Board Assurance Framework 2012-2013. Strategic Objective: Working with strategic partners to provide...

Board Assurance Framework

2012-2013

Strategic Objective: Working with strategic partners to provide high quality, cost effective services that are valued and recognised by patients, commissioners and the wider population

Strategic Risk: 1a - Failure to meet the scale of efficiency savings included in the contract value resulting in inadequate surplus to progress to Foundation Trust, or for reinvestment into services Date added CQC ref Owners Initial risk (Likelihood x Consequence) Date reviewed Risk following review (LXC)

Mar-11 Reg 10 (Outcome 16) GMA/HL 15 (3x5) April 2012 15 (3x5)


Controls Gaps in Controls Mitigating Actions Positive Assurance Gaps in Assurance

LCH have formalised contract negotiations and contract adjustments with LPCTLCH have resolved activity recording issues, recognised by LPCT and accepted that taking on additional activity from this baseline is an efficiency

Block contract mechanism

Quality KPIs to be developed to ensure that high standards of patient safety and effectiveness of care and good patient experience are maintained. (Aug 11) Completed and monitored via the performance report

Deliver 2011/12 agreed Commissioning for Quality and Innovation (CQUIN) and all contractual key performance indicators (KPIs) (March 12)

Engage with Commissioners to agree capacity & demand management model and development of balanced contractual mechanisms to maintain or improve quality. Negotiate fixed baseline with Commissioners..

Alignment of IBP with Commissioning intentions/Clinical Commissioning Group requirements to be undertaken at the Service Improvement Group. On-going - Specific meeting to discuss commissioning intentions with Clinical Commissioning Groups set up for Dec 2011. Outcome that commissioners recognise that they will need to invest in community services to continue out of hospital strategy. Still need to ensure that contract mechanism follows this intention.

Specific meeting with commissioners to performance monitor quality measures and targets.

Monthly performance report provided to the Board. External monitoring of CQUIN undertaken by Liverpool PCT and NHS Sefton and reported via Finance and Commercial Committee and (via minutes) to the Board.

New performance framework developed and reported to the Board monthly

Monthly contract compliance meetings with commissioner, which monitors contract performance as reported to the Board through the Integrated Performance and Quality Report.

Strategic Risk: 1b - Commissioners' short-term approach to contracting and commissioning, focusing on financial efficiency and not acknowledging demand increases may lead to adverse effect on quality of services. Date added CQC ref Owner Initial risk (Likelihood x Consequence) Date reviewed Risk following review (LXC)

Mar-11 Reg 10 (Outcome 16) GMA/HL 12 (4x3) April 2012 12 (4x3)


Strategic Risk:1c - Failure to meet statutory requirements e.g. Health and Safety, Human Rights Act, Equality Act, NICE/NSF, good governance or to achieve external accreditation e.g. Care Quality Commission (CQC) registration/NHS Litigation Authority Level 3 may lead to staff or patient incidents, fines or reputational damage. Date added CQC ref Owner Initial risk (Likelihood x Consequence) Date reviewed Risk following review (LXC)

Mar-11 Reg 9 (Outcome 4)Reg 10 (Outcome 16) Reg 19 (Outcome 17)

GMA 12 (3x4) April 2012 12 (3x4)



Ongoing negotiation with PCTs and SHA re asset ownership, with rationale for LCH's preference.

NHS premises assurance model now in place nationally.

Estates, Accommodation and Facilities Management Strategy approved by the Board in July 2011.

Legal input secured to draft leases and sub leases on transfer.

Submission for asset split sent to SHA October 2011. Final approval for split will be obtained from DH December 2011. Work ongoing on the submitted assumptions. Project Board established with work-stream leads for each area.

No asset ownership or robust licences/leases in place

Strategic Health Authority (SHA) decision on transfer of assets will provide clarity concerning the LCH Estates and Facilities Management responsibility.Delivery of year 1 objectives within the strategyIdentify and train building managers in appropriate procedures.

Need to develop strong tenancy behaviour as per strategy in order to derive best from the accommodation.

Further guidance issued by DH on 4th August which alters our assumptions and requires a further round of negotiation with PCTs

Links identified for each building and Standard Operating Procedures are being developed.

Continue to progress Project Board work-streams.

Active engagement with DH to understand and influence likely outcome.

External review of estates management commissioned to identify gap analysis with best practice to assure LCH that estates / accommodation management will be optimised regardless of the outcome of the DH decision on TCS assets.

Specific briefings provided to the Board and general updates provided regularly as part of the monthly Organisational Strategy and Development Report

Reported through Healthcare Governance Sub-Committee to Integrated Governance and Quality Committee to Board via minutes.

Estates and Accommodation Strategy approved by the Board in July 2011.

Update from Project Board submitted to FCC and reporting on the Premises Assurance Model KPIs to the FCC.

Strategic Risk:1d - Poor quality and utilisation of estates/assets and inability to directly manage the estate could lead to adverse patient/staff experience/safety. Date added CQC ref Owner Initial risk (Likelihood x Consequence) Date reviewed Risk following review (LXC)

Mar-11 Reg 15 (Outcome 10)Reg 16 (Outcome 11)

GMA 9 (3x3) April 2012 9 (3x3)


Controls Gaps in Controls Mitigating Actions Positive Assurance

Gaps in Assurance

Policies and IG training in placeEscalation procedure in placeFull action plan in place to ensure compliance with policies and monitoring of exceptionsEquipment for safe storage of records now in place

Policy on records in storage to cover office movesEvidence of data loss, or poor data security still being reported and recorded. Risk of data loss can never be fully eliminated

Monthly report submitted to Executive Team to monitor IG toolkit action plan, as well as active monitoring by the Healthcare Governance Sub-Committee and Information Governance Assurance Group.

Introduction of IG Working Group and improved compliance with IG Toolkit noted in October 2011 self-assessment submission.

Development of Information Asset Owners and baseline assessment complete (Oct 11)Achieved level 2 compliance at 31/3/12.

IG Group continue to meet to monitor progress to level 3.Ongoing monitoring of data loss incidents.

Policies in place and corporate team working with operations to deliver full compliance.All significant events reported to Board on monthly basis, including actions taken/planned to reduce risk.

Achieved Level 2 standard in Information Toolkit Self Assessment in 2011/12.

IG Toolkit action plan progress reports to IG Working Group and on to IGQC.

Information Governance Assurance Group established and reporting up through Healthcare Governance Sub-Committee

Strategic Risk: 1e - Risk of data loss due to failure of good Information Governance (IG) standards leading to adverse publicity, loss of confidence from patients/commissioners and potential loss of contracts. Date added CQC ref Owner Initial risk (Likelihood x Consequence) Date reviewed Risk following review (LXC)

Mar-11 Reg 20 (Outcome 21) GMA / JOC

12 (4x3) April 2012 9 (3x3)



Delivery of Integration Plans for acquisitions Achievement of all FT application milestones and maintenance/improvement of medium risk score with SHA performance monitoring.

Monthly monitoring returns to SHA have been approved and accepted. Regular meeting cycle with SHA provider development leads now in place.

Controls remain in place and all key milestones continue to be achieved, including submission and feedback on first draft IBP.

Acceptance on to formal SHA/DH FT development programmeFull integration of acquired services and corporate infrastructure.Programme approach to FT application process.

Request for Monitor assessment manager involvement also submitted to SHA and awaiting response. Phase II and Phase III management restructure plans in place and good progress being achieved.

Business planning process for draft 2 ongoing. Long-term financial model to be updated for February 2012 submission. Work-streams continue with specific action plans.

Monthly Board reportsFormal monitoring by SHA following sign off of Tripartite Formal Agreement (TFA)

TFA now signed off by DH and positive response received from SHA re monthly monitoring returns

Strategic Risk: 1f - Failure to achieve CFT status will lead to potential dispersal and/or vertical integration of community services to the detriment of patients and the health economy as a whole.

Date added CQC ref Owner Initial risk (Likelihood x Consequence) Date reviewed Risk following review (LXC)

Mar-11 n/a BC 12 (3x4) April 2012 8 (2x4)



Effective project management of changes. Implementation of divisions and divisional managers to lead change. Work with staff and staff side to communicate changes.

No direct control over partners' financial positions e.g. Royal Liverpool and Broadgreen University Hospitals NHS Trust and Liverpool City Council

Clinical governance process in place. Board approved Quality Strategy in place.

Transformational change programme in place. Monthly performance meetings.

Completed self-assessment of Quality Governance Framework and revise Quality Strategy for Board approval (September 2011)

Effective planning and project management of changes, including business continuity and escalation planning in place for PCMS.

Appropriate HR and OD support to ensure change and transition is compliant with employment legislation, Maintain partnership working with staff to communicate and explain changes planned and agree implementation processes

Working with commissioners to plan service changes and proposed tenders.Working with stakeholders to ensure good engagement. Role and function of the Transformational Board has been revised.

Quality breakthrough aims being developed with harm free care. Energise for Excellence is being implemented. CQUIN targets in place.

Quality and performance reported to Board on monthly basis.

This is now reported through the revised performance frameworkPositive SHA response to Francis Report submitted and reported to the Board, indicating maintenance of quality standards.

Integrated performance and quality dashboard has been developed and is now reported to the Board

Post-TCS integration report submitted to the Board in May 2012, outlining the successful integration of services and staff.

Strategic Risk: 1g - Risk that LCH will not be able to maintain quality of operational service delivery during period of organisational change, transition, economic downturn and uncertainty leading to adverse effects for patients and

potential loss of contracts and CQUIN income. Date added CQC ref Owner Initial risk (Likelihood x Consequence) Date reviewed Risk following review (LXC)

Mar-11 Reg 9 (outcome 4), Reg 22 (Outcome 13), Reg 23 (Outcome 14), Reg 24 (Outcome 6).

HL 12 (3x4) April 2012 8 (2x4)


Controls Gaps in Controls Mitigating Actions Updated actions Nov 11 Positive Assurance Gaps in Assurance

Recent experience of dealing with incidents, including, pandemic flu, severe weather and riots.Major Incident, Heat wave and Fuel Emergency Plans in place, along with On-Call packs.

Business continuity plans in place.

Emergency planning and resilience tested recently during disturbances and Exercise Cunard. Plans reviewed and more robust.Board time out session delivered to reiterate Board's role in major incidents.

Intensive training of key senior managers in emergency planning.

Update business continuity plans.Testing exercise to be undertaken (Oct 2011)Provision of training to relevant staff.

Emergency Planning Group in operation, reporting to Healthcare Governance Sub-Committee.

Strategic Risk: 1i - Lack of emergency preparedness to respond to a major incident may prevent the delivery of high quality, cost effective care and may harm staff, patients and the public.


Aug 11 HL 12 (3x4) April 2012 8 (2x4)

Strategic Objective: To grow our market share by being the provider of choice for established services, and by developing innovative and specialist services

Strategic Risk: 2a - Lack of ability to respond appropriately to commissioning intentions and the uncertainties in the external environment e.g. competing providers could lead to loss of funding or business or failure to win new business. Date added CQC ref Owner Initial risk (Likelihood x Consequence) Date reviewed Risk following review (LXC)

Mar 11 12 (3x4) HL/ GMA

12 (3x4) April 2012 12 (3x4)


Strategic Risk: 2b - Failure to establish effective relationship underpinned by robust governance arrangements with GP Commissioning, patients, public and external partners could lead to loss of business and failure to grow market share


Mar-11 Reg 10 (Outcome 16), Reg 24 (Outcome 6).

BC 12 (3x40 April 2012 12 (3x4)



Board members actively involved in stakeholder management and promoting the success and reputation of the organisation.

Insufficient active marketing and promotion of high quality service delivery and key achievements.

No contracts lost as a result of poor performance and no current significant performance issues.Quality priorities agreed for 2011/12

Robust performance framework in place, with monthly performance meetings for each division.

Establish use of Patient Choices website/LCHT internet to obtain patient ratingsIdentify baseline and key performance indicators as part of Quality Strategy for patient experience

On target to achieve contract

Currently running at 40% achievement.Partially completed though awaiting data.

Monthly reporting to Board on performance and quality indicators

Strategic Risk: 2c - Poor service performance could lead to loss of reputation and loss of contracts/failure to win new business


Mar-11 Reg 10 (Outcome 16) HL 12 (3x4) April 2012 8 (2x4)



Learning and Development Bureau in place with full training programmePDR processes in place Core competency work programme being rolled out.LCH successful in winning awardsLCH have won contracts on the back of innovation and service development

Research and Development (R&D) strategy developed and R&D lead in place.

Lack of systematic approach to stimulate, record and market innovations in LCH successful in winning awards

Commitment given for EMIS implementation.

System in place for supporting innovation across the organisation.LCH participating in the Dallas programme, in partnership with Liverpool PCT and Riverside Housing.

Updated Board approved Technology and Innovation Strategy in place, with increased use of mobile working, telehealth/telemedicine implementation and adoption of technology by Board (iPads and twitter etc)

Introduce corporate mechanism that stimulates, records and markets innovation to deliver this year's objectives outlined in the Technology and Innovation Strategy. (July 11)

Process has been developed, but streamlined web based approach being developed

Continue to review telehealth and exploration of mobile working.

Continue roll out of electronic records.

Progress work LCH is leading on for telehealth and proactive care.

Innovation Workshop led by LCH held with staff and external contacts. Well received and positive responses.

Reported through Clinical Quality Group to HGSC and through to Board via IGQC minutes submitted following each meeting.LCH successful in winning awards

Technology and Innovation Strategy approved by Board in January 2012.

Strategic Risk: 2d - Failure to innovate and keep up with pace of change in market environment and technology, contributing to failure to win targeted contracts.


Mar-11 Reg 21, (Outcome 12), Reg 23 (Outcome 14)

GA/HL 9 (3x3) April 2012 9 (3x3)

Strategic Objective: To reduce health inequalities and improve health in communities by developing as a public health organisation

Strategic Risk: 3a - Inability to demonstrate LCHT’s contribution to long term health improvement leading to potential loss of contractual and CQUIN income


Mar-11 Reg 9 (outcome 4) HL 12 (4x3) April 2012 9 (3x3)

Strategic Objective: To reduce health inequalities and improve health in communities by developing as a public health organisation


Ability of LCH to influence partnership working and risk sharing.Multiagency project on intermediate care and front end QIPP programme.

Partnership with GPs and GP commissioners on Adult ServicesLegal contracts in place for recent/established bids delivered in partnership.

Regular discussions ongoing with partners' governance leads.

Ensure robust governance and performance management arrangements to support partnership working and where pooled budgets are in place (July 11)Work with Liverpool City Council to develop and implement integrated re-ablement services"Identify specific key performance measures to demonstrate LCH contribution to integrated care pathways:- Decreased admissions- Increased patient satisfaction- Reduced duplication- High quality services

Approach to governance arrangements will be incorporated in the Commercial Strategy being developed.

Lack of robust reporting through to BoardProgramme management of front end QIPP and Intermediate Care in placeReported through performance framework to Board

Strategic Risk: 3b - Lack of robust governance and risk sharing arrangements for partnerships and joint working may lead to significant financial and reputational risk.


Mar-11 Reg 10 (Outcome 16) HL 12 (4x3) April 2012

Strategic Objective: To attract, retain, continue to develop and protect a diverse, motivated and flexible workforce, with the skills and competencies to deliver organisational success

Strategic Risk: 4a - Failure to attract, retain and develop a flexible, diverse and skilled workforce will adversely affect the ability to become the employer of choice and deliver against Commissioners’ needs.


Mar-11 Reg 21, (Outcome 12), Reg 22 (Outcome 13), Reg 23

(Outcome 14)

NB 9 (3x3) April 2012 9 (3x3)

Strategic Objective: To attract, retain, continue to develop and protect a diverse, motivated and flexible workforce, with the skills and competencies to deliver organisational success

Strategic Risk: 4b - Lack of investment in development and training will have an adverse effect on the organisation's ability to attract and retain the right workforce, to provide a flexible response to the changing environment and lead to failure to become the employer of choice. Date added CQC ref Owner Initial risk (Likelihood x Consequence) Date reviewed Risk following review (LXC)

Mar-11 Reg 10 (Outcome 16), Reg 21 (Outcome 12), Reg 22 (Outcome 13), Reg 23 (Outcome 14).

MP 9 (3x3) April 2012 9 (3x3)

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