk              G
      4 -6          Moderate risk         Y
      8 - 12        High risk             A
     15 - 25        Extreme risk          R

Table 2 Likelihood score (L)
What is the likelihood of the consequence occurring?

The frequency-based score is appropriate in most circumstances and is easier to identify. It should be used
whenever it is possible to identify a frequency.

Likelihood score     1                        2                       3                    4                     5
Descriptor           Rare                     Unlikely                Possible             Likely                Almost certain
Frequency            This will probably       Do not expect it to     Might happen or      Will probably         Will undoubtedly
How often might      never happen/recur       happen/recur but it     recur occasionally   happen/recur but it   happen/recur,possibly
it/does it happen                             is possible it may do                        is not a persisting   frequently
                                              so                                           issue




Table 3 Risk scoring = consequence x likelihood ( C x L )

                     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
                                                                               6-ERC (09)12                                                    Agenda Item: 8.2.2
                                                                                                                                              Paper No: TB(09)45
Table 1 Consequence scores
Choose the most appropriate do main for the identified risk from the left hand side of the table Then work
along the columns in same row to assess the severity of the    risk on the scale of 1 to 5 to determine the
consequence score, which is the number given at the top of the column.

                            Co nsequence score (severity levels) and examples of descriptors

                            1                   2                       3                       4                       5
Domains                     Negligible          Minor                   Moderate                Major                   Catastrophic
Impact on the safety of     Minimal injury      Minor injury or         Moderate injury         Major injury leading    Incident leading to
patients, staff or public   requiring           illness, requiring      requiring               to long -term           death
(physical/psychological     no/minima l         minor intervention      professional            incapacity/disability
harm)                       intervention or                             intervention                                    Multiple permanent
                            treatment.          Requiring time off                              Requiring time off      injuries or
                                                work for >3 days        Requiring time off      work for >14 days       irreversible health
                            No time off work                            work for 4 -14 days                             effects
                                                Increase in length                              Increase in length of
                                                of hospital stay by     Increase in length      hospital stay by >15    An event which
                                                1 - 3 days              of hospital stay by     days                    impacts on a large
                                                                        4 -15 days                                      number of pa tients
                                                                                                Mismanagement of
                                                                        RIDDOR/agency           patient care with
                                                                        reportable incident     long - term effects

                                                                        An event which
                                                                        impacts on a small
                                                                        number of patients




Quality/complaints/audit    Peripheral          Overall treatment       Treatment or            Non -compliance         Totally
                            element of          or service              service has             with national           unacceptable level
                            treatment or        suboptimal              significantly           standards with          or quality of
                            service                                     reduced                 significant risk to     treatment/service
                            suboptimal          Formal complaint        effectiveness           patients if
                                                (stage 1)                                       unresolved              Gross failure of
                            Informal                                    Formal complaint                                patient safety if
                            complaint/inquiry   Local resolution        (stage 2) complaint     Multiple complaints/    findings not acted
                                                                                                independent review      on
                                                Single failure to       Local resolution
                                                meet internal           (with potential to go   Low performa nce        Inquest/ombudsman
                                                standards               to independent          rating                  inquiry
                                                                        review)
                                                Min or implications                             Critical report         Gross failure to
                                                for patient safety if   Repeated failure to                             meet national
                                                unresolved              meet internal                                   standards
                                                                        standards
                                                                            6-ERC (09)12                                                    Agenda Item: 8.2.2
                                                                                                                                           Paper No: TB(09)45
                                               unresolved            meet internal                                  standards
                                                                     standards
                                               Reduced
                                               performance rating    Major patient safety
                                               if unresolved         implications if
                                                                     findings are not
                                                                     acted on
Human resources/         Short -term low       Low staffing level    Late delivery of key   Uncertain delivery      Non -delivery of key
organisational           staffing level that   that reduces the      objective/ service     of key                  objective/service
dev elopment/staffing/   temporarily           service quality       due to lack of staff   objective/service       due to lack of staff
competence               reduces service                                                    due to lack of staff
                         quality (< 1 day)                           Unsafe staffing                                Ongoing unsafe
                                                                     level or               Unsafe staffing level   staffing levels or
                                                                     competence (>1         or competence (>5       competence
                                                                     day)                   days)
                                                                                                                    Loss of several key
                                                                     Low staff morale       Loss of key staff       staff

                                                                     Poor staff             Very low staff          No staff attending
                                                                     attendance for         morale                  mandatory training
                                                                     mandatory/key                                  /key training on an
                                                                     training               No staff attending      ongoing basis
                                                                                            mandatory/ key
                                                                                            training
Statutory duty/          No or minimal         Breech of statutory   Single breech in       Enforceme nt action     Multiple breeches in
inspections              impact or breech      legislation           statutory duty                                 statutory duty
                         of guidance/                                                       Multiple breeches in
                         statutory duty        Reduced               Challenging            statutory duty          Prosecution
                                               performance rating    external
                                               if unresolved         recommendations/       Improvement             Complete systems
                                                                     improvement notice     notices                 change required

                                                                                            Low performance         Zero performance
                                                                                            rating                  rating
Adverse publicity/       Rumours               Local media           Local media            National media          National media
reputation                                     coverage –            coverage –             coverage with <3        coverage with >3
                         Potential for         short-term            long-term reduction    days service well       days service well
                         public concern        reduction in public   in public confidence   below reasonable        below reasonable
                                               confidence                                   public expectation      public expectation.
                                                                                                                    MP concerned
                                               Elements of public                                                   (questions in the
                                               expectation not                                                      House)
                                               being met
                                                                                                                    Total loss of public
                                                                                                                    confidence
Business objectives/     Insignificant cost    <5 per cent over      5–10 per cent over     Non-compliance          Incident leading >25
projects                 increase/             project budget        project budget         with national 10–25     per cent over
                         schedule                                                           per cent over           project budget
                         slippage              Schedule slippage     Schedule slippage      project budget
                                                                                                                    Schedule slippage
                                                                                            Schedule slippage
                                                                                                                    Key objectives not
                                                                                            Key objectives not      met
                                                                                            met
Finance including        Small loss Risk       Loss of 0.1–0.25      Loss of 0.25–0.5       Uncertain delivery      Non-delivery of key
claims                   of claim remote       per cent of budget    per cent of budget     of key                  objective/ Loss of
                                                                                            objective/Loss of       >1 per cent of
                                               Claim less than       Claim(s) between       0.5–1.0 per cent of     budget
                                               £10,000               £10,000 and            budget
                                                                     £100,000                                       Failure to meet
                                                                                            Claim(s) between        specification/
                                                                                                               confidence
Business objectives/   Insignificant cost   <5 per cent over     5–10 per cent over     Non-compliance         Incident leading >25
projects               increase/            project budget       project budget         with national 10–25    per cent over
                       schedule                                                         per cent over          project budget
                       slippage             Schedule slippage    Schedule slippage      project budget
                                                                        6-ERC (09)12                           Schedule slippage
                                                                                                                                       Agenda Item: 8.2.2
                                                                                        Schedule slippage                             Paper No: TB(09)45
                                                                                                               Key objectives not
                                                                                        Key objectives not     met
                                                                                        met
Finance including      Small loss Risk      Loss of 0.1–0.25     Loss of 0.25–0.5       Uncertain delivery     Non-delivery of key
claims                 of claim remote      per cent of budget   per cent of budget     of key                 objective/ Loss of
                                                                                        objective/Loss of      >1 per cent of
                                            Claim less than      Claim(s) between       0.5–1.0 per cent of    budget
                                            £10,000              £10,000 and            budget
                                                                 £100,000                                      Failure to meet
                                                                                        Claim(s) between       specification/
                                                                                        £100,000 and £1        slippage
                                                                                        million
                                                                                                               Loss of contract /
                                                                                        Purchasers failing     payment by results
                                                                                        to pay on time
                                                                                                               Claim(s) >£1 million
Service/business       Loss/interruption    Loss/interruption    Loss/interruption of   Loss/interruption of   Permanent loss of
interruption           of >1 hour           of >8 hours          >1 day                 >1 week                service or facility
Environmental impact
                       Minimal or no        Minor impact on      Moderate impact on     Major impact on        Catastrophic impact
                       impact on the        environment          environment            environment            on environment
                       environment
                                                                                                        6-ERC(09)12                                                                                            Agenda Item: 8.2.2
                                                                                                                                                                                                              Paper No: TB(09)45
                                                                                                                                                                                                                                6


ASSURANCE FRAMEWORK

ASSESSMENT OF STRATEGIC OBJECTIVES, RISKS AND KEY CONTROLS 2009 - 2010


Strategic aim: To be the provider of choice

Objective 1: To maintain and further improve clinical safety and outcomes and reduce HCAIs using evidence based practice

                      Principal Risks                         Consequences        Key Controls       Positive Assurances                                   Board Reports
                                                                                                                                                                                                                         Risk Rating
                                                                                                           on Controls
What could prevent the objective being achieved             What might happen What                  Where have we gained         What evidence do we     Where are we             Negative            What we have/are R/A/Y/G
                                                            as a result of not controls/systems are evidence that                have risks are being    failing to control/put   evidence or lack        doing to
                                                            managing the risk  in place to manage   controls/systems are         effectively managed     systems in place         of evidence that    manage/mitigate
                                                                               the risk             effective eg audits                                  effectively              the risk is being       the risk
                                                                                                                                                                                  effectively
 POC1. Risk of high rates of hospital acquired infection,                      1a Nominated            1c, d,e,f,g 07/08 MRSA    1a Infection risks       POC1. 1                 1 Part of OBC for   1. SOC approved
specifically C. diff.                                                          Director, Infection     & C Diff Targets within   identified on risk      insufficient side        Estate              by NHS London.
Director of Nursing and Public Involvement                                     Control team and        cumulative trajectory     register                rooms                    2 & 3 Audits to     OBC being
                                                                               committee structures    (Performance              1b Failure to get        POC 1. 2                continue in areas   progressed
                                                                               in place                Scorecard)                consistent hand         Environmental            of highest risk     2 Deep cleaning
                                                                               1b Regular reporting                              washing audit results   cleaning                 4 Mandatory         programme
                                                                               of Infection Control    1c No reports of          > 95% across the        occasionally falls       training project    continuing
                                                                               issues in quarterly     MRSA/C Diff cases in      Trust              1c   below required           Manager to scope    3 Dress Code
                                                                               performance reports     general ICU fin year.     SUIs in relation to     standards                training issues     Policy revised
                                                                               1c Environmental        1d Positive report from   measles and TB.         POC 1. 3 100%            and provision       and disseminated
                                                                               monitoring              HC Inspection on                                  compliance with          5 Draft procedure   4 In progress
                                                                               1d MRSA and C           hygiene code June 08.                             dress code not           for staff           5 in progress
                                                                                                                                                                                                                             Y
                                                                               Difficile Taskforce                                                       being achieved
                                                                               established chaired                                                       POC 1.4
                                                                               by Chief Executive                                                        Cannot
                                                                               1e Rolling deep clean                                                     demonstrate that all
                                                                               programme following                                                       staff have had
                                                                               national guidance                                                         infection control
                                                                               best practice                                                             training
                                                                               1f Audit programme                                                        POC 1.5 No
                                                                               in place                                                                  assurance that
                                                                                                                                                         100% of staff have
                                                                                                                                                         been immunised.


Objective 2: To ensure achievement of National targets, priorities and requirements
                                                                                     6-ERC(09)12                                                                                           Agenda Item: 8.2.2
                                                                                                                                                                                          Paper No: TB(09)45
                                                                                                                                                                                                            7

POC2 Lack of adequate Assurance in relation to meeting        2.a New Corporate     2a Level 3 Maternity    2a SUIs related to                                 Complete action 1.Encryption(i)
some aspects of Information governance (See IM & T Risk       structures ,          Dec 06                  information                                        plans            USB Sticks-
Register)                                                     Committees and                                governance declared                                                 completed 1000;
Chief Operating Officer                                       leads in place        2a NHSLA Risk           in 07/08 and 08/09.                                                 2000 further
                                                              2b Head of IT         Management Standards 2b Negative local and                                                  purchased,1000
                                                              2c information        (RMS) L2 Dec 07         National publicity from                                             for distribution,
                                                              Governance Manager                            recent SUI.                                                         1000 for port
                                                              2d Information        2.a Information                                                                             control (ii) Laptops
                                                              Governance Policies   Governance Toolkit self                                                                     - all Trust laptops
                                                              and procedures in     assessment 08/09                                                                            encrypted, any
                                                              place.                                                                                                            new laptops
                                                                                                                                                                                encrypted as part
                                                                                                                                                                                of deployment (iii)
                                                                                                                                                                                Desktops -
                                                                                                                                                                                investigation into
                                                                                                                                                                                most appro
                                                                                                                                                                                                       A
                                                                                                                                                                                solution on-going,
                                                                                                                                                                                delayed due to
                                                                                                                                                                                staff availability,
                                                                                                                                                                                complexity of
                                                                                                                                                                                solution & cost (iv)
                                                                                                                                                                                Port controls - due
                                                                                                                                                                                to be implemented
                                                                                                                                                                                after desktop
                                                                                                                                                                                security. Delayed
                                                                                                                                                                                due to
                                                                                                                                                                                above.2.Access to
                                                                                                                                                                                the National online
                                                                                                                                                                                IGT tool-e-mail
                                                                                                                                                                                from MD to go out-
                                                                                                                                                                                May09
                                                                                                                                                                                3.Guidance for
POC 3 Lack of optimum space in the neonatal unit, resulting                          3a External review of     3a In 2007/08, NNU       POC 3.1 Close          1.Demand needs staff on phone
                                                                                                                                                                                1.Being assessed
in risk issues in relation to health and safety, infection                          infection control         has had 2 acquisitions    proximity of cots      to be assessed.  by ADN C & W
control and privacy / confidentiality                                               procedures on NNU,        of multiply-antibiotic    poses a risk of        2. Options being 2.Plan & identified
Chief Operating Officer                                                             completed December        resistant Enterobacter.   accidental hand        considered to    space scheme
                                                                                    2006. found:              In 2008/09, there were    contamination by       address space    being costed with
                                                                                    3f. Excellent staff       7 acquisitions of         touch.                 constraints by   timeline for
                                                                                    compliance with hand      multiply-antibiotic       POC 3 .2               freeing up space current year.
                                                                                    hygiene policy            resistant Enterobacter    Utility/Sluice room.   in same locality Capital project to
                                                                                    3e. Substandard           up until 12/03/09.        close proximity of     (April 09)       commence in
                                                                                    environment contributed   3b In 2007/08, there      clean and dirty                         August 2009.
                                                                                    to the outbreak.          were 12 acquisitions of   areas - risk of                                                R
                                                                                                              MRSA in the NNU. In       contaminating clean
                                                                                                              2008/09, there have       equipment.
                                                                                                              been 3 acquisitions of
                                                                                                              MRSA up until 12/3/09.
                                                                                                              3c In 2007/08 there
                                                                                                              were 3 babies who
                                                                                                              acquired influenza A
                                                                                                              infection on the NNU.
                                                                                                              3d Increase in nos of
                                                                                                              deliveries from 3500 in
                                                                                                              2000 to 5000 in 2006
                                                                                             6-ERC(09)12                                                                                             Agenda Item: 8.2.2
                                                                                                                                                                                                    Paper No: TB(09)45
                                                                                                                                                                                                                      8

POC 4 Risk of not having operational capacity to manage            4a Urgent care action    4a Currently meeting a    Daily escalation /         POC 4.1 Inability   1. Work with          1. Action plan
activity pressures due to capacity issues in Theatres, MAU,        plan being               number of National        breech notifications .   to directly control   PCTs to               agreed at CMB re
GICU, 24 hour diagnostic and interventional radiology , NNU        implemented              Targets                   Breeches on 28 day       A&E attendances       implement results     space related
expansion needs , designation as major trauma centre and           4b Trust is on           4d Divisional             guarantee target         and the no. of        of Urgent Care        issues
lack of beds.                                                      trajectory for           performance reviews,                               patients requiring    review. Implement
Chief Operating Officer                                            delivering 18 weeks      sign up from Network                               elective admission.   new model of
                                                                   4c Discussions with      Board members and                                  POC 4.2 Business      acute medicine by
                                                                   private sector pilots    SLA monitoring                                     Continuity,           February 2009
                                                                   to release bed                                                              Escalation Policy     which will provide
                                                                   capacity through                                                            and Access Policy     a dedicated
                                                                   hospital at home by                                                         for Trauma Centre     consultant and                              A
                                                                   mid October.                                                                                      junior doctor team
                                                                   4d Major trauma                                                                                   to the acute
                                                                   project plan, Network                                                                             medicine unit, and
                                                                   Board and SLA                                                                                     facilitate improved
                                                                                                                                                                     continuity of care.
                                                                                                                                                                     2. Develop plan,
                                                                                                                                                                     policy and
                                                                                                                                                                     protocol by Sept
                                                                                                                                                                     09.

POC 5 Inability to maintain single sex accommodation               5a Daily monitoring      5a Daily monitoring       Picker survey results                          Bid for funding       Mixed sex action
Director of Nursing and Public Involvement                         reports                  indicates prevalence of   07/08 SGH in worst                             submitted             plan
                                                                   5b Reports to CMB        problem in small number   20% of Trusts 5d                                                     implementation
                                                                   and Trust Board          of clinical areas         Daily monitoring                                                     being monitored
                                                                   5c Bed management                                  reports show non                                                     by CMB re space
                                                                   team managing issue                                compliance in some                                                   related targets       R
                                                                   on daily basis.                                    areas.
                                                                   5d Guidance for staff
                                                                   to explain to patients

POC 6 The Trust may not meet national patient experience targets   6a OPD Steering          6c Complaints from                                 POC 6.1 No            1. Redesign           1.Work to be
due to inconsistent processes and systems within the outpatients   Group                    Consultants                                        consistent approach   processes across      undertaken as
function at both specialty and corporate level.      Director of   6b Quarterly                                                                at specialty level    specialties           part of the
Transformation / Divisional Director 3rd Div                       performance                                                                 POC 6.2 Delays in     2 Formalise           Transformation
                                                                   management                                                                  sending patient       internal 10 day       Work streams.
                                                                   6c Complaints                                                               information to GPs    target for sending    Phase one -
                                                                   monitoring                                                                                        out GP letters and    central booking
                                                                   6d Feedback from                                                                                  undertake             services review
                                                                   GPs                                                                                               quarterly audits.     due to be
                                                                                                                                                                                           completed by April
                                                                                                                                                                                           2009. Phase two -
                                                                                                                                                                                           patient pathways
                                                                                                                                                                                           within specialities   R
                                                                                                                                                                                           will commence
                                                                                                                                                                                           April 2009.
                                                                                                                                                                                           2. To be
                                                                                                                                                                                           incorporated
                                                                                                                                                                                           within
                                                                                                                                                                                           performance
                                                                                                                                                                                           scorecard.
                                                                                                                                                                                           3. Performance
                                                                                                                                                                                           Management
                                                                                                                                                                                           processes
                                                                                                                                                                                           identified to be
                                                                                                                                                                                           delivered by
                                                                                                       6-ERC(09)12                                                                                     Agenda Item: 8.2.2
                                                                                                                                                                                                      Paper No: TB(09)45
                                                                                                                                                                                                                        9



Objective 3: Make positive patient involvement and experience a key focus of the organisation


POC 7 Risk of poor care and patient / relative experience                   7a Daily staffing         7a Evidence of actions    7a Staffing level                      7a Matron and
                                                                                                                                                           7a Not always                     7a Back to floor
due to sub optimal staffing levels in geriatric areas                       escalation system         taken when low staffing   frequently judged to be    possible to HoN to go "back       initiative underway
Director of Nursing and Public Involvement                                  7b Monthly reporting      levels are judged to be   sub optimal          7b                to the floor" to
                                                                                                                                                           completely rectify                7b Active
                                                                            of vacancy levels         high risk                 Vacancy levels in 2                    support staff. 7b
                                                                                                                                                           the staffing shortfall            participation in
                                                                            7c Assessment of                                    geriatric wards are                    Active                Trust recruitment
                                                                            optimal staffing levels                             above 25%                              participation of      process but
                                                                            against patient                                     7c AUKUH tool                          geriatrics in         without great
                                                                            dependency using a                                  indicates a shortfall of               recruitment/          success. Some
                                                                            nationally recognised                               about 8 WTE staff per                  assessment            new staff recruited
                                                                            tool                                                ward                                   centres and           (March 09) but not
                                                                            7d Monitoring of                                    7d Complaint                           liaison with          yet in post.
                                                                            complaints, accidents                               regarding care of                      Universities;         Recruitment nurse
                                                                            and incidents                                       patient has been                       Temporary             appointed.
                                                                                                                                upheld by the                          appointment of a      7c Appoint a
                                                                                                                                Healthcare                             recruitment/          second Practice
                                                                                                                                Commission.                            retention nurse;      Educator for
                                                                                                                                                                       Trial different       Geriatrics            R
                                                                                                                                                                       approaches to         7d Restructure the
                                                                                                                                                                       attract nurses 7c     Leadership on the
                                                                                                                                                                       Review of nursing     wards. Using
                                                                                                                                                                       establishment /       patient
                                                                                                                                                                       skill mix across      ExperienceTracke
                                                                                                                                                                       the whole of          rs to assess
                                                                                                                                                                       geriatrics is being   patient
                                                                                                                                                                       undertaken            experience.
                                                                                                                                                                       7d Re-establish
                                                                                                                                                                       regular review of
                                                                                                                                                                       nursing quality
                                                                                                                                                                       scorecard, Review
                                                                                                                                                                       senior support
                                                                                                                                                                       and preceptorship
                                                                                                                                                                       capacity as part of
POC 8 Low rating in HCC maternity services survey                           Maternity services     Clinical audit results  Staffing levels do not Data capture still a the establishment
                                                                                                                                                                       1. Birth rate plus
indicative of poor patient experience leading to poor Trust                 improvement board. against indicators are      meet the               problem (4).         audit to be carried
reputation, and not a popular choice for patients.                          Action plan in place. positive. STHA satisfied recommended ratio of Patient satisfaction out.
Director of Nursing and Public Involvement                                  Quarterly reporting to with progress reported. mothers:midwives (1), measures as used 2. Complaints
                                                                            STHA. Bi-monthly                               Level of patient       in the survey are    monitored as part
                                                                            reporting to Trust                             complaints remaining difficult to replicate of workforce sub
                                                                            Board. Additional                              high (2)               (3).                 group as a formal
                                                                            investment in                                                                              KPI.
                                                                            staffing. Dedicated                                                                        3. Patient
                                                                                                                                                                                                                   A
                                                                            project manager in                                                                         Experience
                                                                            post.                                                                                      Trackers in place
                                                                                                                                                                       to monitor
                                                                                                                                                                       customer
                                                                                                                                                                       satisfaction.
                                                                                                                                                                       4. Awaiting
                                                                                                                                                                       upgrade of
                                                                                                                                                                       Euroking system.
                                                                                                             6-ERC(09)12                                                                                         Agenda Item: 8.2.2
                                                                                                                                                                                                                Paper No: TB(09)45
                                                                                                                                                                                                                                  6


ASSURANCE FRAMEWORK

ASSESSMENT OF STRATEGIC OBJECTIVES, RISKS AND KEY CONTROLS 2009 - 2010


Strategic aim: To strengthen and expand our flagship specialist services and network hubs

Objective 4: Substantive establishment of the St George's Acute Stroke Service

        Principal Risks                Consequences             Key Controls             Positive Assurances on                                         Board Reports
                                                                                                                                                                                                                            Risk Rating
                                                                                                 Controls
What could prevent the               What might happen What controls/systems are in Where have we gained evidence What evidence do we                  Where are we       Negative evidence What we have/are doing to R/A/Y/G
objective being achieved             as a result of not place to manage the risk    that controls/systems are effective have risks are being           failing to         or lack of evidence    manage/mitigate the risk
                                     managing the risk                              eg audits                           effectively managed            control/put        that the risk is being
                                                                                                                                                       systems in place   effectively managed
                                                                                                                                                       effectively

SAN 1 Risk of not having                                 1a Performance monitoring      1a,b,c,d Some assumptions          Activity in 07/08 did not   SAN 1.1           1. Implement        Transformation plan
operational and physical                                 1b Joint development of        developed jointly are currently    demonstrate effective       Implementation of Transformation plan presented at CMB in
capacity to implement future                             some assumptions               being reviewed by partners.        demand management           Transformation                        September 08.
strategy (See Strategy Risk                              1c St Georges development      Written support for the activity   especially from non         plan
                                                                                                                                                                                                                                A
Register) Medical Director /                             Forum       1d Development     assumptions in the SOC from 5      elective admissions.
Director of Strategy / Director                          of Transformation plan         local PCTs.                        PCTs focus on World
of Transformation                                        1e SLA negotiations            1d Transformation plan due for     Class Commissioning.
                                                                                        completion and sign off in
 SAN 2 Loss of activity could                            2a On-going dialogue with      September 2008.
                                                                                        2a Some of this activity may be   Hostile competitor            SAN 2.1 Robust Develop marketing Strategic level marketing
result in loss of income and                             Practice based                 replaced by increased flows of    activity.                    marketing strategy strategy ,resourced strategy in place and being
threaten clinical viability (See                         Commissioners & GPs            complex work post "Healthcare for                                                 plan and trauma bid developed as part of the
Strategy/ OBC Risk Register                              2b Active participation in     London"                                                                                               Foundation Trust
Medical Director/ Director of                            NHS London discussions re      2b Foundation Trust Application                                                                       Application. Trust and
Finance / Director of Strategy                           SW London configuration.       underway.                                                                                             Service level plans being
                                                                                                                                                                                                                                G
                                                         2c Specialty level business                                                                                                          developed.
                                                         planning capability being
                                                         developed                 2d
                                                         FT Application preparations
                                                         2e Bid to be major trauma
                                                         centre
SAN 3 Potential losses of                                3a Matter being managed at     3a Position with specialised       3a Kings NHS FT have SAN 3.1 Full              Complete project    Locums recruited interim.
financial income , activity and                          Directors Forum                commissioners being controlled     poached two clinicians project plan            plan                Response to SW London
status of haematology service                            3b Lead Clinician in           3b Recruitment of substantive      to undertake                                                       paper going to CMB August
due to recent loss of key clinical                       Haematology managing           posts taking place                 competitive work 3b                                                08, changed to Amber as           A
personnel ( See Finance Risk                             process of recovery                                               Royal Marsden Hospital                                             no current operational risk
Register) Director of Strategy                           3c Close collaboration with                                       predatory on Bone
                                                         SGUL re academic                                                  Marrow Transplant
                                                         development of service                                            work.

Objective 5: To be a recognised trauma & emergency centre.

        Principal Risks                Consequences             Key Controls                Positive Assurances on                                      Board Reports
                                                                                                                                                                                                                            Risk Rating
                                                                                                    Controls
                                                                                                    6-ERC(09)12                                                                                  Agenda Item: 8.2.2
                                                                                                                                                                                                Paper No: TB(09)45
                                                                                                                                                                                                                  7

       Principal Risks          Consequences             Key Controls             Positive Assurances on                                   Board Reports
                                                                                                                                                                                                            Risk Rating
                                                                                          Controls
What could prevent the        What might happen What controls/systems are in Where have we gained evidence What evidence do we            Where are we       Negative evidence What we have/are doing to R/A/Y/G
objective being achieved      as a result of not place to manage the risk    that controls/systems are effective have risks are being     failing to         or lack of evidence    manage/mitigate the risk
                              managing the risk                              eg audits                           effectively managed      control/put        that the risk is being
                                                                                                                                          systems in place   effectively managed
                                                                                                                                          effectively

SAN 4 Income does not cover                       1. Project plan              1. Divisional performance reviews Inability to influence                                        Detailed costing completed
costs                                             2. Service Level Agreement   2. SLA monitoring                 tariff                                                        and have been reviewed
Chief Operating Officer                           3. TARN admin support /                                                                                                      downwards. Business case
                                                  coding                                                                                                                       to be submitted to Trust
                                                                                                                                                                               Board in July 2009.              A




Objective 6: To support the development of consultant led services into community settings
                                                                                                                        6-ERC(09)12                                                                                         Agenda Item: 8.2.2
                                                                                                                                                                                                                           Paper No: TB(09)45
                                                                                                                                                                                                                                             6

ASSURANCE FRAMEWORK

ASSESSMENT OF STRATEGIC OBJECTIVES, RISKS AND KEY CONTROLS 2009 - 2010

Strategic aim: To develop an Academic Health and Social Care Network in SW London

Objective 7: To ensure all research complies with statutory requirements and best practice

   Principal Risks           Consequences              Key Controls              Positive Assurances on                                                      Board reports
                                                                                                                                                                                                                          Risk Rating
                                                                                          Controls
What could prevent        What might happen as What controls/systems are       Where have we gained                What evidence     Where are we       Negative evidence or               What we have/are doing to      R/A/Y/G
the objective being       a result of not      in place to manage the risk     evidence that                       do we have        failing to         lack of evidence that the          manage/mitigate the risk
achieved                  managing the risk                                    controls/systems are effective      risks are being   control/put        risk is being effectively
                                                                               eg audits                           effectively       systems in place   managed
                                                                                                                   managed           effectively

AHC 1 Lack of                                   1a Research and                Actions for x 2 critical findings   1a MHRA                              1. Implement revised        1. New processes in place
adequate assurance in                           Development Director           from MHRA Report                    Inspection                           processes.                  2 Staff recruited
relation to the                                 1b Research Governance/        completed.                          Report August                        2. Recruit adequate         3. Report recommendations actioned.
management of                                   Ethics Committees              Annual work plan for 08/09 for      2008 major                           staffing                    Awaiting revisit report (March 09)
clinical trials and                             1c Reports to Patient Safety   R&D agreed.                         findings
strategic, operational                          / Governance Committee
and reputation risks in                         1d R&D administrative and
relation to Research                            governance structure and
and Development (                               office revised
See R & D Risk                                                                                                                                                                                                                A
Register)
Medical Director
RGW




Objective 8: Promote the best interests of patients and the community through co-ordinated planning & development of clinical teaching, training & research to improve care & clinical outcomes
                                                                                                        6-ERC(09)12                                                                                           Agenda Item: 8.2.2
                                                                                                                                                                                                             Paper No: TB(09)45
                                                                                                                                                                                                                               6


ASSURANCE FRAMEWORK

ASSESSMENT OF STRATEGIC OBJECTIVES, RISKS AND KEY CONTROLS 2009 - 2010

Strategic aim: To ensure financial sustainability

Objective 9 : To achieve financial targets and improve financial risk rating

       Principal Risks              Consequences          Key Controls          Positive Assurances on                                                                  Board reports
                                                                                                                                                                                                                            Risk Rating
                                                                                         Controls
What could prevent the            What might happen    What                   Where have we gained           What evidence do we have           Where are we       Negative evidence or         What we have/are doing R/A/Y/G
objective being achieved          as a result of not   controls/systems       evidence that                  risks are being effectively        failing to         lack of evidence that the    to manage/mitigate the
                                  managing the risk    are in place to        controls/systems are effective managed                            control/put        risk is being effectively             risk
                                                       manage the risk        eg audits                                                         systems in place   managed
                                                                                                                                                effectively

FIN 1.Achieving £1m surplus for                        1a • Executive         1e,f,g 1c&d Managers have        1 f,g £2m of the. £6.5m gap                         Ongoing monitoring          1. Monitoring in progress,
08/09 (See Finance Risk                                Director of Finance    identified crp's to close gap   still to be found.                                                               monthly updates on the
Registers)                                             responsible for        by £4.5m                        £2.5m of the original crp still                                                  financial position /
Director of Finance                                    leading financial      £12m of the original crp's of   to be found                                                                      progress provided to the
                                                       recovery               £14.5m have been found for                                                                                       Board.
                                                       1b. • Transformation   Q1.                                                                                                              2 Q4 08/09 projected as
                                                       team in place          Gap has been closed through                                                                                      on target to meet surplus.
                                                       1c • Regular reports   Recovery Plan.
                                                       to the Finance and
                                                       Resources Group
                                                       and Finance
                                                       Committee
                                                       1d Financial Plan
                                                       07/08
                                                       1e Special financial
                                                       control measures for                                                                                                                                                     G
                                                       Q4 08/09
                                                       1f Monthly budget
                                                       reviews with
                                                       Directorates
                                                       1g Transformation
                                                       Team implementing
                                                       specific crp's
                                                                                                     6-ERC(09)12                                                                                        Agenda Item: 8.2.2
                                                                                                                                                                                                       Paper No: TB(09)45
                                                                                                                                                                                                                         7

        Principal Risks            Consequences         Key Controls          Positive Assurances on                                                               Board reports
                                                                                                                                                                                                                     Risk Rating
                                                                                      Controls
FIN 2 Loss of SIFT and Madel                         2a Education and       2 NHS London wide group        2. The impact on SIFT will    FIN 2.1 No           Worked with NHS           Action completed
funding will impact on whole                         training strategy in   addressing issues with DH      be in 10/11                  current plans for     London to mitigate this   internally. Work with NHS
organisation                                         draft                                                                              10/11 plus to         risk. Assessment made     London wide group
Director of Finance                                                                                                                     reduce this loss of   and plan drawn up in      completed to mitigate this
                                                                                                                                        income as DH          conjunction with NHS      risk. This risk relates to
                                                                                                                                        decision awaited.     London and actioned.      financial year 2010 /11.
                                                                                                                                                                                                                         R
                                                                                                                                                                                        An update on this to be
                                                                                                                                                                                        received from McKinseys
                                                                                                                                                                                        in March 2009.
                                                                                                                                                                                        Discussions with DH.




Objective 10: To take necessary steps to position the organisation for FT status

FIN 3 Risk of failure to achieve                     3a Programme           3a Programme Management                                      FIN 3.1 Board & 1. Develop programme           1. in progress
FT Status ( See FT Application                       Management             Support in place                                            Executive Team       for Board development 2    2. In progress
Risk Register) (linked to                            approach               3b Overall Programme plan                                   development to                                  3. Governance review
Objective 3)                                         3b Foundation Trust    3c Development of integrated                                support FT status                               undertaken.
Chief Executive                                      Application Steering   business plan underway                                      ongoing                                         4. Communication
                                                     Group                                                                              FIN 3.2                                         strategy finalised.
                                                     3c Foundation Trust                                                                Production of                                   Engagement aspects to
                                                     Application Project                                                                IBP/LTFM which                                  be addressed.
                                                     Manager/ Group                                                                     embraces the plan
                                                     3d Monthly progress                                                                for Transforming
                                                     reports to Trust                                                                   St Georges and
                                                     Board.                                                                             takes into
                                                                                                                                        account the
                                                                                                                                        Trusts' service
                                                                                                                                        development,
                                                                                                                                        workforce and                                                                    A
                                                                                                                                        organisational
                                                                                                                                        development
                                                                                                                                        plans.
                                                                                                                                        Achievement of
                                                                                                                                        financial targets in
                                                                                                                                        9/10 and future
                                                                                                                                        years.
                                                                                                                                        FIN 3.3 Proposed
                                                                                                                                        Governance
                                                                                                                                        arrangements
                                                                                                                                        inconsistent with
                                                                                                                                        FT requirements
                                                                                                                                        FIN 3.4
                                                                                                                                        Stakeholder
                                                                                                                                        involvement and
                                                                                                                                        engagement
                                                                                                          6-ERC(09)12                                                                                               Agenda Item: 8.2.2
                                                                                                                                                                                                                   Paper No: TB(09)45
                                                                                                                                                                                                                                     6


ASSURANCE FRAMEWORK

ASSESSMENT OF STRATEGIC OBJECTIVES, RISKS AND KEY CONTROLS 2009 - 2010

Strategic aim: To be an exemplary employer with career and development opportunities which attract, motivate & retain staff

Objective 11: Ensure we meet statutory employment duties, workforce targets and comply with external assessments

         Principal Risks              Consequences               Key Controls           Positive Assurances on                                   Board Reports
                                                                                                Controls                                                                                                                         Risk Rating

What could prevent the objective What might happen as a What controls/systems are Where have we gained           What evidence do we         Where are we failing to Negative evidence or lack      What we have/are doing R/A/Y/G
being achieved                   result of not managing the in place to manage the risk evidence that            have risks are being        control/put systems in  of evidence that the risk is   to manage/mitigate the
                                 risk                                                   controls/systems are     effectively managed         place effectively       being effectively managed               risk
                                                                                        effective eg audits

MFT1 Attendance at Mandatory                               1a MAST Steering Group      1b Project plan produced 1b Failure to provide         MFT 1.1 Trust wide       1. TNA to be completed.       1. Project Manager in
training cannot be fully                                  1b MAST Project and          and Steering Group set   adequate Assurance of        training needs analysis   2 Implement staff survey     post. TNA to be
demonstrated                                              Project Manager in post.     up.                      meeting Core Standard (      MFT 1.2 Staff survey      action plan                  completed by December
(See Director of HR Risk                                                                                        S4BH) C11b in 07/08          action plan                                            2008
Register)                                                                                                       due to lack of evidence to                                                          2. Implementation of staff
Director of HR                                                                                                  demonstrate staff records                                                           survey action plan
                                                                                                                of statutory / mandatory                                                            overseen by CMB and
                                                                                                                training and lack of                                                                Trust Board.                     A
                                                                                                                comprehensive Trust
                                                                                                                wide training needs
                                                                                                                analysis
                                                                                                                1b Staff survey results
                                                                                                                07/08


 MFT2 Present OH procedures                               1.Returned reports from       None identified          Reported Adverse                                                                   1 COHORT system
relating to staff vaccinations and                        Microbiology checked by                                incidents                                                                          purchased Oct 08
blood test follow up is                                   OHNS                                                                                                                                      2. Training commenced
inadequate due to lack of recall                          2. Clients contacted by                                                                                                                   and system went live mid
systems within the OH dept.                               OHNS                                                                                                                                      March 2009.
This could lead to litigation risks                        3.Documentation in clients                                                                                                               3. Priority being given to
to the Trust and staff contracting                        records                                                                                                                                   immunity checks and
infection / increased sickness                             4.Links with infection                                                                                                                   immunisation.
absence / medical suspension                              control team and consultant                                                                                                                                                A
costs and risks to patients                               virologist re control of
Director of HR                                            infection outbreaks.
                                                           5.Medical suspension for
                                                          non-immune staff where
                                                          necessary/appropriate
                                                           6.Health information
                                                          leaflets for staff re TB, and
                                                          varicella
                                                          Infection control policies on
                                                                                                       6-ERC(09)12                                                                    Agenda Item: 8.2.2
                                                                                                                                                                                     Paper No: TB(09)45
                                                                                                                                                                                                       7

        Principal Risks            Consequences                Key Controls          Positive Assurances on              Board Reports
                                                                                             Controls                                                                                              Risk Rating


MFT3 Difficulty in achieving                              1. Dedicated project                                       MFT 3.1 Not compliant 1. Develop timetable to    1 Timetable being drawn
revised European Working Time                             manager in post.                                           junior Drs rotas      meet compliance by         up and to be discussed
Directive target of 48 hours for                          2. Plan in place.                                                                August 2009                at CMB Action Day.
Junior doctors hours by August                            3. Funding to be agreed.                                                                                    2. Monthly reports sent to
2009                                                                                                                                                                  the Board via the
Director of HR / Director of                                                                                                                                          performance
Transformation                                                                                                                                                        management report re:
                                                                                                                                                                      EWTD compliance.


                                                                                                                                                                                                       A




Objective 12: To support our workforce through a challenging year

MFT4 Insufficient organisational                       4a Monthly Divisional         None identified                 MFT 4.1 Gap analysis 1. ADOs to undertake          1.Funding secured for
management and staffing                                performance Review                                            to be undertaken to       reviews in Divisions   the 18 week team until
capacity which is impacting on                         meetings                                                      identify areas of service                        the end of 08/09. Gaps
delivery of clinical and                               4b Monthly Performance                                        impact                                           identified and additional
                                                                                                                                                                                                       A
operational services                                   scorecard                                                                                                      funding secured for
Chief Operating Officer                                4c Weekly waiting list                                                                                         project management
                                                       meeting.                                                                                                       support . Job
                                                                                                                                                                      descriptions of General
                                                                                                              6-ERC(09)12                                                                                           Agenda Item: 8.2.2
                                                                                                                                                                                                                   Paper No: TB(09)45
                                                                                                                                                                                                                                     6


ASSURANCE FRAMEWORK

ASSESSMENT OF STRATEGIC OBJECTIVES, RISKS AND KEY CONTROLS 2009 - 2010

Objective: To provide an excellent physical environment fit for the delivery of modern healthcare

Objective 13: Ensure compliance with statutory and mandatory duties, regulations and external assessments

        Principal Risks                 Consequences               Key Controls              Positive Assurances on                                         Board Reports                                                        Risk Rating
                                                                                                      Controls
What could prevent the               What might happen as What controls/systems are        Where have we gained           What evidence do we have         Where are we       Negative evidence      What we have/are doing R/A/Y/G
objective being achieved             a result of not      in place to manage the risk      evidence that                  risks are being effectively      failing to         or lack of evidence    to manage/mitigate the
                                     managing the risk                                     controls/systems are effective managed                          control/put        that the risk is being          risk
                                                                                           eg audits                                                       systems in place   effectively managed
                                                                                                                                                           effectively

ENV1 The annual review of the                              1a Estates & Facilities         1b, PEAT Self assessment          Problems identified and       ENV 1.1 6 facet    1. Continue           1. Progress to decrease
action plan from the 2004 '6                               Management Team                 Inspection Report 06 /07         itemised within the “6 facet   survey action      implementation of     backlog maintenance
facet survey' and in year fire                             1b Committee structures in      1d, Area's of risk itemised      survey”.                       plan work being    phased work to        across the Estate to be
guidance highlights areas for                              place Organisational Risk &     and identified within the                                       phased in.         address actions       surveyed during 2008/09
further action in relation to the                          Health, Safety & Fire           independent "6 facet survey"     Estates related SUI's                             from the 6 Facet
Trust's Estates and Facilities                             1c Independent report           1f Disabled Access plan to       Non compliance to Standard                        Survey
(See Director of Facilities & Site                         produced                        comply with the Disability       C20a in Annual Health check
Services Risk Register)                                    1d Annual ERIC Returns          Discrimination Act 1995          in 07/08                                                                                                 A
Director of Estates/ Facilities                            1 1e 5 year Estates Strategy    1f Disability Equality Scheme.
                                                                                           1f Capital identified to
                                                                                           continue programme of work
                                                                                           in 07/08      Condition survey
                                                                                           to be carried out in 08/09.



ENV 2 Some items of planned                                           Management
                                                           2a. Building                                                                                    ENV 2.1 Risk       1.Undertake Risk      1.. 60% of planned
preventive maintenance require                             System                                                                                          Assessment of      assessments of        preventive maintenance is
further assessment( see                                    2b Planned Preventive                                                                           20% of the PPM     outstanding 20% off   in progress for 2008/09. A
Director of Facilities & Site                              Maintenance Programme in                                                                        Programme to       PPM Work.             further 20% is being
Services Risk Register)                                    place. (PPM Planet FM )                                                                         meet operational   2. Produce reports    developed and 20% is
Director of Estates/ Facilities                            2c PPM Reports                                                                                  requirements       from PLANET           being further risk
                                                           2d Random 10% checks by                                                                         ENV 2.2 PPM        system.               assessed.              2.
                                                           supervisors and engineers                                                                       Report                                   Monthly performance              A
                                                           2e PPM Reports                                                                                                                           reports on PPM
                                                           incorporated within quarterly
                                                           performance review




Objective 14: To continually improve the hospital environment through capital investment
                                                                          6-ERC(09)12                                                                                    Agenda Item: 8.2.2
                                                                                                                                                                        Paper No: TB(09)45
                                                                                                                                                                                          7

 ENV3 Significant amount of        3a Regular meetings with        None            3b One power outage in    ENV 3.1 The         1 Work with SGUL       1.Consultants employed to
business critical, equipment and   Medical School Estates                          December 07- Blood Bank   Trust does not     to identify funding     design scheme for
systems not connected to           Department                                      Service affected          own the property   to mitigate risk long   installation of generators.
essential electrical services      3b Briefings for Trust                                                    in which the       term with upgraded      Greater difficulties than
within Jenner Wing ( owned by      Maintenance shift team to                                                 services are       equipment.              expected in finalising the
University Medical School). In     take action in the event of                                               delivered.         2.Instigate short       design due to operational
the event of an external power     power failure                                                                                term action plan        issues and initial planned
failure, failure of Trust high     3c New maintenance                                                                                                   design works by SGUL.
voltage (HV Network) these         contract has now been                                                                                                Design work sent out to
systems will not be available to   placed with the same                                                                                                 tender Dec 2008. Order
provide patient services,          specialist generator                                                                                                 to be placed April 09 and
particularly testing by            maintenance company used                                                                                             work completed in 2010.
laboratories. ( see Director of    by the Trust for all of its own                                                                                      2. Short term actions in
Facilities & Site Services Risk    generator maintenance                                                                                                place and reported to
Register)                          3d SGUL and the Trust                                                                                                SHA.
Director of Estates/ Facilities    have also agreed to                                                                                                                                A
                                   introduce a new testing
                                   regime comprising weekly
                                   non intrusive visual
                                   inspections and monthly „on
                                   line testing‟ of the buildings
                                   essential electrical load for a
                                   minimum period of 1 hour
                                   per month in accordance
                                   with the recommendations
                                   outlined in HTM 06-01
                                   Electrical Services Supply
                                   and Distribution Part B.
                                                                                         6-ERC(09)12                                                                                         Agenda Item: 8.2.2
                                                                                                                                                                                            Paper No: TB(09)45
                                                                                                                                                                                                              8

ENV4 Risk of not implementing                       4a Programme                                  Further high level risks        ENV 4.1             1. Develop            1. Some requests for
the ICLIP Programme in a timely                     management in place.                          identified in Quarter 2 08/09   Functionality       processes to          changes in functionality
manner and consequences of                          4b iCLIP Risk Register                        presented to ICLIP Steering     within core         mitigate areas of     have not been approved .
this on transformation and the                      4c Programme Governance                       Committee. Timescale            modules does not    risk in the areas     Internal processes being
FT application.                                     arrangements                                  slippage due to external        cover all trust     where the product     developed
Chief Operating Officer                             4d Contingency plan being                     factors.                        processes and       does not meet         2 Internal Audit report and
                                                    developed                                                                     interfaces with     internal              comments on revised
                                                    4e Steering Committee                                                         existing systems.   requirements and      governance structure
                                                    chaired by CE in place.                                                                           LPFit has declined    awaited.
                                                                                                                                                      requests for          3. Clarity of understanding
                                                                                                                                                      changes in            around functionality of
                                                                                                                                                      functionality         product and achievable
                                                                                                                                                      2. Audit review of    programme plan between
                                                                                                                                                      Programme             trust and supplier.
                                                                                                                                                      Governance
                                                                                                                                                      arrangements. 3.
                                                                                                                                                                                                          A
                                                                                                                                                      Understand
                                                                                                                                                      workflows/processe
                                                                                                                                                      s and take steps to
                                                                                                                                                      address. 4.
                                                                                                                                                      Implementation of
                                                                                                                                                      change
                                                                                                                                                      management
                                                                                                                                                      programme.




Objective 15: Develop an outline business case for redevelopment of the Tooting campus

								
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