5. Key Identified Risks The key five risks associated with achieving the objectives detailed within this plan are shown below together with the controls identified to mitigate each risk and the assurances sought that controls are mitigating each risk. Principal Risk Existing Key Controls Possible Sources of Results in Gaps in Controls & Exec Lead Current Risk Score Assurance Assurances on Assurances Controls CQC LH Cons Ref Score Risk that Ongoing programme Vacancies in Internal Control Gaps Medical 5 4 20 Director medical of international Locum spend. gastroenterology, National shortage of staffing will fellowship recruitment. Recruitment monitoring. respiratory/acute, doctors not be at the Redesigned medical Risk management and community required rota to ensure reporting. paediatrics, Assurance Gaps numbers or consistent medical Workforce review. emergency Review of on call skills to deliver across the wards. CEO Clinical Sustainability department, service with medical safe and Continued use of NHS Report to Board upper GI, staffing at weekends dignified care. and Agency Locums. CQC internal monitoring anaesthetics, Endoscopy ongoing Active participation in Revalidation and appraisal oncology, capacity review BNSSG wide Urgent processes gynaecology, Discharge planning & Care Groups in Daily Quality Improvement radiology. checklist usage relation to demand Team situation report below target (20%) Safe Domain management and Divisional Governance Physician rota 1:11 health community wide Meetings with only 4 management of Mortality review substantive emergency flow. Service review maintaining this. Hospital OOHs Board Reporting Lack of visible Trust Service. External wide rota. Regular review by Deanery/GMC review Engagement with EMG. NHS TDA dashboard NICE TAG Physicians Assistants doctor to bed ratio assessment. Risk that the Board leadership Internal CQC Intelligent Control gaps Director of 4 4 16 Nursing Trust does not Risk management Quarterly reporting to QGC Monitoring Report Managerial and meet CQC QIT leadership and Risk based CQC style visits Dec 2014 clinical staffing – requirements monitoring IPR reports to Board shortages.
5. Key Identified Risks The key five risks associated with achieving the objectives detailed within this plan are shown below together with the controls identified to mitigate each risk and the assurances sought that controls are mitigating each risk. Principal Risk CQC Ref Existing Key Controls Possible Sources of Assurance Results in Assurances on Controls Gaps in Controls & Assurances Exec Lead Current Risk Score LH Cons Score Risk that medical staffing will not be at the required numbers or skills to deliver safe and dignified care. Safe Domain Ongoing programme of international fellowship recruitment. Redesigned medical rota to ensure consistent medical across the wards. Continued use of NHS and Agency Locums. Active participation in BNSSG wide Urgent Care Groups in relation to demand management and health community wide management of emergency flow. Hospital OOHs Service. Regular review by EMG. Physicians Assistants Internal Locum spend. Recruitment monitoring. Risk management and reporting. Workforce review. CEO Clinical Sustainability Report to Board CQC internal monitoring Revalidation and appraisal processes Daily Quality Improvement Team situation report Divisional Governance Meetings Mortality review Service review Board Reporting External Deanery/GMC review NHS TDA dashboard doctor to bed ratio Vacancies in gastroenterology, respiratory/acute, community paediatrics, emergency department, upper GI, anaesthetics, oncology, gynaecology, radiology. Control Gaps National shortage of doctors Assurance Gaps Review of on call service with medical staffing at weekends Endoscopy ongoing capacity review Discharge planning & checklist usage below target (20%) Physician rota 1:11 with only 4 substantive maintaining this. Lack of visible Trust wide rota. Engagement with NICE TAG assessment. Medical Director 5 4 20 Risk that the Trust does not meet CQC requirements Board leadership Risk management QIT leadership and monitoring Internal Quarterly reporting to QGC Risk based CQC style visits IPR reports to Board CQC Intelligent Monitoring Report Dec 2014 – Control gaps Managerial and clinical staffing shortages. Director of Nursing 4 4 16
Agenda%20Item%20992%2015%20%20Operational%20Business%20Plan%2020152016.docx