Trust Board papers November 2012 - Barking Havering and ...

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BHRUT RISK TREND ANALYSIS FOR 2007- 2012 CORPORATE RISKS ON BAF 6 High Extreme 45 40 CURRENT RISKS ON CORPORATE RISK REGISTER 43 34 Low Moderate High Extreme 6 4 2 1 35 30 25 20 15 10 7 12 0 High Extreme 5 0 Low Moderate High Extreme CORPORATE RISKS BY TYPE 4 2 6 Risks on the BAF: The BAF only reflects residual risks after controls / assurance have been agreed. Currently there are 2 High and 7 Extreme risks. Risks Removed: 17 Risk 339: Complaints has been removed from the BAF, the controls have reduced the residual risk but it would remain on the corporate risk register and monitored via action plans. 30 Risk 323: Risk of adverse impact on profitability due to introduction of new London wide GU and FP Tariff in April 2012, this risk would be managed within the directorate 18 19 Accreditation Clinical Health & Safety Finance Service Delivery Security Reputation Risk 341: End of life Strategy. The internal control and action plan was instrumental in reducing the risk scoring and there is reasonable assurance that it is managed adequately with the aid of the Life Boards Risk 311: Potential severe disruption to services arising from the removal of London Deanery posts pose major difficulties in the delivery of quality care at KGH obstetric services. The London Deanery agreed plans have removed the risks. It is evident that the Internal risk management processes have successfully reduced the number of corporate of risk by mitigating the risk either with local resources or closure because the risk no longer impacts the Department or the Trust objectives. This is widely contributed by the willingness of management and employees to embrace the BHRUT risk management framework of action plan, risk validation forms, closure forms and exception reporting. BHRUT BAF 2nd Quarter 2012: SB/PS 5
DIRECTORATES RISKS REVIEW 12 10 8 6 4 2 0 3 2 Acute Med Anaest. Child ren 3 NO. OF RISKS BY DIRECTORATES 11 0 6 4 0 Emerg.Care Neuro Scie Pathology Radiology Surgery 9 6 6 10 Spec. Surg Spec.M ed Supp. Serv Women Estates 1 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 ANAESTHETIC RISKS 1 1 0 0 Low Moderate High Extreme EM ERGENCY CARE RISKS WOMEN RISKS 7 6 7 6 6 5 4 3 2 1 1 2 1 5 4 3 2 1 1 3 0 0 Low Moderate High Extreme 0 Low Moderate High Extreme BHRUT BAF 2nd Quarter 2012: SB/PS 6
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TRUST BOARD MEETING Wednesday, 7 No
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2 Following Mr White’s concerns r
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4 forecast in terms of community be
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6 The Trust Board noted the Plan fo
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8 The Co-Chair of the Improving Pat
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TRUST BOARD MEETING Actions from Mi
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Agenda Item Action Deadline Date Da
Page 15 and 16: Question: Mr Skillman was pleased t
Page 17 and 18: CQC Trust-wide Action Plan Review a
Page 19 and 20: 1.0 PURPOSE 1.1 Background This rep
Page 21 and 22: • Review the Senior Responsible O
Page 23 and 24: APPENDIX 1 ‐ CQC ACTION PLAN - EX
Page 25 and 26: RECORDS records management to ensur
Page 27 and 28: CQC Update Report 2012 Theme CQC Re
Page 29 and 30: CQC Update Report 2012 ASSESSING &
Page 31 and 32: CQC Update Report 2012 ASSESSING &
Page 33 and 34: CQC Update Report 2012 pathways thr
Page 35 and 36: CQC Update Report 2012 identified i
Page 37 and 38: CQC Update Report 2012 outlining th
Page 39 and 40: CQC Update Report 2012 improvements
Page 41 and 42: CQC Update Report 2012 aware of the
Page 43 and 44: CQC Update Report 2012 are now supe
Page 45 and 46: CQC Update Report 2012 autumn. RECO
Page 47 and 48: CQC Update Report 2012 of the pilot
Page 49 and 50: EXECUTIVE SUMMARY TITLE: Informatio
Page 51 and 52: INFORMATION GOVERNANCE STRATEGY 201
Page 53 and 54: Information is a vital asset in ter
Page 55 and 56: starters as well as being mandatory
Page 57 and 58: The standards are split into the ar
Page 59 and 60: 10a Reapproval of IG training progr
Page 61 and 62: 343 Directorate Anaesthetic: Risk:
Page 63 and 64: Table of Contents TRUST PRINCIPAL O
Page 65: BHRUT STRATEGIC OBJECTIVES WITH EAC
Page 69 and 70: RISKS DETAILS PRINCIPAL RISK What c
Page 71 and 72: PRINCIPAL RISK What could prevent t
Page 77 and 78: RISK DESCRIPTORS OBJECTIVE SAFE, HI
Page 79 and 80: BOARD ASSURANCE FRAMEWORK ELEMENTS
Page 81 and 82: EXECUTIVE SUMMARY TITLE: Risk Manag
Page 83 and 84: Contents Section Page 1 Introductio
Page 85 and 86: incorporate mitigation controls wit
Page 87 and 88: “Risk Register” “Risk Registe
Page 89 and 90: potential risks they may face in ac
Page 91 and 92: 4.1.1 Quality and Safety Committee
Page 93 and 94: • Financial risks: risks associat
Page 95 and 96: Proactive risk assessment enables t
Page 97 and 98: Trust’s risk matrix and will popu
Page 99 and 100: Risk Grading Staff Group Evidence R
Page 101 and 102: 4.8 RISK REGISTER The Risk Register
Page 103 and 104: 5.1 Consultation and Communication
Page 105 and 106: The Trust recognises the importance
Page 107 and 108: timescale with supporting evidence
Page 109 and 110: Checklist for the Review and Approv
Page 111 and 112: Equality Impact Assessment Tool To
Page 113 and 114: Plan for Dissemination of Procedura
Page 115 and 116: Consequence score (severity levels)
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Frequency How often might it/does i
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Appendix 3 Framework for Risk Manag
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Risk Register inventory they are ex
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2. DECISION REQUIRED: CATEGORY: The
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• A review of data capture to ens
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Pilot Wards Division Discharges Per
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Workforce Appraisals - the actions
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Delayed transfers of care (DTOC) -
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EXECUTIVE SUMMARY TITLE: Emergency
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• Training competencies are being
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Appendix A: Trajectory for all type
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would welcome feedback from the Tru
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Maternity Services Monthly Performa
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4. Capping The maternity service is
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7. Obstetric Assessment Unit (OAU)
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10. Serious Incidents Reported Inci
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12. Maternity Dashboard The dashboa
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It should also be noted that the ta
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Priority Action Lead Monitoring Too
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Priority Action Lead Monitoring Too
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Contents Section No: Description Pa
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3. Complaints Activity 3.1 Total Co
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3.5 Themes General care issues and
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Corporate Non Clinical Category Num
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order to resolve concerns. Particul
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The findings of the review were tha
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SELF-CERTIFICATION RETURNS Organisa
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12 AA - Quality Improvement Strateg
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TFA Progress BHR University Hospita
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25 TFA - Final IBP /; LTFM Dec-12 H
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Effectiveness GOVERNANCE RISK RATIN
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Safety 4b MRSA Enter Are you below
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FINANCIAL RISK RATING BHR Universit
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CONTRACTUAL DATA BHR University Hos
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4 Single Sex Accommodation Breaches
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TITLE: EXECUTIVE SUMMARY BOARD/GROU
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causes/ Not specified' will be remo
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Staff In Post Starters & Leavers FT
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TURNOVER Actual Versus Target Annua
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FTE Lost due to Sickness Absence by
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The data on the previous page has b
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Indicator Target Apr-12 May-12 Jun-
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Starters *¹ 7.00 3.60 5.00 7.43 6.
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EXECUTIVE SUMMARY TITLE: COST IMPRO
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Month 6 CIP Performance Workstream
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Governance The Cost Improvement Pro
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1 REPORT TO: REPORT FROM: Trust Boa
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3 Preparations for winter planning
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5 Preparing the Payment by Results
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7 People with dementia to receive m
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9 Clinical Patient Management and H
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102/2012 Apologies Apologies were r
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Action Members were advised that ac
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Action 115/2012 Any Other Business
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EXECUTIVE SUMMARY TITLE: Finance Re
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1. EXECUTIVE SUMMARY Monthly I&E Ru
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Trust I&E summary by Division/Direc
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Income by POD In Month Year to date
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Devolved income Annual Budget Forec
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4. BALANCE SHEET Balance Sheet Curr
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6. Business Unit Summaries Attached
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