BAF 2017-18 template - wwl.nhs.uk · in hospital acquir le harms measur m, implement ch s by 10%...

Trust Board Agenda Item 10. Date: 27 September 2017

Title of Report BAF

Purpose of the report and the key issues for consideration/decision

The Board are asked to receive and agree the scores proposed by sub-committees for September. Consideration is being given to re-wording the risk around the delivery of the Big 12 and CIP and to the inclusion of additional workforce risks around CPD funding, flu vaccine uptake and centralised training records.

Prepared by: Name & Title

Trust Board Secretary Office

Presented by: Paul Howard, Trust Board Secretary

Action Required (please X)

Approve Adopt Receive for information

x

Strategic/Corporate Objective(s) supported by this paper

Governance

Is this on the Trust’s risk register? No

x Yes

If Yes, Score

Which Standards apply to this report?

CQC x NHSLA x BAF Objectives x WWL Wheel x

Have all implications related to this report been considered?

Yes/No/NA Any

Action Required

Yes/ No/NA

Any Action Required

Finance Revenue & Capital Y Equality & Diversity

Y

National Policy/Legislation Y Patient Experience

Y

NHS Contract Y Governance

& Risk Management

Y

Human Resources Y Terms of Authorisation

Y

Consultation/Communication Y Human Rights

Y

Other: Na Na Carbon Reduction

Na Na

If action required please state:

Previous Meetings Please insert the date the paper was presented next to the relevant group

ECC Audit Committee

Quality & Safety

Committee

Finance & Investment Committee

Management Board

Strategy Committee

Workforce Committee

NED Other

Na Na x x Na Na x Na Na

Quality Corporate Objective:

Measureme

What does objective mean?

Key Risk

What are the kerisks to achievincorporate objec

Failure to achian improved benchmarked position for mortality

To deliver scare

ent Moa the10

the To

Key Contro

ey ng this ctive?

What controls/systemcurrently in plamitigate the ris

ieve Weekly death aand annual sumidentifying them Focussed improvements relation to Sepsand AKI; Mortality Framelinking with themanagement oserious inciden Joint project wiCCG reviewingdeaths within 3days of dischar

safe, high quality

ortality; compliancmetric to measureeatre effectivenes00% adherence; ro deliver safe, hig

ols Assurancecontrols

ms are ce to k?

Where we canevidence or asthat our control/systemeffective?

audits mmary mes;

in sis

ework e of nts;

ith the g 30 rge;

HSMR/SHMI dTrust Board Performance R Dr Foster MortAlerts; Quarterly mortreports to QuaSafety Commi

Board

y, effective, evid

ce with 10 DNACPe Right Patient Riss; accurate and veduce unnecessah quality, effective

e on Gaps in Control aAssuranc

n gain ssurance

ms are

Potential areweakness threquire addicontrols/furtconsideratio

data –

Report;

tality

tality ality and ttee.

Trust-wide mortality gro Trust-wide understandiplan for arearequiring focus/impro

d Assurance

ence-based patie

PR Always Eventsght Ward; Develovalidated SLR figuary investigations e, evidence-based

and or ce

Initial risk

Tr

eas of hat may itional ther on?

C L S C

oup

ing/ as

ovement

5

5

25

5

e Framewor

ent

s; reduction in moopment of ward acures; prioritise in tby 10%, interventd patient care

Target risk

Month 2017-18

C L S

5 3

15

April

May

June

rk 2017-18

Lead Director: P Law, Director Medical Director

oderate and seriouccreditation systemerms of short, metions by 10% and

Impact of not achieving the objective

UScl

Committee Dintim

Q&S 12.04.17 Muncoininamingrpr

Q&S 10.05.17 ThthdaIt

Q&S 14.06.17 Thup

of Nursing / S Aryr

us falls; reduction m; reduce avoidabedium and long ter

prescription drugnsafe, poor qualitTEIS reportable ininical claims, poo

iscussion/Rationncluding further amescale for deliv

ortality data for the nscheduled care preontributed to this pocreased morbidity o transfers to care homount of internal wocluding the establisroup. The Committeroposed opening sc

he Mortality Group whe first time on 01.06ata hadn’t changed was agreed to retai

he Committee had rpdate from the Mort

ya, Responsible Quality & Safe

in hospital acquirble harms measurrm, implement chs by 10% ty care, regulatoryncidents (serious

or patient experien

nale for score actions agreed avery

Trust was still highessures had

osition as well as theof patients and delaomes; a significant ork was being done shment of a mortalityee agreed to retain

core of 25

would be meeting fo6.17. The mortality since the last meetin the score at 25

received and noted tality Working Group

Monitoring Comety

red infections; devres through a reduoose wisely UK c

y enforcement; incincidents), compl

nce.

and Relevant Corporate RIdentified In-year

;

e ys

y the

Na

or

ing.

Na

the p

Na

1

mmittee:

velopment of uction in SI’s ampaign with

crease in aints and

isks -

Current Score

C L S

5 5 25

5 5 25

5 5 25

Key Risk


Failure to achian improved benchmarked position for mortality cont

Key Contro

ey ng this ctive?


ieve

t.

System to reviedeaths of patiewith a learning disability.


ms are ce to k?


ew ents


n gain ssurance

ms are


and or ce

Initial risk

Tr


C L S C

5

5

25 5

Target risk

Month 2017-18

C L S

5 3

15

July

August

Sept

Oct

Committee Dintim

anacHothre

Q&S 12.07.17 ThhaduthThexMTh5 im

ECC 29.08.17 ECco

Q&S 13.09.17 MexwofwaCoofCoDTh5


nd had taken assuraction and discussionowever, there rema

he mortality data andetain the score at 25

he Medical Director ad been a reductionuring May and Junehat this trajectory wohe Committee notedxternal organisationortality Working Grohe Committee agreex 5 = 25 pending co

mproving trajectory c

CC reviewed the risould be reduced to 5

ortality group meetixternal stakeholdersith focus on outlyingf deaths in hospital as further improvemoncerns around thef data had been raisommissioning Grouirector level across he Committee agreex 4 = 20


ance that approprians were taking placeained concerns aroud it was agreed to 5

r reported that theren in hospital mortalite. It was anticipatedould continue into Jud that discussions ws and the work of thoup continued. ed to retain the scoonfirmation that thecontinued

sk and agreed that t5 x 4 =20

ings, attended by s, continued to be hg areas. The numbhad reduced but the

ment to be made. e use of disparate sesed at Clinical up (CCG) and Medicthe region. ed to retain the sco


te e.

und

e ty d uly. with he

re at

Na

this Na

eld er ere

ets

cal

re at

Na

2

isks -

Current Score

C L S

5 5 25

5 4 20

5 4 20

Key Risk


Key Contro

ey ng this ctive?



ms are ce to k?



n gain ssurance

ms are


and or ce

Initial risk

Tr


C L S C

Target risk

Month 2017-18

C L S

Nov

Dec

Jan

Feb

March

Committee Dintim




3

isks -

Current Score

C L S

Key Risk

What are the kerisks to achievithis corporate objective?

Failure to achinfection conttrajectories

Key Contro

ey ng


ieve trol

Infection controteam; Strategy and wplan; Infection ContrCommittee; System for infeinvestigations/ scrutiny; Infection controaudits and follo Deep clean schedule; PLACE Assess– Cleanest hosfor three years running.


ms are ce to k?


ol

work-

rol

ection

ol ow up

sments spital

Numbers of CMRSA; MSSAinfections – TrBoard PerformReport; Learning from investigations/ Achievement otrajectory for 2(19); No lapses in c


n gain ssurance

ms are


DT’s; A; e-coli rust

mance

infection /scrutiny;

of CDT 2017-18

care.

Benchmarkiwith other organisation Process for reporting sta Compliancewith ANTT; Availability orooms.

and or ce

Initial risk

Tr


C L S C

ing data

ns

new andards

e issue

of side

5 4 20 5

Target risk

Month 2017-18

C L S

5 3 15 April

May

June

July

August

Committee Dintim

Q&S 12.04.17 AshoraaninhaotThmThpr

Q&S 10.05.17 Thththpoagde

Q&S 14.06.17 L a Coth

Q&S 12.07.17 Thdeplbere

ECC 29.08.17 ECth


s a consequence ofospital system, it waates had started to innd dependency of pcreased susceptibilad been one CDT inther case that was bhere would need to

maintaining the Trusthe Committee agreeroposed opening sc

he Committee had rhe Infection Control he deep clean schedostponed due to bedgreed to retain the seep cleans could be

Barkess Jones advvery challenging yeontrol. The Commi

he score at 20

he Director of Nursieep clean schedulesanned although theed pressures. The etain the score at 5 x

CC reviewed the rishe current score of 2


f the pressures on tas noted that infectioncrease. The acuity

patients meant ity to infection. The

n April and a possibbeing investigated. be focus on

ts internal standardsed to retain the

core of 20

received a paper froteam. It was noted dule had been d pressures. It wasscore at 20 until thee commenced

vised that this wouldear in terms of Infecttee agreed to retai

ng reported that thes were progressing

ese could be affecteCommittee agreed x 4 =20

sk and agreed to ret20


he on y

ere ble

s.

Na

om that

s

Na

d be tion n

Na

e as

ed by to

Na

tain Na

4

isks -

Current Score

C L S

5 4 20

5 4 20

5 4 20

5 4 20

5 4 20

Key Risk


Failure to achinfection conttrajectories co

Key Contro

ey ng


ieve trol ont.


ms are ce to k?



n gain ssurance

ms are


and or ce

Initial risk

Tr


C L S C

Target risk

Month 2017-18

C L S

Sept

Oct Nov Dec Jan Feb Mar

Committee Dintim

Q&S 13.09.17 Inininth


n consideration of th discussions with refections, the Comm

he score at 5 x 4 =20


he challenges outlineegard to C diff

mittee agreed to reta0


ed

ain

Na

5

isks -

Current Score

C L S

5 4 20

Key Risk


Failure to reduclinical variatiand drug cost10%

Key Contro

ey ng


uce ion ts by

Agreement on of scheme: clinvariation and demand management aareas of scopethis work. Onehas been identfor each DivisioColorectal, Gastroenteroloand hips and kProject group established; Plan to undertaretrospective re ‘10 things we sstop doing’ preto ManagemenBoard in Janua2017


ms are ce to k?


focus nical

are two e within e area tified on:

ogy knees;

ake a eview;

should esented nt ary

Weekly DeliveManagement B


n gain ssurance

ms are


ery Board;Board

Availability onecessary aaccurate dainform decismaking

and or ce

Initial risk

Tr


C L S C

of and ata to sion

4 5 20 4

Target risk

Month 2017-18

C L S

4 2 8 April

May

June

July

August

Sept


Committee Dintim

Q&S 12.04.17 R

Q&S 10.05.17 Thcokeag

Q&S 14.06.17 A thFogoCo

Q&S 12.07.17 ThprconoCo5

ECC 29.08.17 ECth

Q&S 13.09.17 It mreThto


isk could not be sco

he Committee notedommenced around cey specialties identifgreed to retain the o

Abbasi advised thahe Divisions and wasortnightly meetings ood progress was bommittee agreed to

he Medical Director rogress was being mosts. In terms of clinoted that data collecommittee agreed to= 20

CC reviewed the rishe score of 20

was noted that goomade, particularly witeduction of drug coshe Committee agree

o 4 x 4 = 16


ored this time

d that work had clinical variation witfied for focus. It waopening score of 20

at work continued ws led clinically. were taking place a

being made. The o retain the score at

r reported that positimade to reduce drugnical variation, it waction continued. Tho retain the score at

sk and agreed to ret

od progress was beith regard to the sts. ed to reduce the sco


Na

h as 0

Na

ithin

and

20

Na

ive g

as e 4 x

Na

tain Na

ng

ore

Na

6

isks -

Current Score

C L S

- - -

4 5 20

4 5 20

4 5 20

4 5 20

4 4 16

WorkCorporate Objective:

Measurem

What doesobjective mean?

Key Risk


Failure to stayunder agency ceiling, impactIR35 and associated imon safe staffinlevels

kforce

Have a safthe servic

ment Padefraenbemsta

s the As

Key Contro

ey ng this ctive?


y

t of

pact ng

Trust GradeMedical posbe advertisemitigate expected vacancies Procuremenframework tsupport reduction in cards

fe and flexible we now and for t

ay bill – reduce aefinition of 7%; Roamework, block conergy, reduction inelow average sickitigate the pay billatistically significas above


ms are ce to k?


e sts to ed to

nt to

rate

Workforce Committee F&I Commi GM StrategWorkforce B GM HRD ne

workforce that the future

gency expenditurostering – vacancontract and localitn health age from kness rate for S4Wl impact of apprenant reduction in re


n gain ssurance

ms are


ttee

gic Board

etwork

GM / NWagreemenimplemen

meets the nee

re below agency ccy rate under 3.5%ty plan; Health & 4 years 7 months

W programme partnticeship levy to ueason for leaving ‘

and or ce

Initial risk

Tr


C L S C

W nt and ntation

5

4

20

5

ds of

ceiling and to unde%, nursing shift fillWellbeing – sicks as defined by Brticipants; Learninnder 4%, statisticlack of personal d

Target risk

Month 2017-18

C L S

5 3

15

April

May June

Lead Director: A Balson, Direct

er 2.11% of pay b rates over 89%, ness rate below 4ritain’s Health Wo

ng and Developmally significant imp

development’ Impact of not achieving the objective

U

Committee Dintim

Workforce Coco

Workforce No

Workforce Thx costthagbere

tor of Workforce

bill, reduce cap bre100% job plan co

4%, statistically sigrkplace survey, b

ment – draw downprovements in pu

nsafe patient care


ould not be scored omplete

ot scored for May

he Committee agree3 = 15. This was oould impact on the ptaffing levels. Howevhe Trust had succesgency spend and preing undertaken to eetention and improve

Responsible Workforce

eaches by 15%, pompletion aligned gnificant improveme in top 50% of B

n more than 85% olse survey scores

e, poor staff mora


for April – template

ed to score the risk n the basis that the provision of safe ver it was noted tha

ssfully reduced its ro-active work was enhance recruitmene wellbeing of staff

Monitoring Com

pay bill reduction bto standardised Sment in pulse survritain’s Healthiest of the apprenticess - personal develo

ale and unsafe sta


not -

-

at 5 risk

at

nt,

Na

7

mmittee:

by Carter SPA vey score for workplaces,

ship levy fund, opment,

affing levels.

isks -

Current Score

C L S

- - -

- - -

5 3 15

Key Risk


Failure to stayunder agency ceiling, impactIR35 and associated imon safe staffinlevels cont.

Key Contro

ey ng this ctive?


y

t of

pact ng

Developmenregional caprates Redesign ofstaffing modto reduce demand for staffing E-locum shimanagemensystem


ms are ce to k?


nt of pped

f dels

temp

ft nt


n gain ssurance

ms are


and or ce

Initial risk

Tr


C L S C

5 4 20 5

Target risk

Month 2017-18

C L S

5 3

15 July

August Sept Oct Nov Dec Jan Feb Mar

Committee Dintim

ECC ECmag

ECC 29.08.17 ECth

Workforce Prtraat


CC noted that goodmade in terms of the greed to retain the s


rogress against the ajectory. It was agrt 5 x 3 = 15


d progress was beinagency ceiling. It w

score at 5 x 3 = 15


agency ceiling wasreed to retain the sc


g was

Na

tain Na

s on core

Na

8

isks -

Current Score

C L S

5 3 15

5 3 15

5 3 15

Key Risk


National shortoccupations ainefficient useavailable reso

Key Contro

ey ng


tage and e of ources

E-rostering system and associated reports Manual job planning processes foMedical Sta Nursing & Midwifery strategy MCH & MMEearn, learn & return progra GM WorkforcStrategy


ms are ce to k?


or ff

ED

mmes

ce

Workforce Committee GM StrategWorkforce B


n gain ssurance

ms are


gic Board

Lack of e-planning system National shortages

and or ce

Initial risk

Tr


C L S C

-job

s

5 4 20 5

Target risk

Month 2017-18

C L S

5 2 10 April

May

June

July

Aug

Sept


Committee Dintim

Workforce Coco

Workforce No

Workforce Th5 inwoprprunar

ECC ECprwespsc

ECC 29.08.17 ECth

Workforce

Ththretato



ot scored for May

he Committee agreex 4 = 20. While sigto rostering and nurould not be implemerogress had been mrogrammes but therncertainties in certaround apprenticeshi

CC noted that thererogress with the Mcere potential issuesponsorship. It was acore at 5 x 4 =20


he Committee had dhe continued challenecruitment. Howeveaken to try to addreso retain the score at



ed to score this riskgnificant work had grse shift patterns, thented until July. Go

made with the Mch re were still in specialties and ip standards

e had been good h programme but th

s around certificatesagreed to retain the


discussed and notenges in nurse er, actions were beinss this. It was agree20


not -

-

k at one

hese ood

Na

here s of e

Na

tain Na

d

ng ed

Na

9

isks -

Current Score

C L S

- - -

- - -

5 4 20

5 4 20

5 4 20

5 4 20

Key Risk


Sickness absence impacts onsafe staffinlevels and ability to reduce pay

Key Contro

ey ng


g

y bill

Attendance ManagemenPolicy Steps 4 Wellness Programme Well Being Partners OccupationaHealth Serv Go Engage The WWL W


ms are ce to k?


nt

s

al vice

– Way

Workforce Committee


n gain ssurance

ms are

Potential areweakness threquire addicontrols/furtconsideratioCounsellicapacity

and or ce

Initial risk

Tr


C L S C

ng 4 3 12 4

Target risk

Month 2017-18

C L S

4 2 8 April

May June

July

Aug

Sept


Committee Dintim

Workforce Coco

Workforce No

Workforce It Loimpo

ECC ECreag

ECC 29.08.17 ECth

Workforce Thinanin4%of



ot scored for May

was agreed to scorots of positive work

mprove sickness levockets of high abse

CC noted that sicknemained at a steadygreed to keep the sc


he Committee noteditiative in place to and wellbeing, uptakecreased. Sickness %. It was agreed tof 12.



re this risk at 4 x 3 =was being undertakels but there remainnce

ness absence levelsy rate of 4%. It was core at 4 x 3 = 12


d that there were assist staff with heale needed to be levels were at just

o retain the current s

1

and Relevant Corporate Risks Identified Inyear

not -

-

= 12. ken to ned

Na

s Na

tain Na

th

over score

Na

10

n-

Current Score

C L S

- - -

- - -

4 3 12

4 3 12

4 3 12

4 3 12

Key Risk


Failure to utilise availresources timprove personal developmeopportunitiwhich impaon retentioand does nmitigate thecost of the apprenticeslevy

Key Contro

ey ng


lable to

nt es,

acts n ot e

ship

WWL RoutePlanner Participationtrailblazer apprenticesprogrammesnursing associate Membershipapprenticesworking groinform new standards Developmenapprenticestargets to Divisions Workforce planning GM workforstrategy


ms are ce to k?


e

n in

hip s e.g.

p of hip up to

nt of hip

ce

Workforce Committee GM HRD ne GM StrategWorkforce B


n gain ssurance

ms are


etwork

gic Board

Lack of suapprenticstandards Out of workplacelearning –impact onstaffing le

and or ce

Initial risk

Tr


C L S C

uitable ceship s

e – n evels

4 4 16 4

Target risk

Month 2017-18

C L S

4 3 12 April

May June

July

Aug

Sept

Oct Nov

Dec Jan Feb Mar

Committee Dintim

Workforce Coco

Workforce No

Workforce Thx ofnoande

ECC ECfusc

ECC 29.08.17 ECth

Workforce Ththapin



ot scored for May

he Committee agree4 =16. The significf CPD funding internoted and the potentnd retention. Thereelay in developing a

CC noted the concending for CPD. It w

core at 4 x 4 = 16


he Committee notedhat was being made pprenticeships howecrease the score to



ed to score this riskant risks around thenally and nationally ial impact on recruit

e was also concern aapprenticeship stand

erns around the lackwas agreed to retain


d the positive progrein terms of

ever iIt was agreed o 4 x 5=20.

1


not -

-

k at 4 e lack were tment at the dards

Na

k of n the

Na

tain Na

ess

to

Na

11

n-

Current Score

C L S

- - -

- - -

4 4 16

4 4 16

4 4 16

4 5 16

Staff EnCorporate Objective:

Measurem


Key Risk


Engagement dnot improve – direct correlatbetween staff engagement apatient satisfa/ outcomes

ngagement

To improvof confideinfluence

ment Ovinf

s the As

Key Contro

ey ng this ctive?


does

tion

and action

Go Engage The WWL W Pulse surve Strategic narrative woprogramme Steps 4 Wellness Programme WWL RoutePlanner Locality

ve levels of stafence and optimchange

verall engagemenfluence, mindset, s above.


ms are ce to k?


– Way

ys

ork

s

e

Workforce Committee National StaSurvey Locality WoPlan Pulse surve

ff engagement, ism where staf

nt score 4 (nationaclarity and recogn


n gain ssurance

ms are


aff

orkforce

eys

Improvedinternal communicmethods intranet) Uncertaincaused byexternal environm

developing a cff can directly

al staff survey); FFnition; implement

and or ce

Initial risk

Tr


C L S C

d

cation (new

nty y

ent

4 4

4 4

16 16

4

4

culture

FT recommendatinew leadership fr

Target risk

Month 2017-18

C L S

4

4

2 2

8 8

April

May

June

July

Lead Director: A Balson, Direct

ions above 80%; sramework and beh


Ple

Committee Dintim

Workforce Coco

Workforce No

Workforce Thx postrerewodiD

ECC ECPurela

tor of Workforce

statistically signifihaviours – assessoor staff morale, p

evels and deteriora



ot scored for May

he Committee agree3 = 12. There was ositive work being utrategic narrative. Tesults from the Frienecommending WWLork. It was noted thp in engagement leivision

CC noted that thereulse survey in June

etain the score at 4 xunch of the strategi

Responsible Workforce

cant improvemensed through new 3poor staff retentioation of staff surve



ed to score the risk a significant amoun

undertaken around tThere had been posnds and Family test L as a good place ofhat there had been aevels in the Corpora

e had been a positivbut it was agreed t

x 3 = 12 pending thc narrative

1

Monitoring Com

ts in pulse survey360

on, increased sickney results.


not -

-

at 4 nt of the sitive

f a te

Na

ve o e

Na

12

mmittee:

y scores -

ness absence

isks -

Current Score

C L S

- - -

- - -

4 3 12

4 3 12

Key Risk


Key Contro

ey ng this ctive?


workforce programmes Partnership working withtrade unions


ms are ce to k?


s

h s


n gain ssurance

ms are


and or ce

Initial risk

Tr


C L S C

Target risk

Month 2017-18

C L S

August

Sept


Committee Dintim

ECC 29.08.17 ECth

Workforce Thunburere



he Committee notedndertaken in relationut noted that the puemained at a plateauetain the score of 12



d the work being n to staff engagemelse scores had u. It was agreed to

2

1


tain Na

ent Na

13

isks -

Current Score

C L S

4 3 12

4 3 12

PerformCorporate Objective:

Measurem


Key Risk

What are the kerisks to achievinthis corporate objective?

Failure to meeA&E 4 hour ta(90% Q1, 91.5%92% Q3, 92.8% If the Trust is unable to manthe level of emergency deit may lead toAn inability to deliver operatistandards. Affquality of carelarge number patients. Unmanageablestaff workloadNegative finanposition. Regulatory act

mance

To meet a

ment A&to

s the Thre

Key Contro

ey ng


et the rget % Q2,

% Q4)

nage

emand o:

ional fect e for of

e ds. ncial

tion.

Emergency De& patient flow management arrangements Emergency Department StaOperating Procedures. Monthly Performanagement meeting NHSI A&E Improvement PWinter ResilienPlan Patient Flow Projects– GettiHIS

ll national acce

& E 4 hour target first treatment an

he Trust is requirelation to A&E, can


ms are ce to k?


emand

andard

rmance

Plan nce

nge

Daily and Weemeetings: Patient Flow mDaily Board ro Achievement astandard repoF&I Committeeboard via PerfReport. Daily/weekly performance dmonitoring/ NHEngland/UrgenDashboards Friends and FaFeedback Output from AQuality ImprovGroup

ess targets

(90% Q1, 91.5% nd 62 day wait urged to meet a numbncer treatment an


n gain ssurance

ms are


ekly

meeting ounds

against rted to e & Trust formance

data HS nt Care

amily

&E vement

Not achievinstandard CommissionContracting (Chorley A& Increased Apatients Weakness iregional Escalation P Co-location Primary Car Managing D Access to Community

Q2, 92% Q3, 92.8gent GP referral tober of national accd diagnostics.

and or ce

Initial risk

Tr


C L S C

ng 95%

ner

&E)

Acuity of

n local/

Process

of re

Demand

Beds

5

4

20

5

8% Q4); 18 weekso first treatment; Dcess targets in

Target risk

Month 2017-18

C L S

5 3

15

April

May

June

Lead Director: M Fleming, Direand Performanc

s/RTT IncompleteDiagnostic-seen w


Imre

Committee Dintim

F&I 25.04.17 ThacthpeThaca

F&I 23.05.17 Ththwepere

20.06.17 F&I ThmthQA&im

ctor of Operationsce e Pathway (92%);

within 6 weeks. mpact on quality oegulatory action.


he Committee notedchievement of natiohe achievement of Aerforming well at ovhere were no concechievement in April.score of 5 x 3 = 15

he Committee notedhe revised trajectoryere currently no conerformance. The Coetain the score of 15

he Committee notedmeeting the revised there were no concer1. However it was &E team had implem

mprovement initiative

s Responsible Finance and I

Cancer targets –

of care and financi


d that the only risk tnal access targets w

A&E. Currently, A&Eer 90% achievemen

erns around the The Committee ag

d that A&E had achy of 90% in April. Thncerns around ommittee agreed to

5

d that A&E was currtrajectory of 90% anrns around the delivnoted that, whilst thmented a number oes, there were incre

1

Monitoring Comnvestment

2 weeks to be se

ial position. Possi


to the was E was nt.

greed

Na

ieved here

o

Na

rently nd very of he of eased

Na

14

mmittee:

een, 31 days

bility of

n-

Current Score

C L S

5 3 15

5 3 15

4

4

16

Key Risk


Failure to meeA&E 4 hour tacont.

Key Contro

ey ng


et the rget


ms are ce to k?

Where we canevidence or asthat our control/systemeffective? A&E Delivery Outputs Systems ResilOperational gr CQC inspectio


n gain ssurance

ms are


Board

lience roup

on

and or ce

Initial risk

Tr


C L S C

5 4 20 5

Target risk

Month 2017-18

C L S

5 3

15

July

Aug

Committee Dintim

atpaprpoatthtaIt haprasimTh

F&I 18.07.17 ThcohainhaBoth

ECC 29.08.17 Than5


ttendances to A&E batients and out of arrovided additional potentially put year et risk. The Committhe potential to lose Sarget not be achieve

was agreed that theave visibility of GP orojects and communssurance around the

mpacting on deliveryhe Committee agree

he Committee notedontinued to be undead been achieved w centre activity. Thead been escalated toard. The Committ

he score to 4 x 5 = 2

he risk was reviewend it was agreed to x 4 = 20 to better re


by young mental herea patients which ressure and could nd achievement of ee noted and discu

S&T funding should ed. e Committee needeout of hours, deflectnity bed plans to gae external factors y. ed to score as 4 x 4

d that A&E performaer pressure and thatwith the inclusion of e concerns of the Bto the A&E Delivery ee agreed to increa

20

ed and discussed at amend the risk sco

eflect the position

1


ealth

95% ssed the

ed to tion in

4 = 16

ance t Q1 walk

Board

ase

Na

ECC re to

Na

15

n-

Current Score

C L S

4

4

16

4 5 20

5 4 20

Key Risk


Failure to meeA&E 4 hour tacont.

Key Contro

ey ng


et the rget


ms are ce to k?



n gain ssurance

ms are


and or ce

Initial risk

Tr


C L S C

Target risk

Month 2017-18

C L S

Sept

Oct Nov Dec

Jan

Feb

March

Committee Dintim

F&I 19.09.17 ThTrthanthplthag


he Committee receirust was delivering a

he exception of A&En area of challenge.hat there were tacticace to help improve

he basis of continuingreed to retain the s


ved assurance thatall national targets w

E which continued to. Assurance was gical and strategic plae A&E performanceng A&E challenge, itscore at 5 x 4 = 20

1


t the with o be ven ns in . On t was

Na

16

n-

Current Score

C L S

5 4 20

FinanceCorporate Objective:

Measurem


Key Risk


Failure to Delivthe 12 big sch

e

To achieve

ment Fi

s the As

Key Contro

ey ng this ctive?


ver emes

Executive Lfor all big schemes; Weekly delivmeetings; Monthly ManagemenBoard

e two year bud

nancial Budget an

s above


ms are ce to k?


eads

very

nt

Strategy Committee;Finance anInvestment;Trust BoardMonthly FinReport (withand variancanalysis); Eaudit/internsign off revi

get stability

nd Control Total; F


n gain ssurance

ms are


; d ; d: nance h trend ce External al audit iews.

Savings 12 big schemes defined; BSummaryreports

FRR; Big 12 sche

and or ce

Initial risk

Tr


C L S C

from

to be Big 12 y

5

3

15

5

emes; Capital Inve

Target risk

Month 2017-18

C L S

5 1

5

April May

June

July

Lead Director: R Forster, DirecInformatics

estment versus pla


BT

Committee Dintim

F&I 25.04.17 Thtim

F&I 23.05.17 ThBianthpl

F&I 20.06.17 Thbethth

F&I 18.07.17 Thcolikdewo

tor of Finance and

an

udget overspend ransformation fun


he Committee was me as the template

he Committee notedig 12 continued to pnticipated that the she full savings requirace to cover the sh

he Committee notede thorough investigahe Big 12 schemes. he risk at 5 x 3 = 15

he Committee notedontinued to be madekely that some of theeliver as anticipatedould be considered

d Responsible Finance and I

will lead to non-and


not able to score thnot complete

d that work around tprogress. It was notchemes would delivred but plans were ortfall by Divisional

d that there continueation into and scruti It was agreed to sc

d that, while progrese on the Big 12, it we schemes may not

d. Replacement sch. The Committee a

1

Monitoring Comnvestment

chievement of the


is Na

the t ver in CIP

Na

ed to ny of core

Na

ss was t hemes greed

Na

17

mmittee:

e Sustainable

n-

Current Score

C L S

- - -

5 3 15

5 3 15

5 4 20

Key Risk


Failure to Delivthe 12 big schcont.

Key Contro

ey ng this ctive?


ver emes


ms are ce to k?



n gain ssurance

ms are


and or ce

Initial risk

Tr


C L S C

5 3 15 5

Target risk

Month 2017-18

C L S

5 1 5

Aug

Sept


Committee Dintim

to

ECC 29.08.17 Thanof

F&I 19.09.17 Thrisapanintha m


o increase the score

he risk was discussnd it was agreed tof 20

he Committee notedsk as there was nowpproach being takennd the Big 12 and Ccorporated into this

he score of 5 x 4 = 2new risk being put f

meeting for considera


e of the risk to 5 x 4

ed and reviewed at retain the current sc

d the need to refocuw a more holistic n to delivering savin

CIP had been s. It was agreed to r20 this time with a viforward at the next ation

1


= 20

ECC core

Na

us this

ngs

retain iew to

Na

18

n-

Current Score

C L S

5 4 20

5 4 20

Key Risk


Failure to Deliver Divisional C

Key Contro

ey ng


CIPs

CIP Oversigreviews; Divisional PerformancReviews


ms are ce to k?


ght

e

Strategy Committee;Finance anInvestment;External audit/internsign off revi


n gain ssurance

ms are


; d ;

al audit iews.

Divisionaprocess/pQuality ImAssessme

and or ce

Initial risk

Tr


C L S C

l CIP plan; mpact ents

5 3 15 5

Target risk

Month 2017-18

C L S

5 1 5 April May

June

July

Aug

Sept

Committee Dintim

F&I 25.04.17 Thtim

F&I 23.05.17 Thscto

F&I 20.06.17 ThDbywoD£4=

F&I 18.07.17 ThthhaC=

ECC 29.08.17 Thanof

F&I 19.09.17 Thrisapanintha m



he Committee had ncrutinise CIP plans ao score the risk at 5

he Committee had nivisional CIP plans y the ED team that Dork on plans. It wasivisional CIP require4m. It was agreed t15

he Committee notedhe Director of Operaad been put in placeIPs. It was agreed 15

he risk was discussnd it was agreed tof 15

he Committee notedsk as there was nowpproach being takennd the Big 12 and Ccorporated into this

he score of 5 x 3 = 1new risk being put f

meeting for considera



not had the opportuas yet so it was agrx 4 = 20

not yet seen the but assurance was Divisions continueds also noted that theement had reduced to score the risk at 5

d that a process ledations and Performae to monitor divisionto score the risk at

ed and reviewed at retain the current sc

d the need to refocuw a more holistic n to delivering savin

CIP had been s. It was agreed to r

5 this time with a viforward at the next ation

1


is Na

nity to reed

Na

given to e to

5 x 3

Na

d by ance nal 5 x 3

Na

ECC core

Na

us this

ngs

retain iew to

Na

19

n-

Current Score

C L S

- - -

5 4 20

5 3 15

5 3 15

5 3 15

5 3 15

Key Risk


Failure to Deliver Divisional Ccont.

Key Contro

ey ng


CIPs


ms are ce to k?



n gain ssurance

ms are


and or ce

Initial risk

Tr


C L S C

Target risk

Month 2017-18

C L S


Committee Dintim



2


20

n-

Current Score

C L S

Key Risk


Budget overspend;Cashflow reductions liquidity

Key Contro

ey ng


;

and

Divisional PerformancReviews; DFweekly cashmonitoring; Monthly CapCommittee.


ms are ace to sk?


ce FM h

pital

Finance anInvestment;Trust BoardMonthly FinReport (withand variancanalysis); Rescalation oyear’ risks; External audit/internsign off revi


n gain ssurance

ms are


d ; d: nance h trend ce REMC of ‘in-

al audit iews.

None iden

and or ce

Initial risk

Tr


C L S C

ntified 5 3 15 5

Target risk

Month 2017-18

C L S

5 1 5 April May

June

July

Aug

Sept

Oct Nov

Committee Dintim

F&I 25.04.17 Thtim

F&I 23.05.17 Thtostx

F&I 20.06.17 Thwaplcosc

F&I 18.07.17 Thcothburis

ECC 29.08.17 ThECsc

F&I 19.09.17 Thcocure



he Committee notedo plan and that the ctrong. It was agreed2 = 10

he Committee notedas overspent, thereace to address thisontinued to be goodcore the risk at 5 x 2

he Committee notedontinued to be closehere continued to beudget in M3. It was sk at 5 x 3 = 15

he risk was discussCC and it was agreecore of 15

he Committee notedontinued to be closeurrently ahead of plaetain the score at 5 x



d that M1 had achiecash position was d to score the risk a

d that, whilst the bue were robust plans . The cash position

d. It was agreed to 2 = 10

d that the cash posiely monitored howeve overspend against

agreed to score the

ed and reviewed at ed to retain the curr

d that the cash posiely monitored and wan. It was agreed tox3 = 15

2


is Na

eved

at 5

Na

dget in

n

Na

tion ver t e

Na

rent Na

tion was o

Na

21

isks -

Current Score

C L S

- - -

5 2 10

5 2 10

5 3 15

5 3 15

5 3 15

Key Risk


Budget overspend;Cashflow reductions liquidity co

Key Contro

ey ng


;

and ont.


ms are ace to sk?



n gain ssurance

ms are


and or ce

Initial risk

Tr


C L S C

Target risk

Month 2017-18

C L S

Dec Jan Feb Mar

Committee Dintim



2


22

isks -

Current Score

C L S

IT Corporate Objective:

Measurem


Key Risk


Failure to achiHIS Phase 2 ptimescales

Make the mefficiency

ment HI

s the As

Key Contro

ey ng this ctive?


ieve roject

Senior IT TeDigital DelivBoard; HIS Phase 2 proplan.

most of our IT I

IS phase 2 implem

s above


ms are ce to k?


eam; very

oject

See gaps inAssurance External anInternal AudReports; IG

Investment to i

mentation; HIS us


n gain ssurance

ms are


n

nd dit

G toolkit

IT Trust BReport; Ndefined reporting arrangemfor IM&T following ceasing oIM&T StraBoard

mprove quality

age; paper reduc

and or ce

Initial risk

Tr


C L S C

Board No

ments

the of the ategy

3

3

9

3

y and

tion usage; succe

Target risk

Month 2017-18

C L S

3 1

3

April

May June July August Sept

Lead Director: R Forster, DirecInformatics

ess on GM Digital


Committee Dintim

Strategy Coco

Strategy No

ECC 03.07.17 It

ECC ThIt

ECC 29.08.17 ECth

Review by Exec

Refoin

tor of Finance and

funding applicatio



ot scored for May

was agreed to scor

he launch of the A&was agreed to scor


eview undertaken bor Informatics with a crease the score to

d Responsible Strategy

on; digital maturity



re this risk at 3 x 3 =

&E system was on trre at 3 x 3 =9


by Executive Directorecommendation to

o 3 x 4 = 12

2

Monitoring Com

y score


not -

-

=9 Na

rack. Na

tain Na

or o

Na

23

mmittee:

isks -

Current Score

C L S

- - -

- - -

3 3 9

3 3 9

3 3 9

3 4 12

Key Risk


Failure to achiHIS Phase 2 ptimescales con

Key Contro

ey ng this ctive?


ieve roject nt.


ms are ce to k?



n gain ssurance

ms are


and or ce

Initial risk

Tr


C L S C

3 3 9 3

Target risk

Month 2017-18

C L S

3 1 3 Oct

Nov

Dec

Jan

Feb

Mar

Committee Dintim



2


24

isks -

Current Score

C L S

Key Risk


Failure of thorganisatiosuccessfuladopt technology

Key Contro

ey ng


he on to ly

y

Senior IT TeDigital DelivBoard; HIS Phase 2 proplan; HIS Champand Floorwa


ms are ace to sk?


eam; very

oject

ions alkers

Audit Comm Other Comm(F&I, Q&S) SIRO meet Data Qualitmeetings


n gain ssurance

ms are


mittee

mittees

ings

ty

IT Trust BReport; Ndefined reporting arrangemfor IM&T following ceasing oIM&T StraBoard

and or ce

Initial risk

Tr


C L S C

Board No

ments

the of the ategy

3 3 9 3

Target risk

Month 2017-18

C L S

3 1 3 April

May June July

Aug

Sept

Oct

Nov

Dec

Jan

Feb

Mar

Committee Dintim

Strategy Thtim

Strategy No

ECC 03.07.17 It

ECC ThstHoredesc

ECC 29.08.17 ECin

Review by Exec

Refore



ot scored for May

was agreed to scor

he adoption of HIS atrong and was cited owever, the remova

eduction in paper haemonstrated. It wascore at 3 x 3 = 9

CC reviewed the riscrease the score to

eview undertaken bor Informatics with a etain the score to 5 x



re this at 3 x 3 = 9

at WWL had been as an exemplar.

al of costs following ad not yet been s agreed to leave th

sk and agreed to o 5 x 4=20


x 4 = 20

2


is Na

-

Na

the

he

Na

Na

or o

Na

25

isks -

Current Score

C L S

- - -

- - -

3 3 9

3 3 9

5 4 20

5 4 20

Key Risk


Failure to mitigate against Cybattacks

Key Contro

ey ng


ber-

Senior IT TeIT Helpdeskalerts procedisseminatininformation across the organisationBusiness Continuity PSIRO MeetiIncident Deb Malware Software


ms are ace to sk?


eam;k and ess ng

n;

Plans; ngs; briefs

External anInternal Audreports GM Digital


n gain ssurance

ms are


nd dit

Board

Intelligencfrom latesincident (Debrief scheduled

and or ce

Initial risk

Tr


C L S C

ce st

d)

5 4 20 5

Target risk

Month 2017-18

C L S

5 1 5 April

May June

July

Aug

Sept

Oct

Nov

Dec

Jan

Feb

Mar

Committee Dintim

Strategy Thtim

Strategy No

ECC 03.07.17 It unwareco

ECC Wcysc

ECC 29.08.17 ECre

Review by Exec

Refoin



ot scored for May

was noted that worndertaken to strengtas agreed to score

educe further once iomplete

Work continued with yber security. It wascore at 4 x 4 = 16

CC reviewed the riseduce the score to 4




rk was being then cyber security.at 4 x 4 = 16 and tomplementation was

regard to strengthes agreed to keep th

sk and agreed to 4 x 3 =12


o 4 x 3 = 12

2


is Na

-

. It o s

Na

ening is

Na

Na

or o

Na

26

isks -

Current Score

C L S

- - -

- - -

4 4 16

4 4 16

4 3 12

4 3 12

Key Risk


Lack of funfor upgradeand developme

Key Contro

ey ng


nding es

nts

Senior IT Te Capital prioritisation SIRO Meeti


ms are ace to sk?


eam;

n

ngs

See gaps inAssurance External anInternal AudReports; SIRO breacreports


n gain ssurance

ms are


n

nd dit

ch

Security patches Windows 2003/XP Quarantininfected devices External systems (patches controlledWWL)

and or ce

Initial risk

Tr


C L S C

ne for

not d by

5 3 15 5

Target risk

Month 2017-18

C L S

5 1 5 April

May June

July

Aug

Sept

Oct

Nov

Dec

Jan

Feb

Mar

Committee Dintim

Strategy Thtim

Strategy No

ECC 03.07.17 It avupwa

ECC It avag

ECC 29.08.17 ECth

Review by Exec

Refoin



ot scored for May

was noted that somvailable to the IT teapgrades and develoas agreed at 4 x 3 =

was noted that fundvailable for necessagreed to reduce the





me funding had beenam for necessary opments. The score= 12

ding had been madeary upgrades. It was score to 4 x 2 = 8



o 4 x 2 =8

2


is Na

-

n

e

Na

e s

Na

tain Na

or o

Na

27

isks -

Current Score

C L S

- - -

- - -

4 3 12

4 2 8

4 2 8

4 2 8

PartnersCorporate Objective:

Measurem


Key Risk


Failure to agreGovernance Structures

ships

Improve hlocality coto best me

ment Ph20Lo

s the

Key Contro

ey ng this ctive?


ee Cross Boroustakeholder meetings including Heand WellbeiBoard and Wigan LeadSecondary CTransformatBoard

hospital serviceommissioners aeet the needs o

hase 2 of Transfo018; ICS metrics aocality Plan succe


ms are ce to k?


ugh

ealth ng

ders; Care tion

Trust Board

es through Partand local providof Wigan reside

rmation Fund sucagreed by Septemessfully delivered


n gain ssurance

ms are


d IntegratedCommunServices Model: relationshbetween cand effecmetrics;

tnership with Wder partners in

ents

ccessfully achievember 2017; Primar

and or ce

Initial risk

Tr


C L S C

d ity

hip cause

ct

3

4

12

3

Wigan order

ed; WWL to be intery Care (including

Target risk

Month 2017-18

C L S

3 1

3

April

May June

July

August

Lead Director: R Mundon, DirecPlanning

egral part of Healt GP OOH) to be l


P

Committee Dintim

Strategy Coco

Strategy No

ECC 03.07.17 It = mfra

ECC Wsifrasc

ECC 29.08.17 ECth

ctor of Strategy a

thier Wigan Partnocated adjacent t

atient flow and qu



ot scored for May

was agreed to incre16 given the ongoin

move to single commameworks and the a

Work continued in rengle commissioningameworks. It was acore at 4 x 4 = 16


nd Responsible Strategy

ership through allto A&E by Octobe

uality of healthcare



ease the score to 4 ng work around the

missioning and proviassociated risks

lation to the move tog and provision agreed to retain the


2

Monitoring Com

iance agreement er 2017; WWL com

e is diminished; lo


not -

-

x 4

sion

Na

o Na

tain Na

28

mmittee:

by March mponent of

oss on income

isks -

Current Score

C L S

- - -

- - -

4 4 16

4 4 16

4 4 16

Key Risk


Failure to agreGovernance Structures con

Key Contro

ey ng this ctive?


ee

nt.


ms are ce to k?



n gain ssurance

ms are


and or ce

Initial risk

Tr


C L S C

3 4 12 3

Target risk

Month 2017-18

C L S

3 1 3 Sept


Committee Dintim

Review by Exec

ReThbrCocoalThinWdr


ecommend that thishe Council and CCGroad components ofommissioning Funcommunicated by theongside the commishe alliance contract place by the end o

Wigan Partnerships Wriving this forward


s remains at 16. G have agreed the f the Strategic

ction and this shoulde end of Septemberssioning intentions. for the ACO shouldf the year. HealthieWorking Group is

2


d be r

d be r

29

isks -

Current Score

C L S

4 4 16

Key Risk


Changes tocommissioarrangemenin Greater Manchestemay slow processes

Key Contro

ey ng


o ning nts

r

WWL relationshipswith commissionand informasharing


ms are ace to sk?


s

ners ation

GM Health Social CarePartnershipStrategy Committee;Healthier WPartnership


n gain ssurance

ms are


and e p;

; Wigan p Board

Consideraof further strengtheof relationwith appropriastakehold

and or ce

Initial risk

Tr


C L S C

ation

ening nships

ate ders

3 3 9 3

Target risk

Month 2017-18

C L S

3 1 3 April May June July Aug

Sept

Oct

Nov

Committee Dintim

Strategy Thtim

Strategy No

ECC 03.07.17 It as

ECC Thris

ECC 29.08.17 ECth

Review by Exec

ReThnoarDesiexthisscodo



ot scored for May

was agreed to retais there was little det

here had been no csk so it would remai


ecommend that thishe GM Review of Cow meeting regularlrrangements. Feedeeprose) suggests milarity between Boxpected to have supheir design work. Thsue is about GM v Lommissioning, but thown Wigan specific



in the score at 3 x 3tail around this

hange in relation toin at 3 x 3 = 9


s remains at 9. Commissioning Grou

y and overseeing thback from the PM (that there is signific

oroughs and PwC apported each throughe biggest outstandiLocality based his is unlikely to slosolutions significan

3


is Na

-

3 = 9 Na

o this Na

tain Na

up is hese (Tim cant re

gh ng

w ntly

30

isks -

Current Score

C L S

- - -

- - -

3 3 9

3 3 9

3 3 9

3 3 9

Key Risk


Changes tocommissioarrangemenin Greater Manchestemay slow processes cont.

Key Contro

ey ng


o ning nts

r


ms are ace to sk?



n gain ssurance

ms are


and or ce

Initial risk

Tr


C L S C

Target risk

Month 2017-18

C L S

Dec

Jan

Feb

Mar

Committee Dintim



3


31

isks -

Current Score

C L S

StandarCorporate Objective:

Measurem


Key Risk


Healthier TogeFailure to achistandardised hospital serviccould result instranded serviand costs WWunable to mee

rdised Hosp

Fully suppplay a lead

ment HTpla

s the

Key Contro

ey ng this ctive?


ether: ieve

ces n ices

WL are et

TransformatFund; Healthier Together Delivery BoaNorth West Sector Partnership Board

ital Care port Standardisd provider role

T implementation ace; MoU in place


ms are ce to k?


tion

ard;

Strategy Committee;Board

sed Hospital Cain standardisin

underway by June with GM/CMFT


n gain ssurance

ms are


; Trust None iden

are across GM ang Orthopaedic

ne 2017; Shared Sby June 2017; GM

and or ce

Initial risk

Tr


C L S C

ntified 4

4

16

4

and cs

Services Board to M Theme 3 implic

Target risk

Month 2017-18

C L S

4 2

8

April

May June

July August

Lead Director: R Mundon, DirecPlanning

have met 4 timesations scoped by


WG

Committee Dintim

Strategy Coco

Strategy No

ECC 03.07.17 It terecoat

ECC` Thdi

ECC 29.08.17 ECth

ctor of Strategy a

s; NW Sector priorSep 2017

Wigan residents reGreater Mancheste



ot scored for May

was noted that the eam had been madeelation to stranded considering these. Tt 4 x4=16 pending r

here had been no cscussion. This wou


nd Responsible Strategy

rity services scop

eceive poorer server



Healthier Together e aware of concernscosts and were The score would remresolution

hange since the lasuld remain at 4 x 4 =


3

Monitoring Com

ed and implemen

vices than other re


not -

-

s in

main

Na

st = 16

Na

tain

32

mmittee:

tation plan in

esidents in

isks -

Current Score

C L S

- - -

- - -

4 4 16

4 4 16

4 4 16

Key Risk


Healthier TogeFailure to achistandardised hospital serviccould result instranded serviand costs WWunable to meecont.

Key Contro

ey ng this ctive?


ether: ieve

ces n ices

WL are et


ms are ce to k?



n gain ssurance

ms are


and or ce

Initial risk

Tr


C L S C

4

4

16 4

Target risk

Month 2017-18

C L S

4 2

8

Sept


Committee Dintim

Review by Exec

ReGimexSecadotrara


ecommend that thisM now pushing ahe

mplementation. Comxpected to approve eptember, which wiapital funds. Outstaouble ambulance joainees and counterb

aised with HT team a


s remains at 16. ead with mmittees in Commobusiness case on 1ll trigger release of

anding issues arounurneys, surgical balancing flows all and being addresse

3


on 19th

nd

ed

33

isks -

Current Score

C L S

4 4 16

Key Risk


NW Sector: Fato agree what portfolio of services looksand to understhe co-dependences services in theporfolio

Key Contro

ey ng


ailure the

s like stand

of e

NW Sector Priorities GrNW Sector Partnership Board; SharServices Bo


ms are ace to sk?


roup;

red oard



n gain ssurance

ms are


; Trust Clinical Engagem

and or ce

Initial risk

Tr


C L S C

ment 3 4 12 3

Target risk

Month 2017-18

C L S

3 2 6 April May June

July Aug

Sept


Committee Dintim

Strategy Thtim

Strategy No

ECC 03.07.17 PrNWtasc

ECC Dpoth

ECC 29.08.17 ECth

Review by Exec

ReJoshseco



ot scored for May

riority services had W Sector and detai

aking place. It was acore at 3 x 4 =12

iscussions continueortfolio of services. he score at 3 x 4 = 1CC reviewed the ris

he current score to 4

ecommend that thisoint Strategy team whould help with this.ervices and jigsaw monsequences of sce



been agreed withinled discussions weragreed to retain the

ed with regard to a It was agreed to re2

sk and agreed to inc4 x4 = 16

s remains at 16. working with Bolton Clarity on four in-s

model developed to enarios

3


is Na

-

the re

e

Na

etain Na

crease

scope show

34

n-

Current Score

C L S

- - -

- - -

3 4 12

3 4 12

4 4 16

4 4 16

Key Risk


GM Theme 3: Failure to genorthopaedic business or togenerate too mbusiness to mdemand

Key Contro

ey ng


erate

o much

meet

Theme 3 Delivery BoGM Health aCare PartneBoard


ms are ace to sk?


ard; and ership



n gain ssurance

ms are


; Trust Completiodetailed p(in designstage)

and or ce

Initial risk

Tr


C L S C

on of plan n

3 4 12 3

Target risk

Month 2017-18

C L S

3 2 6 April

May June

July

Aug

Sept

Oct Nov Dec Jan Feb

Committee Dintim

Strategy Thtim

Strategy No

ECC 03.07.17 A thththfo4x

ECC DOth

ECC 29.08.17 ECth

Review by Exec

ReOCThpren



ot scored for May

GM wide consensuhe consolidation of Ohere was analysis tohe potential impact oor this reason to incrx4=16

iscussions continuerthopaedic activity.

he score at 4 x 4 = 1


ecommend that thisrthopaedic case forlinical Reference Ghe clinical model, wroposed reconfigurand of December



us had been agreedOrthopaedic activity o be undertaken aroof tariff. It was agrerease the score to

ed with regard to It was agreed to re6


s remains at 16. r change going to Group on 22 Septem

which describes ation, will follow by t

3


is Na

-

d on but

ound eed

Na

etain Na

tain

M ber.

the

35

isks -

Current Score

C L S

- - -

- - -

4 4 16

4 4 16

4 4 16

4 4 16

Key Risk


Key Contro

ey ng



ms are ace to sk?



n gain ssurance

ms are


and or ce

Initial risk

Tr


C L S C

Target risk

Month 2017-18

C L S

Mar

Committee Dintim



3


36

isks -

Current Score

C L S

BAF 2017-18 template - wwl.nhs.uk · in hospital acquir le harms measur m, implement ch s by 10%...

Documents

Transcript of BAF 2017-18 template - wwl.nhs.uk · in hospital acquir le harms measur m, implement ch s by 10%...