1.0 the Assurance Framework Background 3

ASSURANCE FRAMEWORK

Date: May 2008

Version: 18

1 CONTENTS

0 The Assurance Framework – Background 3

2.0 Risk Classification Matrix 3 2.1 Potential Outcome Severity Matrix 3 2.1.1 Definitions 3 2.1.2 Likelihood 4 2.1.3 Consequence 4 2.1.4 Risk Rating And Action Plan 5 2.2 Matrix

3.0 Principal Objective One 6 Capital investment to improve;  Patient and staff environment.  Health and safety.  Investment required to sustain business activity.  Energy measures.  Risk management.

3.1 Principal Objective Two 8 Develop and implement robust recruitment and retention measures.

3.2 Principal Objective Three 11 Effective governance arrangements that reflect current Trust business.

3.3 Principal Objective Four 13 To be an effective and efficient provider of orthopaedic and musculo-skeletal services.

3.4 Principal Objective Five 15 To achieve financial balance

3.5 Principal Objective Six 17 Develop and implement the modernisation plan – bringing about changes in clinical practice and organisation to increase productivity. Reform the model of care.

3.6 Principal Objective Seven 19 To achieve full compliance with the national waiting list targets.

3.7 Principal Objective Eight 21 Develop and implement a cohesive and integrated IM&T Strategy.

3.8 Principal Objective Nine 23 Redevelopment of the RNOH Stanmore campus to provide a modern healthcare building.

3.9 Principal Objective Ten 25 To achieve Foundation Trust status

2 1.0 THE ASSURANCE FRAMEWORK - BACKGROUND More than ever before, as the NHS embraces a culture of decentralisation, increasing local autonomy and local accountability, Boards need to be confident that the systems, policies and people they have put in place are operating in a way that is effective in driving the delivery of objectives by focusing on minimising risk. In support of that challenge, “Assurance: The Board Agenda” was issued in July 2002 and set out the principles for an assurance framework to give Boards the confidence that they need.

The Assurance Framework provides organisations with a simple but comprehensive method for the effective and focused management of the principal risks to meeting their objectives. It also provides a structure for the evidence to support the Statement On Internal Control. This simplifies Board reporting and the prioritisation of action plans, which, in turn, allow for more effective performance management.

2.0 RISK CLASSIFICATION MATRIX The Trust accepts that in an ideal situation any level of risk is unacceptable. However, in a real healthcare work setting, this is not realistic. It is necessary therefore, to set standards to establish the level of tolerable risk. This enables the Trust to evaluate residual risk levels, which can then be prioritised and properly controlled. This is achieved by using the Trusts Risk Classification Matrix as detailed below; -

2.1 POTENTIAL OUTCOME SEVERITY MATRIX 2.1.1 DEFINITIONS

2.1.2 LIKELIHOOD RATING DESCRIPTION

Rare Very unlikely. 1 May only occur in exceptional circumstances. Unlikely Could occur at some time but unusual. 2 Possible May occur at some time, reasonable to expect at some point although infrequent. 3 Likely Will probably occur in most circumstances, not a surprise. 4 Almost Certain Is expected to occur in most circumstances. 5 No doubt that this event will occur frequently.

3 2.1.3 CONSEQUENCE

RATING DESCRIPTION

Insignificant Negligible injury, damage or outcome. 1 Process delays. Loss of production. Minor Minor first aid injury. 2 Minor damage to property or equipment. Slight delay in service provision. An element of financial loss (between £500 and £10,000) Low radiation dose incident (dose is a fraction of the dose limit for a member of the public) Minor clinical incident – no immediate effect on patient safety or patient care. Lost time. Moderate Major injury, disabling illness, major accident. 3 Medical treatment required. Significant but temporary damage to property or equipment. Financial loss (between £10,000 and £100,000) Temporary delay to service provision. Clinical incident may require patient to require additional treatment or change to planned regime / care. Significant but limited (medium) radiation dose incident (not exceeding dose limits) Major Single avoidable death. 4 Extensive injuries or negative clinical outcome. Medical treatment / intervention required. Significant (permanent or long term) damage to property or equipment. Major financial loss (£100,000+) Long term delays in service provision. Significant clinical incident where patient requires additional treatment with possible permanent effects and negative outcome. Over exposure (high) radiation dose incident (exceeding dose limit) Catastrophic Multiple fatalities. 5 Permanent loss of services, equipment and property. Major loss of public confidence.

2.1.4 RISK RATING AND ACTION PLAN Risk Rating Level Of Risk Action Required To Reduce Risk

Green Very low Accept risk.

Yellow Low Make every effort to minimise risk wherever possible. Orange Medium Urgent action required NOW to reduce risk. Red High STOP the activity until risk has been significantly lowered

4 2.2 MATRIX

Insignificant Minor Moderate Major Catastrophic CONSEQUENCE 1 2 3 4 5

LIKELIHOOD

Almost certain Low Low Medium High High 5

Likely Low Low Medium High High 4

Possible Very low Low Medium High High 3

Unlikely Very low Very low Low Medium High 2

Rare Very low Very low Low Medium High 1

Acceptable Risk A risk is considered acceptable when there are adequate control measures in place and the risk has been managed as far as is considered reasonably practicable. Risks falling in the green “very low” and yellow “low” risk section are considered “acceptable” although the Trust will still need to take action on these risks where the assessment has identified that risks can be easily minimised.

Significant Risk All risks in the orange “moderate” or red “high” risk rating will be considered “significant”. The Risk / Clinical Risk Manager must be notified of these risks.

5 3.0 PRINCIPAL OBJECTIVE ONE Principal Description of all associated Key Controls Assurances Gaps in Risk Action plan and Board lead objectives risks on controls controls rating implementation (L x C) date Capital investment Insufficient funding to maintain or Standards For Standards For Standards For 3 x 4 = 12 The reason for non Director of to improve; - provide care in an environment that Better Health final Better Better Healthcare High compliance relates to Projects, promotes patient and staff well-being and declaration (April Healthcare (C20, (C20, C21, not the inherent design of Estates and  Patient and staff respect for patient’ needs and preferences 2008) C21) met) the buildings and estate, Facilities environment. in that they are designed for the effective but these design issues and safe delivery of treatment, care or a Estates Risk With backlog cannot be fully  Health and specific function, provide as much Profile. Feb 2005 maintenance being addressed until the site safety. privacy as possible, are well maintained estimated at is re-developed. (2011 – and are cleaned to optimise health Estates Strategy c£50m, annual anticipated date for  Investment outcomes for patients. (Stanmore) 2005 CRL limits of completion of site required to around £1m will do redevelopment) sustain business little to improve the activity. overall condition of Alternative solutions to Director of the estate until the be reviewed i.e. 2 phase Projects,  Energy redevelopment is development of site Estates and measures. complete. over 25 years. October Facilities 2006.  Risk Trust prosecuted Updated November management. Prosecution from Health And Safety HSE have signed by the HSE 2007: SHA panel have Executive (HSE), due to non-compliant off the following the met to review options  Backlog estate. improvement steam incident – but this is currently maintenance. notice. (Nov 2005. Date of under review regarding 2005) prosecution – 10th due process.  Fire September 2007. January 2008: SHA precautions. Progress reports Trust pleaded have decided to pursue to Risk guilty. Fined Stanmore total Management £15,000 + court development as Board. costs. preferred option and no other options are to be HSE action plan. considered.

Weekly Increased potential for infection inspections of outbreaks. hospital cleanliness by Contract Monitoring Officer. Audit sheets are placed on the Trust’s intranet.

7 PRINCIPAL OBJECTIVE ONE CONTINUED Principal Description of all associated Key Controls Assurances Gaps in Risk Action plan and Board lead objectives risks on controls controls rating implementation (L x C) date Capital investment Prosecution from LFEPA, due to non- Strategic overview Board briefing Enforcement notice 3 x 4 = 12 Continue to implement Director of to improve; - compliant estate. report produced by paper (January from London Fire High the annual LFEPA Projects Lawrence Webster 2006) And Emergency action plan. Review and Estates and  Patient and staff Forrester - Fire Planning Authority agree plan for 2008. Facilities environment. Engineering And Risks have been (LFEPA) (Dec Invite LFEPA to Fire Risk prioritised and 2005) approve  Health and Management budget setting (April 2008) safety. Consultants (LWF) process Failure to recruit a (March 2006) completed. Fire And Security Develop a fire risk Director of  Investment Capital Planning Management assessment programme Projects, required to Health and Safety Minutes. Officer. Interviews and implement Estates and sustain business Advisor has (February 2006) held on 5th (On-going) Facilities activity. attended a September. One NEBOSH fire Fire management applicant offered Arrange maternity cover Director of th th  Energy course(10 – 14 action plan (May position subject to for Health and Safety Corporate measures. September 2007) references but offer Advisor. Internal advert Affairs and 2007)and been withdrawn (Oct 06) placed for Fire And Human  Risk awarded LFEPA due to poor Security Officer (3 day Resources management. qualification. inspection of references and per week) Risk Manager Bolsover Street police checks. Completed: February th  Backlog Part time Fire (6 November 2008 maintenance. Officer – seconded 2007) for 2 days per week Fire Officer to complete Fire Officer  Fire from Estates. E-mail form Fire NEBOSH. precautions. Currently studying John Hawkins Completed: April 2008 for Fire NEBOSH (LFEPA certificate inspector) Commence recruitment Risk Manager providing process to appointment Funding to positive a full time Fire Officer appointment full feedback on the (June 2008) time Fire Officer Trusts fire risk approved by assessment pro- Vacancy Panel forma (May 2008) (November 2007) 3.1 PRINCIPAL OBJECTIVE TWO Principal Description of all associated risks Key Controls Assurances Gaps in controls Risk Action plan and Board lead objectives on controls rating implementation (L x C) date Develop and Failure to retain staff. Workforce IWL Plus Poor transport links. 3 x 3 = 9 Continue to monitor Director of implement Strategy. (Draft) Validation. Medium vacancy/turnover, Human robust Failure to recruit sufficient staff to provide (Updated 2007) (Achieved Uncertainty of future sickness levels on a Resources recruitment and enough capacity to meet 18 week target January 2006) redevelopment. monthly basis. and Corporate retention e.g. in theatres / spinal surgeon. Provider (Ongoing) Affairs measures Sustainability Plan HR Performance Poor quality Director of An increased reliance on bank and agency 2006/07 to Report Monthly accommodation on- Develop the Workforce Human staff in areas such as ITU, theatres, spinal 2009/10. Page 21. incorporated into site. Plan and strategy with Resources injuries, physiotherapy, occupational top 10 targets. regards to the Clinical and Corporate therapy and radiography can contribute to Monthly (Monitored Low appraisal and Model and new Affairs the Trusts financial overspend. monitoring of monthly) Performance And hospital. (May 2007) vacancy Development Plans Update March 2008. rates/payroll costs Staff survey (PDP) take up. Draft completed but (August 2007) report. (March requires inclusion of 2006) Perceived pressure on workforce plans for Joint Staff staff and high stress OBC. Director of Management Workforce levels. Human Committee Planning / Raise uptake of Resources (monthly) development of High level of perceived appraisals to 70% and Corporate new roles as part bullying and across all staff groups. Affairs Theatre staffing of OBC. harassment. (March 2007) meeting (bi- Update: weekly) Equal Inflexibility of pay Approximately 60% opportunities framework i.e. Agenda achieved. Aiming for Director of Bank and agency monitoring For Change 70% by June 2008 Human monitoring meeting report to Board Resources (bi-weekly) (twice yearly – Management Continue to monitor October 2007) development equality data. – Director of Vacancy control programme requires quarterly HR panel Employee further development relation case Review and implement Agenda For reports to Board No agreed plan for management Change rates (quarterly – Feb compliance with development Director of agreed for bank 2008) European Working programme HR staff Time Directive (EWTD ) - 2009 Rota being developed Director of International in theatres (July 2008) HR recruitment being undertaken Agree EWTD plan (October 2008) PRINCIPAL OBJECTIVE TWO - CONTINUED Principal Description of all associated Key Controls Assurances Gaps in Risk Action plan and Board lead objectives risks on controls controls rating implementation (L x C) date Develop and Facilitation process HR Department to Director of implement robust undertaken with maintain Agenda For Human recruitment and Spinal Deformity Change job evaluation Resources retention measures Unit (commenced system (December and Corporate Feb 2008) 2006) Completed Affairs

HR Director Support mechanisms in Director of attends HR place for bullying and Human Directors Network stress – further action to Resources (bi-monthly) be taken. and Corporate Affairs HR Director attends Healthcare Values to be reviewed Director of People through workshops. Human Management (April 2008) Resources and Association (bi- Corporate monthly) Affairs

Agree consistent bank / Director of on-call rates across the Human Trust. (March 2007) Resources Update March 2008: and Corporate Agenda for Change Affairs rates agreed

Failure to ensure that staff concerned with Standards For Theatres / recovery 2 x 3 = 6 Develop Director of all aspects of the provision of healthcare Training and Better to employ at least Low implementation plan Human are appropriately recruited, trained and development e.g. Healthcare one paediatric regarding Modernising Resources qualified for the work they undertake. leadership and (C11A) nurse to lead the Medical Careers (April and Corporate management development of an 2007 – Updated March Affairs development Strategic Health improved child 2008 – COMPLETED programme in Authority led friendly particular for front “Clinical Review environment. Recruit paediatric nurse Acting line clinical staff. Of The (July 2006) Action for theatres. Advert Director of BELL programme. Desirability And not yet met. placed - Nursing Times. Nursing Sustainability Of Updated (May 2008) Re-introduction of Retaining The February 2008: Recruitment process 10 in-house nursing Royal National Appointed continues – Updated bank. Orthopaedic candidate May 2008 withdrew. PRINCIPAL OBJECTIVE TWO - CONTINUED Principal Description of all associated Key Controls Assurances Gaps in Risk Action plan and Board lead objectives risks on controls controls rating implementation (L x C) date Develop and Recruitment And Hospital As A Updated May 2 x 3 = 6 All staff caring for Director of implement robust Selection Guidance Stand Alone 2008: New advert Low children to have Nursing recruitment and Notes. (June 2003) Single Specialty placed received paediatric retention measures Hospital.” basic life support training and an Race Equality NHSLA advanced paediatric Scheme (May 2005 assessment trained member of staff – May 2008) (November to be part of the crash 2007) team. (October 2006) Equality And Updated February Diversity Policy Contract with 2008: Training dates (October 2002) NWL to provide have been published, surgical and database of attendance Standards For medical cover kept. On 29th February Better Health final 2008, 185 out of 211 declaration (April staff had attended 2007) training. (On-going) At least two Director of children’s trained All staff working with Nursing nurses on duty on paediatrics to receive each shift on the mandatory in-house paediatric wards. paediatric training. (On-going) Additional Child Director of Nursing Branch nurses Improve training for across children’s staff to provide high pathways. dependency nursing on paediatric wards. Mandatory study (On-going) days are Updated May 2008: incorporated into Paediatric rotation in induction. place

11 12 3.2 PRINCIPAL OBJECTIVE THREE Principal Description of all associated Key Controls Assurances Gaps in Risk Action plan and Board lead objectives risks on controls controls rating implementation (L x C) date Effective Failure to achieve key / principal Trust Board Internal and Limited local risk 2 x 4 = 8 Ensure that Risk Director of Governance objectives and top ten targets minutes and external audit registers. Medium Management Strategy is Human arrangements that monitoring reports. reports. reviewed annually and Resources reflect current Failure to take a strategic approach to Lack of knowledge discussed by the Board. Trust business risk. Provider Clinical and understanding (March 2008) Sustainability Plan Negligence leads to a lack of Failure to comply with national priorities Scheme For engagement in All senior managers to Director of such as waiting list targets, Standards For Clinical Trusts (CNST) management of attend mandatory Human Better Healthcare. Governance Board risk. training. Resources minutes. Risk Pooling (October 2008) Failure to develop and support managerial Scheme For Not full Trustwide and clinical leadership and accountability, Risk Management Trusts (RPST) engagement with Design templates and Director Of as well as the organisation’s culture, Board minutes. risk management implement scheduler for Human systems and working practices to ensure Key indicators processes monthly reports to be Resources probity, quality assurance, quality Risk register. reported to the automatically sent to improvement and patient safety are Board Standards For Executive Team and central components of all the activities of Audit Committee Better Health – Audit Committee) the Trust. minutes. Standards For C20, C21, C13 – (September 2006) Better Health not met Update: Completed - Standards For (C1 – 4, C7, C8, directorate risk Better Health final C9, C10, C11, registers distributed to declaration (April C12) Executive Team on a 2008) monthly basis for Formal review. (November NHSLA operational risk 2006.) assessment – level register in place. Update May 2008 2 Monthly Incident Safeguard risk Summary reports are management now being sent to all database. areas. A Chief Executive risk register Local audit / has been developed and inspection is automatically reports. forwarded each month for review Training records Temporary Safeguard Assurance manager to be trained to framework (to progress work relating Board bi- to database. monthly) (On-going)

PRINCIPAL OBJECTIVE THREE CONTINUED Principal Description of all associated Key Controls Assurances Gaps in Risk Action plan and Board lead objectives risks on controls controls rating implementation (L x C) date Effective Review of the NHSLA level 2 2 x 4 = 8 Link the assurance Director of Governance integration of risk (November Medium framework with the Human arrangements that to ensure a holistic 2007) corporate risk register Resources and reflect current and cohesive and Standards For Corporate Trust business approach. (Risk Use of MaPSaF Healthcare and top ten Affairs / Management (Manchester targets - develop a Acting Strategy –April Patient Safety reporting template. Director of 2007 and Risk Framework) by (April 2007) Nursing Management Board executive team, Update: Report creation minutes –May Risk Officers, training has been 2007) Health and attended (February Safety 2007) and all reports are Annual risk Committee. being reviewed. awareness training Anticipated date of session for completion is April executive team and 2008 on-going training Update May 2008: No as part of Risk action has been taken Management as SFBH data has not Board. been entered onto system Local induction templates for Annual monitoring of Director of senior managers, use of local induction Human consultants, templates Resources and executive team and (November 2008) Corporate NED’s Affairs

Key users have received Safeguard training

Risk Officer network

14 3.3 PRINCIPAL OBJECTIVE FOUR Principal Description of all associated Key Controls Assurances Gaps in Risk Action plan and Board lead objectives risks on controls controls rating implementation (L x C) date To be an effective Failure to provide and effectively monitor Data collection. Trust Annual Data collection and 3 x 3 = 9 Produce a strategy for Chief and efficient performance and provide a quality (Safeguard risk report monitoring systems Medium networking to ensure Executive provider of service. management (Safeguard risk that staff are facilitated orthopaedic and software) Patient Advice management in experiencing active Director of musculo-skeletal Failure to communicate data effectively Liaison Service database) participation in Operations and services. and efficiently. Training. (PAL’s) issues appropriate clinical Service (Mandatory and complaints. Standards For networks and Improvement Poor working environment. training Better Healthcare – professional programme as well Annual Clinical C13, C20, C21 – development Medical as additional Audit report Not met opportunities with Director Failure to sufficiently and effectively training arranged (2005) others outside the Trust. cooperate with other healthcare / social through Human Critically examine July 2006 care organisations to ensure that patient’s Resources Incident on-going care Action point not yet individual needs are properly managed Development reporting. arrangements of completed. and met. Team) patients following Key indicators. discharge. Strengthen relationships Director Of Failure to effectively enhance patient Performance June 2006 with Commissioners. Finance safety by the use of health care processes, monitoring. Healthcare Action point not On-going working practices and systematic Commission yet completed. activities that prevent or reduce the risk of Service level Review. Achieve key targets: Acting harm to patients. agreements. Produce a strategy Key target 6 Director of Standards For for networking to a) Zero MRSA Nursing Insufficient funding to maintain or Clinical standards. Better Health ensure that staff are bacteraemia provide care in an environment that (C1, C2, C3, C4, facilitated in cases promotes patient and staff well-being and Benchmarking. C5, C6, C21) experiencing active contracted respect for patient’ needs and preferences participation in within RNOH in that they are designed for the effective Infection control SHA led appropriate clinical Updated May 2008: and safe delivery of treatment, care or a surveillance. “Clinical Review networks and Achieved 2007 / 08 specific function, provide as much Of The professional b) Zero privacy as possible, are well maintained Clinical policies Desirability And development Clostridium and are cleaned to optimise health and procedures. Sustainability Of opportunities with difficile cases outcomes for patients. Retaining The others outside the contracted Estates Risk RNOH As A Trust. within RNOH Failure to comply with the Health Act Profile. Feb 05 Stand Alone July 2006 (31.03.08) 2006: The Code Of Practice For The Single Speciality Action point not Updated May 2008: Prevention And Control Of Healthcare Standards For Hospital.” yet completed. 9 cases 2007 / 08 Associated Infections (DH 2006) Better Health final declaration (April 9 cases of 2008) clostridium difficile during Commissioning 2007 / 08 Forum May 2008 PRINCIPAL OBJECTIVE FOUR CONTINUED Principal Description of all associated Key Controls Assurances Gaps in Risk Action plan and Board lead objectives risks on controls controls rating implementation (L x C) date To be an effective RNOH is a full Standards For Non identified. 3 x 3 = 9 Achieve key targets: Acting and efficient member of the Better Medium Key target 7 Director of provider of specialist Healthcare (C Action plan Zero pressure sores Nursing orthopaedic and orthopaedic 4A, 13, 14, 15, developed incurred in RNOH musculo-skeletal hospital’s alliance 16) following the HCC (31.03.08) services. (established 2005) inspection report at Updated May 2008: 0 Maidstone and pressure ulcers during Clinical Audit Tumbridge Wells March 2008 Lead NHS Trust (Board November 2007) The reason for non Annual Infection compliance relates to Control the inherent design of Programme (Board the buildings and estate, 2007) but these design issues cannot be fully Failure to fit into Trusts financial strategy Patient Satisfaction addressed until the site if the prices attributed to the complex Survey (Nov 2005) is re-developed. (2011 orthopaedic procedures under the – anticipated date for Payment By Results tariffs do not cover Provider completion of site re- the costs of such procedures. Sustainability Plan development) – November 2005. Failure to provide healthcare in Page 21. Implement and monitor partnership with patients, their carers and Trusts infection control relatives, respecting their diverse needs, Pathology contract action plan. To be preferences and choices, and in provided by Barnet monitored by Trust partnership with other organisations & Chase Farm Board and Infection (especially social care organisations) NHS Trust Control Committee. whose services impact on patient well- (April 2008) being.

16 17 3.4 PRINCIPAL OBJECTIVE FIVE Principal Description of all associated Key Controls Assurances on Gaps in Risk Action plan and Board lead objectives risks controls controls rating implementation (L x C) date To achieve Failure to achieve activity targets. Annual Financial Recovery Plan (3 Explicit annual 4 x 5 = 20 The 06/07 – 09/10 Director Of financial balance Plan - Provider year plan May budget holder sign High Business Plan (PSP) Finance and maintain Failure to secure a rate of reimbursement, Sustainability 2005, updated 5 off has been agreed by liquidity with regards to the national tariff that Plan (3 year plan year plan draft 23rd Board and the 0//08 accurately reflects the real cost of the May 2005, November 2005, Budget holder Budget will be specialist treatment provided. updated 5 year 10 year financial training submitted to the March plan draft 23rd plan in OBC 2nd 2007 Board. The Trust Reduction in Service Level Agreement November 2005, December 2005) More sophisticated has plans to deliver income by Primary Care Trusts (PCT’s). 10 year financial forecasting based financial surpluses in plan in Outline Budget setting on inpatient cases 06/07 and 07/08 to Inability of PCTs to pay for additional Business Case process. booked for the restore financial activity delivered within contract terms. (OBC) 2nd remainder of the stability but this December 2005) Monthly financial year. remains a significant Failure to identify all end of year cost monitoring reports challenge and the Trust pressures. Training for - monthly Detailed budget still needs to fully budget holders. reporting to setting process and resolve the payment by Failure to achieve Foundation Trust Finance service results tariff loss issue status. Cost Committee, development and by 08/09. improvement reviewed by business case Failure for the projected increase in programmes (e.g Board and SHA. approval process Continue to collaborate Director Of volume of specialist orthopaedic activity theatre not in place with Specialist Finance to materialise. procurement, Activity reports – Orthopaedic Alliance pharmacy spend, weekly reports and DOH regarding Failure of Trust to be able to deliver car parking available on resolving payment by activity at a cost in line with the national strategy) Refer to Trust’s intranet. results issues. (On tariff and ultimately achieve a page 32 of going) contribution from additional activity Provider Weekly bank levels required for the new hospital in Sustainability /agency Ensure all PCT Director Of 2010/2011. Plan – November monitoring tool contracts signed and Finance 2005. being reviewed information / billing every 2 weeks by flows delivered in line Bank & Agency with National review meeting. Timetables – on going quarterly national timetable.

18 PRINCIPAL OBJECTIVE FIVE CONTINUED Principal Description of all associated Key Controls Assurances on Gaps in Risk Action plan and Board lead objectives risks controls controls rating implementation (L x C) date To achieve Failure to repay £3.8m relating to the Project plans to Proposals from 4 x 5 = 20 Achieve key target: Director of financial balance 04/05 deficit. The ability to do this is deliver land sales Green & Kessab High Key target 1. Finance and maintain dependent on land sale receipts in 05/06 (Director Of regarding further £2.5m surplus achieved liquidity (£1.75m) and 06/07 (£2.08m) – the main Estates November savings that are by 31 March 2008 risks here are associated with the timing 2005) potentially of receipt associated with planning available should Achieve key target: Director of consent timescales and not the sale Activity Model there be any Key target 2. Human receipt itself. (OBC – December shortfall on cost Payroll cost to be kept Resources 2005) improvement within financial plan programme and below £3,473k for delivery. March 2008 (31.03.08) Work with Failure to contain redevelopment project Assessment of Orthopaedic Achieve key target: Director of expenditure within available funding redevelopment Alliance & DOH. Key target 3. Operations and sources. project costs. Activity target – 9,968 Service (OBC – December Internal audit. inpatients discharged Improvement 2005) (31.03.08) External audit. New Clinical Achieve key target: Director of Directorate Key target 8. Finance Structure Limit loss making implemented activity to level of October 2005. transitional funding a) Maintain current ratio of R03 to R10 (i.e. not above 0.90) b) Limit soft tissue sarcoma activity to 2004 / 05 levels (31.03.08)

19 3.5 PRINCIPAL OBJECTIVE SIX Principal Description of all associated Key Controls Assurances Gaps in controls Risk Action plan and Board lead objectives risks on controls rating implementation (L x C) date Develop and Lack of engagement of staff – in Ad hoc Board Individual Ad hoc reporting to 2 x 4 = 8 Modernisation Director of implement the particular clinicians. reports. (Pre- appraisals and Board. There is no Medium initiatives have been Operations and modernisation plan Operative objective setting. robust framework in brought together in the Service – bringing about Lack of resource – financial and assessment, place, but there has CSIP. Implement action Improvement changes in clinical workforce issues and in turn failure to September 2005) SHA been an increase in plan, monitor and practice and increase capacity (refer to objective performance performance review. (31.03.07) organisation to two) Outline Business monitoring the reporting to the increase Case For Trust. Board regarding Continue to develop the Director of productivity. Begin Failure to reduce patients length of stay Redevelopment outcomes e.g. length Clinical Development Operations and to implement new through managed discharges and the use describes the Standards For of stay, Programme. (31.03.07) Service model of care. of process templates. Failure to achieve activity, workforce Better Healthcare cancellations. Improvement this objective will negatively impact on and financial (C22, C23, C24) the achievement of financial and access projections for the targets. next 10 years. Sir John Temple Report. No coherent overall strategy in place. Provider (July 2005) Sustainability Plan Capability issues relating to staff. – November 2005 CSIP Reported – page 19. to Trust Exec Lack of dedicated day case facilities and Board every reduces the Trusts efficiency and does The Modernisation month (May not assist with the achievement of Agency “10 High 2006) financial and access targets. Impact Changes.” (HIC)

Standards For Better Health final declaration (April 2008)

18 week project plan and project management meetings (every two weeks)

20 PRINCIPAL OBJECTIVE SIX - CONTINUED Principal Description of all associated Key Controls Assurances Gaps in controls Risk Action plan and Board lead objectives risks on controls rating implementation (L x C) date Develop and Failure to design and deliver Waiting List 3 x 4 = 12 Achieve key target: implement the programmes and services in Policy (December High Key target 3. modernisation plan collaboration with all relevant 2005) Activity target – 9,968 – bringing about organisations and communities to inpatients discharged changes in clinical promote, protect and improve the health Develop the skills (31.03.08) practice and of the population served and reduce of managers with organisation to health inequalities between different regards to Achieve key target: Director of increase population groups and areas. modernisation Key target 8. Operations and productivity. Begin developments. Limit loss making Service to implement new SHA programme activity to level of Improvement model of care. has been attended transitional funding by nominated a) Maintain individuals. current ratio of Director of (Completed July R03 to R10 Finance 2006) (i.e. not above 0.90) SHA b) Limit soft modernisation tissue sarcoma programme activity to attended by senior 2004 / 05 managers (July levels 2006) (31.03.08)

21 3.6 PRINCIPAL OBJECTIVE SEVEN Principal Description of all associated Key Controls Assurances Gaps in controls Risk Action plan and Board lead objectives risks on controls rating implementation (L x C) date To achieve full Failure to ensure effective and efficient Centralised Standards For Individuals failing to 3 x 4 = 12 Project team to work Director of compliance with utilisation of available capacity. booking. Better fully comply with High through implementation Operations and the national Healthcare (C17, Trust policies and of 18 week pathway by Service waiting list targets. Failure to ensure flexible capacity levels Policies and C18, C19, D11) procedures. 2008. (Part of Clinical Improvement to ensure that fixed costs can be stepped procedures System Improvement up or down in line with activity variations (Waiting List Reports to every Plan - CSIP) from the base case. Policy – Trust Board December 2005) (May 2006) Work with PCT’s to Director of Failure to ensure that patients receive ensure agreements are Operations and services as promptly as possible, have ICS (Integrated Weekly waiting reached about Service choice in access to services and Computer list Potential additional activity Improvement treatments, and do not experience Services) Breach List needed and unit targets. unnecessary delay at any stage of service (PTL) reporting (March 2008) delivery or of the care pathway. Standards For to SHA. Better Health Work with PCT’s to Director of Failure for a tariff to be set at a level that final declaration Data Quality ensure agreements are Operations and will adequately support the funding of the (April 2008) Review Of reached about Service specialist activities that the Trust Waiting Lists additional activity Improvement undertakes. Project Plan (18 (PKF) (March needed and cancer Week) Project 2006) targets. (March 2008) Board (monthly) Achieve key target: Director of Waiting List Key target 4. Operations and Meeting No breaches of current Service (weekly) inpatient and outpatient Improvement access targets. Theatre (31.03.08) Scheduling Meeting Achieve key target: Director of (weekly) Key target 5. Operations and Achieve 18 week target Service Operational (31.03.08) Improvement Managers Group Meeting (weekly)

22 PRINCIPAL OBJECTIVE SEVEN CONTINUED Principal Description of all associated Key Controls Assurances Gaps in controls Risk Action plan and Board lead objectives risks on controls rating implementation (L x C) date To achieve full 18 Week Team 5 x 3 = 15 18 week data validation Director of compliance with Meeting Medium to be completed. Operations and the national (Weekly) (On-going) Service waiting list targets. Update: March 2008 Improvement Support through 82% of validation line management completed but new the Centralised priorities have Booking Unit to emerged which are ensure that been addressed targets can be achieved using PTL and relevant reports to monitor progress.

Specific data validation plan for March.

23 3.7 PRINCIPAL OBJECTIVE EIGHT Principal Description of all associated Key Controls Assurances Gaps in controls Risk Action plan and Board lead objectives risks on controls rating implementation (L x C) date Develop and Failure of Information Management And Provider IT Infrastructure Lack of development 4 x 4 = 16 Continue to seek Director Of implement a Technology (IM&T) to contribute to the Sustainability Review. 5th and training of IT High approval of process and IM&T cohesive and business strategies of the Trust and Plan – November October 2005. staff, so more funding from Board. integrated IM&T facilitate the delivery of the national 2005 (page 23) reliance on external (On-going) Strategy. targets. Controls suppliers / Development assurance – self contractors than there Document long term Failure of IM&T to facilitate the delivery Plan 2006 – assessment should be. technical strategy. of the Trust’s operational requirements. 2009 (March against IM&T 2005) standard (2005) Security is poor A subset of funding has Failure of IM&T to support seamless (Refer to OT been approved so that clinical and patient care. PACS Project Information Technical minimum work can be Office. Governance Infrastructure Review undertaken during 2006 Failure to prepare for and support the Audit (Internal October 2005) – 2007 (April 2008) implementation of National Programmes Detailed project Audit Report – for IT. plans for PACS Draft – October No disaster recovery / Implement action plans and 2006) business continuity – monitor and review Failure to secure funding. infrastructure plan in place. (On-going) upgrades. Funding for specific Digitalisation PAS has not been Policy approved.

PACS risk register

Costing Model for PAS (November 2006)

Improving Information Project Steering Group Meetings (24th November 2006)

24 3.8 PRINCIPAL OBJECTIVE NINE Principal objectives Description of all Key Controls Assurances Gaps in controls Risk Action plan and Board lead associated risks on controls rating implementation (L x C) date Redevelopment of the Failure to meet costs / Regular reports Robustness of Outline Business 5 x 5 = 20 Continue to work with Director of RNOH Stanmore campus affordability. to Executive and costs – Quantity Case (OBC) not High SHA, address Finance. Chief to provide a modern Trust Board and Surveyor approved by SHA. affordability issues. Executive. healthcare building. Project Board (Nisbet)advisor (Ongoing) Director of Regular is experienced in Continue to lobby Projects, meetings and Private Funding centrally to get tariff Estates and correspondence Initiative (PFI). at realistic rate. Facilities between Trust Process cost of and SHA. scheme DOH testing Gain support for Director of benchmarked affordability /scope revised scheme from Finance. Chief Meetings with against other PFI of all PFI schemes. PCT’s , UCL, Institute Executive. the Capital projects. Director of Investment Unit Projects, – SHA Activity being Estates and remodelled by Facilities RNOH RKW and OBC(March benchmarking. Develop joint academic Director of 2008) strategy with UCL Finance. Chief Architectural Executive. drawings Director of Decision made (Devereux) Estates and by SHA to Facilities pursue Stanmore Letter received total from London Develop a revised Director of development as SHA (January scheme and OBC with Finance. Chief preferred option 2007) affordability envelope Executive. and no other site Updated May 2008: Director of options are to be Review impact Submitted April 2008 Projects, considered. of reducing Estates and (January 2008) scheme and Facilities exploring phased Achieve key target development Key target 10 Director of plan ready for Gain approval from Projects, SHA review SHA for hospital Estates and scheduled for rebuild Facilities Completed January 25 January 2007. 2008 Completed

PRINCIPAL OBJECTIVE TEN Principal objectives Description of all Key Controls Assurances Gaps in controls Risk Action plan and Board lead associated risks on controls rating implementation (L x C) date To achieve Foundation An outcome of the SHA review Trust Board External advisors SHA Review 4 x 4 = 16 Implement the Director of Trust status that would suggest that RNOH will (monthly) High Foundation Trust action Finance, not continue to be stand alone. SHA plan (DH application Director of Executive 1st November 2007; Projects and Directors Nomination 31st Estates and meeting December 2007) Facilities, Chief Foundation Trust Executive Steering Group Private Patient Income cap – the (monthly) Trust needs to retain financial Update financial plan to Director of viability but with PP income meet PP income cap by Finance restricted to 2002/03 levels 1st November 2007 Updated November 2007: COMPLETED

Reflect HR Workforce Director of Model and fixed asset Finance model in long term financial model. (30th November 2007) Updated February 2008: Completed but fixed asset model needs to be more fully integrated (September 2008)

Achieve key target Director of Key target 10 Finance Hit all milestones in Foundation Trust

26 timetable (30.04.08)