Professional Documents
Culture Documents
160
Cause: Reduced funding due to top slicing by NHS London, unfavourable distribution of budgets at Cluster and practice levels - Increase in acute activity due to rise in unscheduled care; increased referrals; increased conversion rate from OPA to procedure. - Significant increase / demand in Healthcare - Ineffective contract management framework - Insufficient investment in primary care - Loss of local control re. acute activity now moved to Cluster
Escalation process with cluster in place should overspend and/or non-delivery of QIPP arise Practice level reports run manually until live system go live QIPP reporting to Local QIPP Committee on monthly basis Robust monthly monitoring of acute activity performance against plans Sollis Clarity reporting and analysis at practice level for acute activity Access available to clinical & non-clinical commissioning groups. Regular reports to KCC
Establish detailed analysis of underlying causes of KHT over-performance and set robust plans for 2012/13 SLAs
Person Responsible: Tonia Michaelides To be implemented by: 31/03/2012
Disaggregation of financial & performance information by consortia and practice basis as appropriate
Person Responsible: Yarlini Roberts To be implemented by: 31/01/2012
Develop information infrastructure (systems & processes) to enable intelligent reporting of activity levels and costs.
Person Responsible: Yarlini Roberts To be implemented by: 31/03/2012
161
Failure to deliver Vital Signs and Operating Plan targets - areas of responsibility delegated to KCC
Risk Owner: Tonia Michaelides Last Updated: 05/01/2012
Cause: -Insufficient performance data to assess delivery of all areas of responsibility delegated to Kingston pathfinder, as identified delegation of Measures list - Failure to take remedial action if we are not aware that we are failing to deliver in any area. - Need to balance financial pressures with delivery of performance targets may mean that
3 3 High (9)
Read access to Performance Accelerator available Performance reports in place Approved delegation with cluster defined processes
3 3 High (9)
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Effect: 162 Risk to Service Development and quality of future patient care services
Risk Owner: Annette Pautz Last Updated: 04/01/2012
Cause: Lack of shared vision between commissioners and Your Healthcare Effect: Service development and quality of patient care is compromised.
2 3 Moderate (6)
5yr Block contract in place (4yrs to run) Agreed set of KPIs Monthly Performance Review & Qtrly Quality Review
2 2 Moderate (4)
Develop costed activity plans for 2012/13 with more sensitive and benchmarked performance measures
Person Responsible: Julia Gosden To be implemented by: 29/02/2012
Update and review current service specifications to include clear and specific outcomes in line with KCC vision for community services
Person Responsible: Annette Pautz To be implemented by: 31/03/2013
163
Failure to meet CQC Essential Standards for quality & safety and Inadequate follow-up of SIs in Mental Health Commissioned Services
Risk Owner: Phil Moore Last Updated: 05/01/2012
Cause: Lack of effective delivery of the Mental Health Services by SWL&StG due to failure to meet CQC essential standards and inadequate follow-up of serious incidents (SIs)
5 3 Extreme (15)
Mental Health Contract in place with key performance indicators and performance management processes and in built financial penalty clauses Performance management framework at cluster and borough levels SWL&StG action plans in place.
4 3 High (12)
Effect:
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Cause: Lack of ownership by Pathfinders Effect: The quality of patient care is compromised
4 3 High (12)
4 3 High (12)
-Pathfinder OD work to include areas where there are identified gaps in knowledge / experience
Person Responsible: Tonia Michaelides To be implemented by: 31/12/2011
165
Cause: Financial forcasting lack robustness Focus of responsibility requires clarification Lack of joint working with ACU Effect: The quality of patient care is compromised Cause: Lack of effective systems and procedures Effect: Adult death or serious injury occurs
4 4 Extreme (16)
ACU management Board KHT Clinical Quality Meetings Regular Acute Performance reports
4 4 Extreme (16)
166
5 3 Extreme (15)
Joint Health & Social Care Service Adult Safeguarding team in place Safeguarding Adults Partnership Board in place (Chaired by David Smith)
5 2 High (10)
Page 4 of 8
Cause: Lack of capacity (Designated Nurse: 0.4) Organisational changes lead to lack of clarity around reporting systems Effect: Child death or serious injury occurs Financial liability Reputational damage Cause: - Lack of action and learning from previous serious incident occurences and deaths Effect: - Risk of further preventable SIs and deaths occuring - Reputational damage - Financial liability Cause: -Lack of readily available robust data and over optimistic planning assumptions -Demand management: New pathways do not effectively reduce/ replace acute activity -delayed start to Urology, Gynaecology, Falls & Neurology projects -straight line trajectories for delivering savings Effect: - Expected savings not achieved - Failure to achieve financial balance
5 3 Extreme (15)
- Established Framework and Child Protection Team within the Kingston Health Economy.
5 2 High (10)
Secure clarity re. capacity of Named/ Designated Nurse roles/structures within Kingston and across cluster.
Person Responsible: Christine Robjohn To be implemented by: 31/10/2011
168
5 2 High (10)
Incident and Serious Incident Policies in place. SWL Risk Management Committee and Strategy in place
5 1 Moderate (5)
169
3 4 High (12)
Monitoring of KPIs Review of Flash reports (includes project specific risks)at QIPP meetings Regular project specific meetings with project managers Review of QIPP programme by KCC Performance review meeting with providers
3 4 High (12)
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Cause: -Failure to engage and take account of the views of patients and the public shape service planning and improvements in quality of care, including hard to reach groups. - Lack of engagement with clinicians in primary and secondary care may compromise ability to deliver new models of care.
4 2 High (8)
Better Services Better Value initiative Cluster level PPI and Comms team Deliberative events held (July 2011)
4 2 High (8)
171
5 3 Extreme (15)
Cluster Emergency Planning Cabinet EPLO Network -NHS London Emergency planning network -RBK Contingency planning forum (multi-agency) -Business Continuity Plan; Major Incident Plan; Severe Weather (snow) Plan; Communications Plan Heatwave Plan; Flood plan; Flu Plan; and Fuel Plan all in place.
4 3 High (12)
Arrange and hold emergency exercises -6 mthly Communications exercise -Annual table top exercise -3yrly live exercise
Person Responsible: Taryn Milton To be implemented by: 31/12/2011
Page 6 of 8
172
Failure to maintain effective functioning and robust governance for Kingston as a PCT statutory body operating within a Cluster arrangement
Risk Owner: Jill Pearse Last Updated: 05/01/2012
Cause: Potential for making decisions that are ultra-vires or for not adequately maintaining a statutory function, with potential for legal challenge or financial penalty Effect: Reputational damage due to confusion about functioning or decision making
4 4 Extreme (16)
4 3 High (12)
173
Breaches of Confidentiality and Data Protection Act (Information Governance requirements compliance)
Risk Owner: Jill Pearse Last Updated: 04/01/2012
Cause:
4 3 High (12)
Completion of Information Governance Toolkit (IGT) Local Information Governance Steering Group (IGSG) Mandatory IG Training
4 3 High (12)
Ensure all Kingston staff complete IG training: - Monitor training status for individual staff - issue reminders and - report to senior management.
Person Responsible: Jill Pearse To be implemented by: 31/03/2012
Review IG Toolkit Submission arrangements with Cluster - i.e. whether to submit Kingston specific submission in March 2012 or complete as part of Cluster wide submission
Person Responsible: Jill Pearse To be implemented by: 29/02/2012
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Cause: Inadequate input from ACU to support IFR process Effect: IFR process runs risk of not being robust. Patients may not get care that is appropriate or vice versa
4 3 High (12)
4 3 High (12)
Establish collaborative working arrangements with Public Health Teams in Wandsworth and Merton & Sutton. Secure GP input into IFR process
Person Responsible: Jonathan Hildebrand - Director of PH To be implemented by: 31/01/2012
Page 8 of 8