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

PRINCIPAL RISK
What could prevent the objective being
achieved
Risk no, Date on Risk Register
& Risk Scoring:
KEY EXISTING CONTROLS
What controls/systems are in
place to assist in securing delivery
of objective and managing
principle risks?
CQC REF:
RESIDUAL RISK
ASSURANCES ON
CONTROLS & IMPACT
Where we gain evidence
that our controls/systems, on
which we are placing
reliance, are effective? The
impact following assurances.
PROGRESS AGAINST
RISKS/ ACTION
PLAN UPDATE
What Actions are undertaken to
mitigate the actual risks?
GAPS IN ASSURANCE
Where we are failing to gain
evidence that our controls /
systems, on which we place
reliance, are effective
GAPS IN
CONTROL
Where are we
failing to put
controls / systems
in place? Where are
we failing in making
them effective?
LEAD
Strategic Objective 4: Services Are Rated Positively By Patients. Families & All Stakeholders
Principal Objective: To embed a reputation of being a high performing Trust with the best outcomes for patients with all external stakeholder & the media
Risk No: 258 Failure to
provide timely quality of
care will compromise the
Trusts reputation which
will impact on future
service business,
development & recruitment
opportunities.
Date on Register: 23.02.2011
Rating Scoring: Impact: 3 x
Likelihood:5 = 15
Area: Trust-wide
Impact on:
Patient: Outcomes/ service/
developments/achievements
Staff: ~ Staff morale and staff
engagement
Trust: Media interest which
compromised the Trust Reputation
Quality and Safety Committee
to identify root causes and to
disseminate learning and
monitor improvements in care.
Quality and Improvement plan
focus and resource for
improvement.
Clinical Governance Team
monitor Directorate
implementation.
16
Extreme Red
Quality & Safety
Committee bi-monthly
reviewed the risks
Learning Lessons Group
meeting identify trends
from PALS, Complaints,
Incidents and other
feedback.
Audit quarterly patient
experience reports
Reputational risks are
escalated to the
Executive and impending
media coverage alerted
to the Trust Board. Trust
Board is also made
aware by satisfaction
surveys
CQC Action plan provides the
knowledge of key issues and
concerns liable to affect
reputation.
Whistle blowing policy is being
widely promoted
There is a drive to strengthen
the relationship between all
stakeholders and the Trust.
CQC Report on Maternity
Directorate reflected that out
of the 16 recommendations 9
were fully met and 6 were
partly met and only 1 was not
met, this was added to the
BHRUT development plan for
review on the 1/11/12.
Evidence for reputation
rebuilding, particularly
focusing on Emergency
department performance,
improved patient
experience, complaints
handling, finance.
Resourcing of expanded
programmes of staff and
community engagement.
None identified
following review
Imogen Shillito, Director of Comms
Details updated: 19.10.2012
BHRUT BAF 2nd Quarter 2012: SB/PS
13