Appendix 1: Croydon Clinical Commissioning Group Risk Register … body... · 2014-07-11 ·...
17
Page 1 of 17 Appendix 1: Croydon Clinical Commissioning Group Risk Register and Board Assurance Framework - 9th April 2013 Principal Objectives Sub Objectives Risk to Delivery Key controls Gaps in controls Assurance on controls Gaps in assurance Original Risk (LxS) Planned Actions Residual Risk (LxS) Owner What would prevent this objective from happening What systems do we have in place to secure delivery of our objective Where are we failing to put controls in place Evidence that shows we are reasonably managing our risks? Where are we failing to gain evidence that our controls are effective Impact x Likeli- hood Actions to manage gaps including the risk register action plan Impact x Likeli- hood 1. To achieve financial sustainability in three years (2013-2014 to 2015-2016) Lead: Director of Finance and Recovery 1.1 To ensure contracts perform within their financial envelope Patient demand and supplie4r induce4d demand exceeds contract volumes Contracts have been negotiated based on maximised efficiency and minimised risk.SLCSU provide contract management for SEL contracts. Rigorous investigation of CHS over performance Year end negotiations Evident reduction of activity Governing Body not receiving reports on a specialty basis; requires special level reporting and drivers Acute Task Group Monthly contract meetings Senior Mgmt. Team / Recovery Group QIPP Operational Board 25(5x5) Actions to reduce A&E/UCC attendances. More control over non-elective activity needed. Working with CUH to understand demand and capacity Review waiting list data at CUH (31/03/13) 25(5x5) Di Carter CSU Contracts Manager 1.2 To ensure delivery of QIPP schemes (2013 – 2014) Failure of acute pathway redevelopments to deliver savings Planned care developments included in contract LTC savings have long stop date of 30 th May for inclusion Acute Task Group 20 (5x4) Pathway activity data to be reflected in SLAM from M4. (31/3/13) 20 (5x4) Di Carter CSU Contracts Manager
Transcript of Appendix 1: Croydon Clinical Commissioning Group Risk Register … body... · 2014-07-11 ·...
Page 1 of 17
Appendix 1: Croydon Clinical Commissioning Group Risk Register and Board Assurance Framework - 9th April 2013
Principal Objectives
Sub Objectives
Risk to Delivery Key controls Gaps in controls Assurance on controls
Gaps in assurance
Original Risk (LxS)
Planned Actions Residual Risk (LxS)
Owner
What would prevent this objective from happening
What systems do we have in place to secure delivery of our objective
Where are we failing to put controls in place
Evidence that shows we are reasonably managing our risks?
Where are we failing to gain evidence that our controls are effective
Impact x Likeli-hood
Actions to manage gaps including the risk register action plan
Impact x Likeli-hood
1. To achieve financial sustainability in three years (2013-2014 to 2015-2016) Lead: Director of Finance and Recovery
1.1 To ensure contracts perform within their financial envelope
Patient demand and supplie4r induce4d demand exceeds contract volumes
Contracts have been negotiated based on maximised efficiency and minimised risk.SLCSU provide contract management for SEL contracts. Rigorous investigation of CHS over performance Year end negotiations
Evident reduction of activity Governing Body not receiving reports on a specialty basis; requires special level reporting and drivers
Acute Task Group Monthly contract meetings Senior Mgmt. Team / Recovery Group QIPP Operational Board
25(5x5) Actions to reduce A&E/UCC attendances. More control over non-elective activity needed. Working with CUH to understand demand and capacity Review waiting list data at CUH (31/03/13)
25(5x5) Di Carter CSU Contracts Manager
1.2 To ensure delivery of QIPP schemes (2013 – 2014)
Failure of acute pathway redevelopments to deliver savings
Planned care developments included in contract
LTC savings have long stop date of 30
th
May for inclusion
Acute Task Group
20 (5x4) Pathway activity data to be reflected in SLAM from M4. (31/3/13)
20 (5x4) Di Carter CSU Contracts Manager
Page 2 of 17
Principal Objectives
Sub Objectives
Risk to Delivery Key controls Gaps in controls Assurance on controls
Gaps in assurance
Original Risk (LxS)
Planned Actions Residual Risk (LxS)
Owner
What would prevent this objective from happening
What systems do we have in place to secure delivery of our objective
Where are we failing to put controls in place
Evidence that shows we are reasonably managing our risks?
Where are we failing to gain evidence that our controls are effective
Impact x Likeli-hood
Actions to manage gaps including the risk register action plan
Impact x Likeli-hood
MH/SLAM Acute inpatient financial over performance
Risk agreement with SLaM; regular contract monitoring, which has been included in this year’s contract.
Approach for management Business case not yet completed and agreed as at 07-03-2013
QIPP Operational Performance SMT/ Recovery
16(4x4) Approve SLaM business case for service re-design, including new triage ward. (31/3/13) 2013/2014 contract negotiations
12(3x4) John Haseler CCG Senior Mental Health Commissioner
Insufficient commissioning resource available to deliver savings.
Temporary resource identified to support key areas, e.g. urgent care, LTCs. Additional support from Price Waterhouse Cooper (PWC)
NEW None identified
NEW SMT/Recovery
NEW None identified
16 (4x4)
Adopt matrix structure at SMT level. NEW Rapidly progress recruitment into posts covered by interims Development of ICU structure NEW Maximise CSU support for all related areas
12 (4x3)
Stephen Warren CCG Director of Commissioning
Slippage in QIPP delivery
Developing and delivering QIPP plan that delivers PCT/CCG only supporting new investments that
Too early in the process to assess results
Robust reports which triangulate activity and QIPP schemes
Too early in the process to assess results TBC
25(5x5) Develop QIPP plans that will deliver. NEW EMW regular opportunity with wider engagement to develop new QIPP schemes
25(5x5) Stephen Warren CCG Director of Commissioning
Page 3 of 17
Principal Objectives
Sub Objectives
Risk to Delivery Key controls Gaps in controls Assurance on controls
Gaps in assurance
Original Risk (LxS)
Planned Actions Residual Risk (LxS)
Owner
What would prevent this objective from happening
What systems do we have in place to secure delivery of our objective
Where are we failing to put controls in place
Evidence that shows we are reasonably managing our risks?
Where are we failing to gain evidence that our controls are effective
Impact x Likeli-hood
Actions to manage gaps including the risk register action plan
Impact x Likeli-hood
supports QIPP.
Continuing care retrospective review result in additional claims
New dedicated CC Nurse working on this. Claims being reviewed Admin resource has been identified and allocated to assist the CC nurse.
Final findings of review awaited
Developing and delivering QIPP plan that delivers PCT/CCG only supporting new investments that supports QIPP.
Final findings of review awaited
12(3x4) -Consideration being given to participation in cluster centralised approach to ensure sufficient capacity to undertake the reviews.
12(3x4) Stephen Warren CCG Director of Commissioning
1.3 To identify plans for longer term recovery (2013/2014 to 2015/2016))
Unable to identify further schemes
All scheme to be stretched where possible e.g. prescribing, corporate. Ongoing project with PWC to review benchmark and develop new initiatives OD plan with GP networks including
Further understanding of potential areas to focus on
Governance structure in place. Strengthened by QIPP network across South London, initiated in Croydon. QOB SMT/Recovery
25(5x5) PWC engaged to support development of schemes
Financial review
Benchmarking
Impact testing from elsewhere
Support development of local schemes (to 30-04-2013)
Engagement event with Pharmacists, LTC stakeholders
20(5x4) Mike Sexton CCG Chief Finance Officer
Page 4 of 17
Principal Objectives
Sub Objectives
Risk to Delivery Key controls Gaps in controls Assurance on controls
Gaps in assurance
Original Risk (LxS)
Planned Actions Residual Risk (LxS)
Owner
What would prevent this objective from happening
What systems do we have in place to secure delivery of our objective
Where are we failing to put controls in place
Evidence that shows we are reasonably managing our risks?
Where are we failing to gain evidence that our controls are effective
Impact x Likeli-hood
Actions to manage gaps including the risk register action plan
Impact x Likeli-hood
leadership (David Colin-Thome)
1.42013/2014 To identify and manage financial risk arising from allocation/PBR e.g. specialist commissioning; primary care (added by CFO 07-03-2013)
Increase the recurring financial challenge
Reconciliation of baseline return and NCB working papers Reconciliation of specialist commissioning transfers
Limited information from NCB
Formal approach to NCB seeking resolution
25 (5x5) Escalating discussions with NCB
15 (3x5)
Mike Sexton CCG Chief Finance Officer
2. To commission integrated, safe, high quality service in the right place at the right time Lead: Director of Governance and Quality
2.1 To achieve the improvement and performance targets with a specified focus on A&E, RTT, and Imms
Lack of understanding of the key issues and so actions do not deliver the necessary change
Monthly dashboard reports reviewed by SMT & governing body Monthly performance discussions at CQR Escalation to
Full root cause analysis of poor performance Comprehensive dashboard not in place
SMT CQR Performance Task and finish group
Leads responsible for ensuring action are in place
16(4x4) CSU to undertake full analysis of key acute indicators not performing to inform action Ensure dashboard covers all indicators - end of February. COMPLETED NEW Review the governance for
12(3x4) Fouzia Harrington CCG Director of Governance and Quality
Page 5 of 17
Principal Objectives
Sub Objectives
Risk to Delivery Key controls Gaps in controls Assurance on controls
Gaps in assurance
Original Risk (LxS)
Planned Actions Residual Risk (LxS)
Owner
What would prevent this objective from happening
What systems do we have in place to secure delivery of our objective
Where are we failing to put controls in place
Evidence that shows we are reasonably managing our risks?
Where are we failing to gain evidence that our controls are effective
Impact x Likeli-hood
Actions to manage gaps including the risk register action plan
Impact x Likeli-hood
provider management of provider performance - by the end of April
A&E performance – Type 1 and all performance recovery
Action plan in place Ongoing meeting of the Clinical Outcomes/ Service Spec Operational provider leads group Daily situation reporting from ED and UCC. A&E prioritised action plan NEW Recovery Trajectory agreed following Emergency Care Intensive Support Team follow up review
Effective streaming and pathway
Urgent Care Integrated Governance Group SMT/Recovery
20(4x5) Review of the protocols and processes for patient pathways management to ensure effectiveness. Revised streaming pathway to be agreed between ED and UCC clinical leads completed. Agreed pathway documentation to be approved by the Urgent Care Integrated Governance Board. NEW Hold system wide summit to review emergency pathway NEW Review of urgent care diagnostic
20 (4x5) Stephen Warren CCG Director of Commissioning
Page 6 of 17
Principal Objectives
Sub Objectives
Risk to Delivery Key controls Gaps in controls Assurance on controls
Gaps in assurance
Original Risk (LxS)
Planned Actions Residual Risk (LxS)
Owner
What would prevent this objective from happening
What systems do we have in place to secure delivery of our objective
Where are we failing to put controls in place
Evidence that shows we are reasonably managing our risks?
Where are we failing to gain evidence that our controls are effective
Impact x Likeli-hood
Actions to manage gaps including the risk register action plan
Impact x Likeli-hood
RTT Performance Recovery
Meeting held with CHS Action plan to clear back log agreed
NEW Action plan for sustainable performance
SMT - 20(4x5) Further analysis to be completed with action plan (Mid Feb) COMPLETED NEW CCG input to the development of a sustainable action plan by end of April
20 (4x5) Fouzia Harrington CCG Director of Commissioning
Unable to deliver Improving Access to Psychological Therapies in accordance with the NHS Operating Framework
-CCG clinician led review group for all psychological therapies. -Current budgets and services reviewed
-Value for money reviewed at monthly SLAM CQR (part 2 Business/Performance) & at relevant contract meetings with other providers.
16(4x4) -Report going to SMT regarding gap with demand and current commissioned service
12(3x4) John Haseler CCG Senior Mental Health Commissioner
2.2 To achieve improved quality of service at CHS
Lack of focus on key issues
CHS clinical quality review group has a programme of focus
Alignment of all interested organisations expectations Clear measurable improvements not defined
Quality Monitoring Group CHS Clinical Quality Review Group SMT
20(4x5) Agree with CHS, NCB and TDA priorities and improvement expected (mid march 2013) Revised time scale – end of May
Development of dashboard (mid march 2013) (NEW) Revised timescale – end of
15(3x5) Fouzia Harrington CCG Director of Governance and Quality
Page 7 of 17
Principal Objectives
Sub Objectives
Risk to Delivery Key controls Gaps in controls Assurance on controls
Gaps in assurance
Original Risk (LxS)
Planned Actions Residual Risk (LxS)
Owner
What would prevent this objective from happening
What systems do we have in place to secure delivery of our objective
Where are we failing to put controls in place
Evidence that shows we are reasonably managing our risks?
Where are we failing to gain evidence that our controls are effective
Impact x Likeli-hood
Actions to manage gaps including the risk register action plan
Impact x Likeli-hood
Quality Sub Committee
May Align CQUINS where possible (mid march 2013) Develop a quality strategy and plan. (end of May 2013)
Failure to deliver an effective Community Diabetic Service
Improvement action plan agreed with clinical lead and CHS 7.12.12. LES brought back to CCG by 1.12.12. Assurances to be provided by CHS on patient education arrangements NEW Project plan on place to re-procure intermediate service and
NEW None identified
NEW SMT/recovery Discussion of risks at CQR April 2013
NEW None identified
16(4x4) CCG to carry out a peer lead skills development programme for Primary Care.
12(4x3) Stephen Warren CCG Director of Commissioning
Page 8 of 17
Principal Objectives
Sub Objectives
Risk to Delivery Key controls Gaps in controls Assurance on controls
Gaps in assurance
Original Risk (LxS)
Planned Actions Residual Risk (LxS)
Owner
What would prevent this objective from happening
What systems do we have in place to secure delivery of our objective
Where are we failing to put controls in place
Evidence that shows we are reasonably managing our risks?
Where are we failing to gain evidence that our controls are effective
Impact x Likeli-hood
Actions to manage gaps including the risk register action plan
Impact x Likeli-hood
patient education – to April Governing Body
2.3 To achieve improved patient experience
Lack of focus on key issues
CHS clinical quality review group has a programme of focus
Alignment of all interested organisations expectations Clear measurable improvements not defined
Quality Monitoring Group CHS Clinical Quality Review Group SMT Quality Sub Committee
20(4x5) Agree with CHS, NCB and TDA priorities and improvement expected (mid march 2013) Revised time scale – end of May
Development of dashboard (mid march 2013 Revised timescale – end of May Align CQUINS where possible (mid march 2013) Develop a quality strategy and plan. (end of May 2013)
15(3x5) Fouzia Harrington CCG Director of Governance and Quality
2.4 To ensure safe services
Management of Safeguarding within Health Visiting
Bank staff have been used. Weekly prioritisation of allocated workload.
TBC Weekly meetings with Sector Director of Nursing, designated Nurse for Safeguarding Commissioners
20(4x5) -Escalation plan to be reviewed by CBT and Sector. CBT commissioners to confirmed core requirements for 2012/13.
9(3x3) Jane McAllister CCG Senior Children’s Commissioner
Page 9 of 17
Principal Objectives
Sub Objectives
Risk to Delivery Key controls Gaps in controls Assurance on controls
Gaps in assurance
Original Risk (LxS)
Planned Actions Residual Risk (LxS)
Owner
What would prevent this objective from happening
What systems do we have in place to secure delivery of our objective
Where are we failing to put controls in place
Evidence that shows we are reasonably managing our risks?
Where are we failing to gain evidence that our controls are effective
Impact x Likeli-hood
Actions to manage gaps including the risk register action plan
Impact x Likeli-hood
Fully used of skill mix. Child health clinics reduced. 3 year CQUIN agreed that includes increase to number of HV's to an acceptable ration Root cause analysis carried out on low levels of under-one reviews.
and Public Health. CHS HVs up to establishment of 52 WTE as of 13-02-2013
Target level of 60 WTE by 31-03-2013; 62 WTE by 2014/2015
Insufficient assurance regarding Urgent Care Safeguarding Children processes
Liaison Health Visitor in place Action Plan in place and regular meetings with designated Safeguarding Lead. Further
Named GP Lead Children's Safeguarding Governance Group.
16(4x4) Provision of evidence that Safeguarding processes are being followed in accordance with contract. Action plan (see controls) may not be meeting all its milestones because of insufficient assurance/evidence received from provider.
9(3x3) Sally Innis CCG Head of Safeguarding
Page 10 of 17
Principal Objectives
Sub Objectives
Risk to Delivery Key controls Gaps in controls Assurance on controls
Gaps in assurance
Original Risk (LxS)
Planned Actions Residual Risk (LxS)
Owner
What would prevent this objective from happening
What systems do we have in place to secure delivery of our objective
Where are we failing to put controls in place
Evidence that shows we are reasonably managing our risks?
Where are we failing to gain evidence that our controls are effective
Impact x Likeli-hood
Actions to manage gaps including the risk register action plan
Impact x Likeli-hood
engagement from UCC.
Insufficient assurance regarding Edridge Road Safeguarding children processes
Action Plan in place and regular meetings with designated Safeguarding Lead. Action plan updated Dec 2012, and progress made. Lead nurse has increased capacity to manage safeguarding children.
TBC Named GP Lead Children's Safeguarding Governance Group.
16(4x4) Evidence to be provided that robust processes are in place and being followed. Although some evidence has been received this will remain an action until all assurances received.
9(3x3) Sally Innis CCG Head of Safeguarding
Lack of assurance within GP Practice DBSDisclosure and Barring Service (DBS) checks have been completed
DBS check is completed for all GPs when joining their Performers List stating they know there are no gaps and all GP on their Performers List will have had an enhanced DBS undertaken
16(4x4) SW London Primary Care Team provided assurance/evidence of DBS checks as part of Primary Care Report NEW DBS checks in GP Practices now the responsibility of CQC as part of the registration process – risk
CLOSED
Stephen Warren CCG Director of Commissioning
Page 11 of 17
Principal Objectives
Sub Objectives
Risk to Delivery Key controls Gaps in controls Assurance on controls
Gaps in assurance
Original Risk (LxS)
Planned Actions Residual Risk (LxS)
Owner
What would prevent this objective from happening
What systems do we have in place to secure delivery of our objective
Where are we failing to put controls in place
Evidence that shows we are reasonably managing our risks?
Where are we failing to gain evidence that our controls are effective
Impact x Likeli-hood
Actions to manage gaps including the risk register action plan
Impact x Likeli-hood
because it is a mandatory requirement
transferred
No Named GP for Safeguarding Children.
Recommendation reported to SMT. SMT have approved recruitment into post. -Action plan in place for the recruitment process. -Post is advertised on NHS Jobs.
Recruitment process to be completed - interview date now arranged.
SMT 12(4x3) COMPLETED
9(3x3) Sally Innis CCG Head of Safeguarding
No assurance of Accreditation of Intermediate Services (GPSI) and Enhanced Services
Intermediate/Enhanced Services CQR has established an accreditation document to record information and this has been reviewed at the monthly CQR meeting. Vasectomy Intermediate
TBC CQR Medical Director has provided assurance in relation to the
12(4x3) Assurance to be provided that all Enhanced services are accredited where relevant and recorded on the approved accreditation document reviewed at the monthly CQR.
9(3x3) Stephen Warren CCG Director of Commissioning
Page 12 of 17
Principal Objectives
Sub Objectives
Risk to Delivery Key controls Gaps in controls Assurance on controls
Gaps in assurance
Original Risk (LxS)
Planned Actions Residual Risk (LxS)
Owner
What would prevent this objective from happening
What systems do we have in place to secure delivery of our objective
Where are we failing to put controls in place
Evidence that shows we are reasonably managing our risks?
Where are we failing to gain evidence that our controls are effective
Impact x Likeli-hood
Actions to manage gaps including the risk register action plan
Impact x Likeli-hood
Service currently not GPSi accredited
safety of the service to the lead commissioner.
CAMHS Demand and Capacity not being met
Additional investment of £250k negotiated through the NHS contract for SLAM 2012/13. Shared Care Prescribing Protocols.
Further management of demand Addressing capacity Additional assurance of safeguarding
CAMHS Partnership Commissioning Group SLAM Clinical Quality Review Group Croydon Borough CCG SMT /Recovery QIPP Operational Board
NEW None identified
16(4x4) Review of prescribing and intensive outreach support required at Primary Care level through enhanced service provision (Complete) Review of the referral criteria. (Complete) Shared Care Prescribing Protocols to be extended. (Complete) Data to be reviewed on current estimated waiting times of 7 months. (31/3/13) Data to be reviewed on why approximately 50% of referrals from Primary Care are rejected. (31/3/13)
12(4x3) Jane McAllister CCG Senior Children’s Commissioner
Page 13 of 17
Principal Objectives
Sub Objectives
Risk to Delivery Key controls Gaps in controls Assurance on controls
Gaps in assurance
Original Risk (LxS)
Planned Actions Residual Risk (LxS)
Owner
What would prevent this objective from happening
What systems do we have in place to secure delivery of our objective
Where are we failing to put controls in place
Evidence that shows we are reasonably managing our risks?
Where are we failing to gain evidence that our controls are effective
Impact x Likeli-hood
Actions to manage gaps including the risk register action plan
Impact x Likeli-hood
Recruitment requirements to be reviewed. (31/3/13) Safeguarding issues to be reviewed. (31/3/13)
3. To have collaborative relationships to ensure integrated approach Lead: Director of Governance and Quality
3.1 To improve and sustain robust and effective working relationships
Deterioration of relationships
CCG led Transformation Board has all partners Active CCG Membership of the HWBB Engagement strategy in place Increased GP engagement. Review of partnership executive meetings. Seeking alternative methods of engagement
Implementation of engagement strategy
Engagement Manager post established SMT
- 12(3x4) Present priorities to SMT ((February 2013) COMPLETE Appoint to Engagement Manager position (March 2013) Review of key partnership executive meetings to be completed by 28.2.13 COMPLETED
8(2x4) Fouzia Harrington CCG Director of Governance and Quality
Page 14 of 17
Principal Objectives
Sub Objectives
Risk to Delivery Key controls Gaps in controls Assurance on controls
Gaps in assurance
Original Risk (LxS)
Planned Actions Residual Risk (LxS)
Owner
What would prevent this objective from happening
What systems do we have in place to secure delivery of our objective
Where are we failing to put controls in place
Evidence that shows we are reasonably managing our risks?
Where are we failing to gain evidence that our controls are effective
Impact x Likeli-hood
Actions to manage gaps including the risk register action plan
Impact x Likeli-hood
other than formal meetings where practical.
4. To develop as a mature membership organisation Lead: Director of Governance and Quality
Executive & Senior focus and Capacity
Clear Organisational Objectives Prioritised Director Objectives & Work Plans Full Recruitment to Permanent Posts (see below) Delivery of End to end CSU service (see below) Contingency monies available for gaps in
Prioritised Director Objectives & work plans See below See below
Integrated Strategic Operating Plan (ISOP) Regular 1:1 with CO See below See below
Formalised assessment of progress Formalised assessment of Progress
12 (3x4) Quarterly Review of Progress against ISOP Development of prioritised director Objectives & work plans by function (End of May 2013) Monthly Review of Progress.
9 (3x3) Paula Swann Chief Officer
Page 15 of 17
Principal Objectives
Sub Objectives
Risk to Delivery Key controls Gaps in controls Assurance on controls
Gaps in assurance
Original Risk (LxS)
Planned Actions Residual Risk (LxS)
Owner
What would prevent this objective from happening
What systems do we have in place to secure delivery of our objective
Where are we failing to put controls in place
Evidence that shows we are reasonably managing our risks?
Where are we failing to gain evidence that our controls are effective
Impact x Likeli-hood
Actions to manage gaps including the risk register action plan
Impact x Likeli-hood
functions not commissioned
Lack of Permanent Recruitment to Commissioning & PMO posts
Full Recruitment to Permanent Posts
Vacancies in team
Vacancy Monitoring
Manpower Reporting Review of Capacity
16(4x4) Recruitment plan for permanent posts. Monthly Review of Manpower & Capacity
16(4x4) Stephen Warren Director of Commissioning
CSU do not deliver the commissioning support required
End to end service specification in place with KPIs including responsiveness CSU MD is the CCG account manager Contingency monies available for gaps in functions not commissioned
Responsiveness of CSU Staff understanding Croydon and the new model of commissioning
Monthly Contract Meeting Monthly KPI reporting Performance management escalation process in contract Deputy Director lead for contract management Monthly contract meetings
Regular Monthly Contract Meeting Monthly KPI reporting
20 (5x4) Internal Audit Review of CSU Contract Management Formal review of capacity CSU and CCG staff joint event (May 2013) Develop an exit strategy including alternative structure and process in case of CSU non-delivery
16(4x4) Stephen Warren Director of Commissioning
Page 16 of 17
Principal Objectives
Sub Objectives
Risk to Delivery Key controls Gaps in controls Assurance on controls
Gaps in assurance
Original Risk (LxS)
Planned Actions Residual Risk (LxS)
Owner
What would prevent this objective from happening
What systems do we have in place to secure delivery of our objective
Where are we failing to put controls in place
Evidence that shows we are reasonably managing our risks?
Where are we failing to gain evidence that our controls are effective
Impact x Likeli-hood
Actions to manage gaps including the risk register action plan
Impact x Likeli-hood
4.1 To achieve authorisation
Delivery of the authorisation conditions and directions
Progress reports to SMT and CCG Board
Single project plan for addressing each of the caveats
Regular report to SMT and CCG Governing Body
- 20(4x5) Authorisation implementation plan (COMPLETE)
8(2x4)
Fouzia Harrington CCG Director of Governance and Quality
4.2 To ensure wider GP member involvement in the commissioning agenda
GPs do not engage sufficiently
GP network s with CL leading each network Development of commissioning support to networks and engagement framework. Delegation of budgets / QIPP Plan to GP Practices. Engagement LES
Plans still to be implemented
Governing Body Clinical Leadership Group
- 20(5x4) Implementation of : -Commissioning support -Engagement LES
16(4x4) Stephen Warren CCG Director of Commissioning
Lack of understanding and willingness from GP’s to engage
As above As above As above - 20(4x4) GP development programme to be implemented (Start March 2013)
12(3x4) Stephen Warren CCG Director of Commissioning
Page 17 of 17
Principal Objectives
Sub Objectives
Risk to Delivery Key controls Gaps in controls Assurance on controls
Gaps in assurance
Original Risk (LxS)
Planned Actions Residual Risk (LxS)
Owner
What would prevent this objective from happening
What systems do we have in place to secure delivery of our objective
Where are we failing to put controls in place
Evidence that shows we are reasonably managing our risks?
Where are we failing to gain evidence that our controls are effective
Impact x Likeli-hood
Actions to manage gaps including the risk register action plan
Impact x Likeli-hood
4.3 To Ensure Conflict of interests are managed effectively
Lack of robust governance structures in place with effective training
Governance in place – conflicts of interest register updated monthly GB and CL members
Lack of formal governance and reporting processes by practice cluster groups
Integrated Governance and Audit Committee
20(4x5) Implement management of conflict of interest training by 2013 Roll out formal conflicts of interest register to all members (Sept 2013)
12(3 x4) Fouzia Harrington CCG Director of Governance and Quality
5.1 To ensure all functions/ responsibilities / contracts are handed over
Failure to manage effective transition
PWC leading on transition
Capacity of commissioners
Progress reports to SMT.
20(5x4) Ensure function sheets completed Identify additional capacity for commissioners (Feb 2013) Completed Identify project manager capacity post 1 April NEW
16(4x4) Fouzia Harrington CCG Director of Governance and Quality
