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					     Portsmouth City Teaching PCT - Commissioning Assurance Framework and Strategic Risk Register
                                                                                                                                                                                                                                                                                              Cross References
     Reference   Date        Strategic Risk Description of Risk                              Controls in Place               Assurances          RL RI    Residual Responsible     Gaps in Control        Action          Expected     AP      Gaps in     Action    Expected         AP      S4BH     UoR         NHSLA   Other    Change Note
                                                                                                                                                          Risk     Director                               Planned         Implementati Cross   Assurance   Planned   Implementation   Cross
                                                                                                                                                          Score                                                           on Date      Ref                           Date             Ref
     08-C-018    6/27/2008   Meet key NHS        Failure to meet targets would risk poor     Operational Plan;               Regular            4     5   20       Innes           Signed workstream Under                                                                                    C18,     1.2, 1.3                       -
                             (& Operational      health care service for patients at point   Performance monitoring;         Performance                           Richens,        action plan for 18 development                                                                             C19, C7f
                             Plan) targets       of need leading to loss of good opinion     Contracts with service          Reporting to the                      Director of     week wait.         between
                                                 and confidence of stakeholders and          providers;                      Board (I/P);                          Strategy &                         stakeholders
                                                 increased performance management            Demand management               Contract                              System                             and PHT.
                                                 by SHA                                      action plans – ISTC,            monitoring reports                    Management
                                                                                             Independent Contractors,        (I/P);
                                                                                             OoH;                            STIES reporting
                                                                                             Integrated Care Pathways;       (I/P).
                                                                                             Weekly South East
                                                                                             Hampshire Stakeholder to
                                                                                             monitor progress;
                                                                                             Signed workstream action
                                                                                             plan for A&E 4 hour waits.




     09-C-007    8/6/2009    To ensure that      Local residents will die and/or suffer      National, Regional and Local    Major Incident       3   4   12       Dr Paul         Still some             Working with                                                                                                                ↓
                             NHS                 harm because essential and critical         standard Emergency              Plans including                       Edmondson-      ineffective or         Directors to
                             Portsmouth is       services for people suffering from          Planning structures and         Pandemic Flu                          Jones,          absent business        ensure plans
                             able to lead and    Pandemic Flu or those with other            processes that are well         Plan.                                 Director of     continuity plans for   are in place.
                             coordinate the      serious clinical conditions are             rehearsed and exercised         Board approval for                    Public Health   corporate &
                             planning for, the   insufficient or ineffective.                                                major incident and                    & Wellbeing     commissioning
                             preparation for,                                                National, Regional and Local    pandemic Flu                                          directorates
                             the response to     Local healthcare organisations will fail    Pandemic Flu specific plans     Plans and regular
                             and the             to meet mission critical and business       and processes that have         Emergency
                             recovery from       essential targets and patient safety,       been well rehearsed and         Planning Updates
                             the current         financial balance and organisational        exercised.                      provided to Board
                             Influenza           performance will be compromised and                                         Gold, Silver and
                             Pandemic in a       suffer.                                     Effective, well tried local     Bronze Command
                             safe, effective                                                 systems and processes in        Structure in place
                             and timely                                                      place to jointly identify and   and working well.
                             manner.                                                         minimise risks to               National Pandemic
                                                                                             organisations, services and     Flu Service, local
                                                                                             individuals across the health   Antiviral Collection
                                                                                             economy.                        Points and other
                                                                                                                             systems and
                                                                                                                             processes also in
                                                                                                                             place and working
                                                                                                                             well.
                                                                                                                             Business
                                                                                                                             Continuity Plans
                                                                                                                             well developed
                                                                                                                             across most areas
                                                                                                                             of healthcare
                                                                                                                             provision including
                                                                                                                             secondary care,
                                                                                                                             community care
                                                                                                                             and primary care.




     08-C-004    6/16/2008   To deliver a        Failure to provide appropriate use of       Community Hospital Sub-         PCT Board receipt 4      5   20       Debbie          Full business case PCT Board           Nov-09                                                              C7d,     1.1, 2.1, 5.8       OP:        ↑
                             Community           resources to meet patient and political     committee;                      of OBC & SOC                          Tarrant,                                                                                                                   C7f,     3.2                 5.3.6;
                             Hospital            expectations and provide effective          OBC;                            May08 (I/P);                          Director of                                                                                                                C20a,                        10.11
                             (Healthcare         healthcare leading to unwarranted           SOC;                            PCT Board receipt                     Primary Care                                                                                                               C20b,
                             campus) on St.      financial expenditure and patient           Project Plan;                   of Community                                                                                                                                                     C22c
                             Mary’s site by      disatisfaction. Impact on ISTC retender     Performance Management          Hospital Sub-
                             2011.               - financial and service implications.       by DoH/SHA;                     committee minutes
                                                                                                                             on a regular basis
                                                                                                                             (I/P)




     08-C-013    6/16/2008   To ensure           Failure to achieve financial targets and    Signed Service Level            Board discussion 4       4   16       Pam Hobbs,                                                                                                                 C7a&c,   1.1, 1.2,                      -
                             sound financial     return required surplus level will impact   Agreements;                     of Finance Reports                    Director of                                                                                                                C7d      1.3
                             delivery in year    on future management of the PCT and         Finance Reports;                at each meeting                       Finance
                             and recurrent       opportunities made available to the         Audit Committee;                (I/P);
                             financial           PCT. Whole systems issues impact            External / Internal Audit of    Audit Committee
                             balance             on PCT.                                     Financial arrangements;         consideration of
                             together with                                                   Sustainability Board.           audit reports (I/P).
                             other financial
                             duties.




Commissioner                                                                                                                                                                            1 of 4                                                                                                                                         Post IGC January 2010
     Portsmouth City Teaching PCT - Commissioning Assurance Framework and Strategic Risk Register
                                                                                                                                                                                                                                                                                       Cross References
     Reference   Date        Strategic Risk Description of Risk                             Controls in Place              Assurances          RL RI   Residual Responsible   Gaps in Control      Action        Expected     AP      Gaps in       Action    Expected         AP      S4BH     UoR         NHSLA   Other      Change Note
                                                                                                                                                       Risk     Director                           Planned       Implementati Cross   Assurance     Planned   Implementation   Cross
                                                                                                                                                       Score                                                     on Date      Ref                             Date             Ref
     08-C-020    6/27/2008   Manage          Overheat of acute contracts would lead         Service Provider contracts     Demand              4   4   16       Innes                                                                                                                  C7d,     1.3, 2.2            OP 8.4       -
                             demand across to financial pressures on the PCT.               and monitoring;                Management                           Richens,                                                                                                               C7f,
                             all acute                                                      Monthly demand monitoring      action plan                          Director of                                                                                                            C17,
                             contracts to                                                   via all contracts;             reporting (I/P);                     Strategy &                                                                                                             C18,
                             ensure it                                                      Financial contingency          Performance                          System                                                                                                                 C19,
                             remains within                                                 planning;                      notice issued for                    Management                                                                                                             C22a,
                             agreed activity                                                Operational Plan;              data (PHT) (I/P).                                                                                                                                           C22c
                             plans                                                          Joint strategy for Health &
                                                                                            Social Care of Older People;
                                                                                            Joint commissioning unit
                                                                                            proposed with Portsmouth
                                                                                            City Council;
                                                                                            Capacity map;
                                                                                            CE system group;
                                                                                            GP Clinical Leads;
                                                                                            Evidence based referral
                                                                                            management.




     09-C-004    4/20/2009   Develop,           The PCT as a Commissioner has the           HCC Surveys and other          Board             3     4   12       Rob Dalton,   1. Board                                                WCC report                               OP 9.10 C8b,     2.1, 3.2,           OP 14.1,     ↓
                             establish and      legal requirement to ensure effective       surveys;                       consideration and                    Director of   Development                                             identifying                                      C11a,    3.3                 14.5,
                             maintain an        engagement processes. WCC                   Portsmouth LINk;               approval of                          Corporate &   Programme                                               improvement                                      C11c,                        14.7
                             engagement         standards require delivery to a certain     Overview & Scrutiny Panel      Commissioning                        Support                                                                                                                C17,
                             infrastructure     standard. The PCT may not have the          (OSP);                         and Operational                      Services                                                                                                               C22a&c
                             that supports      resource, infrastructure or expertise to    Public Involvement &           Plans Spring 2009
                             effective          deliver against the requirements            Communications Manager;        (I/P);
                             commissioning      leading to potential poor                   Patient Experience Team;       OSP regular                                        2. Staff achieving
                             of services.       commissioning and reputational              Public Health needs            quarterly report                                   Masters in
                                                issues.                                     analysis;                      (I/P);                                             Commissioning
                                                                                            Commissioning Plan;            Survey report to                                   qualification
                                                                                            Operational Plan and           IGC 2008 (I/P).
                                                                                            distinct part of form
                                                                                            regarding engagement;
                                                                                            Organisational Development
                                                                                            Plan;                                                                             3. WCC                             Autumn 2009
                                                                                            WCC Competancy Skills                                                             assessment 09/10
                                                                                            Framework;
                                                                                            Redesigned Commissioner
                                                                                            structure;
                                                                                            Communications &
                                                                                            Engagement Strategy
                                                                                            2009/10.
     09-C-006      5/12/2009 Introduction of    Failure to implement national criteria at   Review of national criteria                        4   4   16       Innes         1. Impact          Conduct and                                                                                                        OP 8.4       -
                             new national       a local level in a timely manner may        being conducted locally;                                            Richens,      assessment of new report to Feb
                             continuing care    result in delays in continuing care         Financial impact                                                    Director of   criteria (1/10/09) PEC
                             criteria for       reviews. Financial impact of new            assessment;                                                         Strategy &
                             children.          criteria on PCT allocations for             Dedicated manager and                                               System
                                                continuing care.                            team for continuing care;                                           Management
                                                                                            CCC Project Group.

     08-C-011    6/16/2008   Implementation     Aligning direction of travel in order to    PCT attendance at key          Quarterly report to 3   4   12       Pam Hobbs,    New Informatics      Currently     Board Mar '10                                                         C9,      2.1, 2.2, -                      -
                             of Connecting      maximise benefits of technology             meetings and regular liaison   PCT Chair and                        Director of   Strategy             under                                                                               C13c,    3.2
                             for Health         across health community and social          with SHA to influence          Local IT                             Finance                            development                                                                         C16
                             agenda             care and delivering the PCT IM&T            direction;                     Deployment Board
                                                priorities within the resources             Informatics Strategy 2005-     (I/P);
                                                available.                                  2008;                          Individual reports
                                                                                            Board lead;                    on each system to
                                                                                            Local IT Deployment Board ;    Local IT
                                                                                            IT business case process;      Deployment Board
                                                                                            Operational Plan;              (I/P);
                                                                                            RIO approved by Provider       PCT Business
                                                                                            Committee.                     Plan quarterly
                                                                                                                           report to the Board
                                                                                                                           (I/P).

     08-C-012    6/16/2008   Provide suitable   Sub-standard premises may be                Capital programme and          Regular PEAT        3   4   12       Ted Griggs,                                                                                                            C20a,    3.2         3.1                  -
                             21st century       provided which could impact on              plan;                          reports (I/P);                       Director of                                                                                                            C20b,
                             accommodation      service delivery and patient/staff safety   Estates Strategy 2003-         Backlog                              Estates and                                                                                                            C21,
                             for                leading to potential litigation and sub-    2008;                          maintenance                          Facilities                                                                                                             C7d
                             commissioned       optimal PCT development.                    SSDP;                          statistics (I/P);                    Management
                             services,                                                      PEAT inspections;              Consideration of
                             maintaining                                                    Premises & Environment         key risk issues
                             estate/premises                                                Committee.                     such as ligature
                             used for                                                                                      points (I/P).
                             patients and
                             staff to
                             adequate
                             standards.




Commissioner                                                                                                                                                                       2 of 4                                                                                                                                         Post IGC January 2010
     Portsmouth City Teaching PCT - Commissioning Assurance Framework and Strategic Risk Register
                                                                                                                                                                                                                                                                                            Cross References
     Reference   Date        Strategic Risk Description of Risk                            Controls in Place               Assurances         RL RI    Residual Responsible   Gaps in Control   Action          Expected     AP      Gaps in         Action       Expected          AP      S4BH     UoR         NHSLA     Other      Change Note
                                                                                                                                                       Risk     Director                        Planned         Implementati Cross   Assurance       Planned      Implementation    Cross
                                                                                                                                                       Score                                                    on Date      Ref                                  Date              Ref
     08-C-021    6/27/2008   Provide and        Harm to patients, staff or PCT where       Training Calendar;              Minutes of IGC,     3   3   9        Ros Jack,                                                            1. Healthcare   1. Report to 1. Mar 2010 IGC           C5b,     3.3, 2.4    Standard 2 OP 14.6     -
                             ensure uptake      appropriate training is not available or   Training statistical reports;   Ops Board, PEC                       Director of                                                          Commission      IGC when                               C5c,
                             of mandatory       undertaken possibly resulting in           Learning & Development          and Board                            Workforce &                                                          judgement       received                               C5d,
                             training           increased litigation and poor publicity.   Strategy;                       discussing training                  Development                                                          2008/09                                                C11b,
                                                                                           Learning & Development          issues                                                                                                                                                           C11c
                                                                                           Department;                     (I/P);
                                                                                           Standards for Better Health     Regular domain
                                                                                           Assessment 2007/08;             reporting of
                                                                                           Operational Plan &              training statistics
                                                                                           Performance report;             (I/P).
                                                                                           Local L&D training matrices.
                                                                                           NHSLA Level 1 2009




     09-C-005    4/20/2009   Ensure effective   The PCT must continue to comply with       S4BH process & domain           ‘A’ rated Business 2    4   8        Rob Dalton,   1. Integrated     Develop by                  OP                                                              C7a&c    2.2, 2.3,                          -
                             governance,        legal and national requirements and        reports;                        Assurance                            Director of   Governance        Oct 2009                    14.14                                                                    2.4
                             accountability     ensure transparency in decision            UoR process;                    Framework (by                        Corporate &   Strategy
                             and decision       making and effective record keeping to     NHSLA Group;                    SHA 08/09) (E/P);                    Support
                             making             prevent failures with possible public      Integrated Governance           NHSLA Level 1                        Services
                             processes          loss of confidence, clinical risk,         Committee;                      March 2009 (E/P);
                             during             reduced quality, reduced patient           AF&SRR & GAP;                   UoR Level 2 April
                             organisational     safety, reputational risk and legal        Business Services support       2009 presented to
                             change             challenge.                                 to first level Board            Audit Committee                                    2. Improve       Complete                     WCC AP                                                          C22a&c
                                                                                           committees;                     Sept 09 (E/P).                                     adherence to WCC WCC actions
                                                                                           Business Pro-forma &                                                               requirements     from review by
                                                                                           related materials;                                                                                  Mar 2010
                                                                                           MoU for Provider Services
                                                                                           & updates SO and SoD.




                                                                                                                           I - Internal
                                                                                                                           E - External
                                                                                                                           P - Positive
                                                                                                                           N - Negative




Commissioner                                                                                                                                                                       3 of 4                                                                                                                                                Post IGC January 2010
Portsmouth City Teaching PCT - Provider Arm Assurance Framework and Strategic Risk Register
                                                                                                                                                                                                                                                                                          Cross References
Reference   Date        Strategic Risk Description of Risk                            Controls in Place              Assurances         RL RI    Residual Responsible      Gaps in Control     Action         Expected     AP      Gaps in         Action      Expected           AP      S4BH     UoR        NHSLA       Other    Change Note
                                                                                                                                                 Risk     Director                             Planned        Implementati Cross   Assurance       Planned     Implementation     Cross
                                                                                                                                                 Score                                                        on Date      Ref                                 Date               Ref
09-P-002    4/16/2009   Implementation Financial cost of new system and               Project team                   Report on          5    4   20       Judy Hillier,    Merged strategic    CEOs to        Feb '10                                                                     C6,      1.1,1.2,                          -
                        of RIO (Clinical potential problems with staff ‘buying-in’    Project plan                   progress to                          Director of      direction           review final                                                                               C11a &   2.2, 3.3
                        system)          to new system causing an impact on           Monitoring reports to IT       Provider                             Provider                             plan                                                                                       b, C17
                                         clinical staff time in terms of training     Deployment Group               Committee on a                       Services
                                         and ongoing usage. Strategic                 Board/Corporate support        regular basis.
                                         alignment within the new provider            Strategic IT plan              Solent Kaleido
                                         (particularly the Child Health System).      Communications plan            project report.
                                                                                      Workforce plan

09-P-003    4/16/2009   Transforming        Failure to meet the strategic intention   Project governance             Project            3    5   15        Judy Hillier,   1. Staff change     Staff          Ends end of                                                                                                 OP 9.7     -
                        Community           of the Commissioner and failing to        arrangements include:          documentation;                        Director of     document            consultation   Feb '10
                        Services - a        meet the national timetable, business     Project management;            Options appraisal                     Provider                            on document
                        major               continuity during change process          Project plan;                  report;                               Services
                        organisational      leading to potential patient safety       Consultation strategy (staff   Record of legal
                        change              issues, public misconception of           and other stakeholders);       meetings;
                        programme           changes and adherence to legal            Legal advice available.        Hosting discussion
                        affecting the       requirements irrespective of staffing,                                   paper.
                        whole PCT and       notably type, and competition and co-
                        over two            operation guidance.
                        thousand staff
                        in the provider
                        function.

08-P-002    Apr-08      Provision of        Lack of Social Workers (employed by       Social Care Professional       Workforce           4   3   12        Judy Hillier,   1. Pay review       Underway                            1.Evidence of   1. Report to 1. IGC Mar 2010           C6,      2.1        Standards              -    Recommendation
                        effective care to   Portsmouth City Council) causing          Lead in PCT;                   numbers / training                    Director of                                                             minimum safe    IGC                                    C22a,               4&5                         by JH to de-
                        mental health       breakdown in care pathway and delays      Integrated Mental Health       statistics                            Provider                                                                coverage        minimum                                C22c                                            escalate to
                        patients            in assessment resulting in staff,         Team;                          presented regularly                   Services                                                                                safe                                                                                   Directorate Risk
                                            service and client risk.                  S75 Partnership meetings;      to DMT (I&E/P)                                                                                                                coverage                                                                               register once IGC
                                                                                      Membership of AMH Assoc.                                                                                                                                     satistical                                                                             receives a report
                                                                                      Dir in Portsmouth City                                                                                                                                       information                                                                            on s75
                                                                                      Council DMT;
                                                                                      ASW / Social Workers
                                                                                      using PCT AER forms;
                                                                                      Mental Health Act Panel.


08-P-008    5/25/2008   Have a              Full adherence to procedures must be      Medical Devices policy;        Response to SABs 2      4   8         Judy Hillier,                                                           1. Judgement of 1. Report to 1. Mar 2010 IGC           C1b,     2.4        2.7, 3.7               -    Recommendation
                        framework in        in place to prevent risk of harm to       Medical Devices SLA with       on CAS website                        Director of                                                             Healthcare      IGC when                               C4a,                                            by RD to reduce
                        place within        patients and staff and increased          PHT and monitoring             (E/P);                                Provider                                                                Commission      received                               C4b,                                            likelihood and
                        which the Board     potential for litigation.                 arrangements;                  NHSLA level 1                         Services                                                                assessment                                             C4c,                                            close issue
                        may be assured                                                CAS Alert system;              assessment 2009                                                                                               2008/09;                                               C4e, C5a                                        (following report
                        that there is                                                 Healthcare Commission          (E/P).                                                                                                                                                                                                               to panel by Katie
                        safe and                                                      assessment;                                                                                                                                                                                                                                         Hovenden & IGC
                        effective                                                     Domain reports to IGC;                                                                                                                                                                                                                              review of S4BH
                        management of                                                 Decontamination Policy;                                                                                                                                                                                                                             declaration in
                        medical                                                                                                                                                                                                                                                                                                           April 09) once
                        devices.                                                                                                                                                                                                                                                                                                          SABs
                                                                                                                                                                                                                                                                                                                                          investigation
                                                                                                                                                                                                                                                                                                                                          completed.




                                                                                                                     I - Internal
                                                                                                                     E - External
                                                                                                                     P - Positive
                                                                                                                     N - Negative




Provider                                                                                                                                                                              4 of 4                                                                                                                                              Post IGC January 2010