Public Board papers 31.03.22

Appendix 2 BOARD ASSURANCE FRAMEWORK 2022-23

Corporate objective 1 - To demonstrate excellent and equitable clinical outcomes and patient safety, patient experience and clinical effectiveness for those patients living with and beyond cancer

Gaps in assurance

Risk appetite

Principal Risks

Key Control established

Assurance

Exec Lead

Key Gaps in Controls

Number

Likelihood

Impact

Current Risk Score

Opening Position

Position at end of Q1

Position at end of Q2

Position at end of Q3

Position at end of Q4 Target risk score

Target date for completion

4 NIPR meetings continuing. Levels reported through performance report to Management Board and Board of Directors and quarterly to NHS Improvement. IPC BAF presented to Board Jan 22. 6 Management Board and Board of Directors monthly Integrated performance and quality report. National survey results presented to Board of Directors. Action plans monitored through the Patient Experience Committee

Patients with known or suspected HCAI are isolated. Medicines management policy contains prescribing guidelines to minimise risk of predisposition to C-Diff & other HCAI's. Need to maintain low levels of Gram negative bacteraemia. RCA undertaken for each known case. Induction training & bespoke training if issues identified. Close working with NHS England at NIPR meetings. Monthly patient satisfaction survey undertaken and reported through performance report. Negative comments fed back to specific area and plans developed by ward leaders to address issues. Action plans developed and monitored from national surveys. Complaints and PALs procedures in place. Collaborative projects in place. All falls come through executive nursing panel process. Call don't fall initiative. Falls group. Introduction of the TAB system. Executive review group looks at attribution of avoidable / unavoidable. Trust aim to maintain 16/17 levels. System for assessment of ulcers / grading used. Training across the trust (focus on theatres/critical care). NHSI criteria for assessment & expectations around pressure ulcers - internal review undertaken.New NHSI requirments for reporting pressure ulcers from Nov 18, reported from Dec 18. Maintain low rates of catheter associated UTI's and maintain 95%+ VTE assessments. Increase in low harm Clinical Advisory Group in place.Updates to all staff. Daily monitoring of staffing / patient impact. Following national guidance and internal escalation process. Leading cancer care through the Cancer Hub. Biosecurity measures on site to maintain a COVID secure environment. Adherence to surgical standards around safe surgery during COVID-19. Continued planning for next phase in terms of capacity & demand. Modifications made to treatments as approved through Clinical Adsvisory Group. Review of harm undertaken.

None identified. No formal threshold set by commissioners.

1.1 Risk to patients and reputational risk to trust of exceeding the HCAI thresholds

CN&EDoQ 2 2

None identified Low

0

Year end

Failure to learn from patient feedback (patient satisfaction survey / external patient surveys / complaints / PALS)

1.2

None identified Low

CN&EDoQ 2 3

None identified

4

6 Regular reports to Quality Assurance committee and board (through the integrated performance report).

1.3 Risk of exceeding the thresholds for harm free care indicators (falls, pressure ulcers) CN&EDoQ 2 3

None identified

None identified Low

4

Clinicl Advisory Group meeting regularly. Regular trustwide communications to staff. Biosecurity measures under weekly review. Regular communication with internal and external stakeholders. Reports to Board. Weekly briefings to Board throughout peaks of pandemic.

Uncertanties associated with the virus & the timeframes of the impact 9

8

None identified Low

1.4 Impact of the COVID-19 pandemic on clinical outcomes, safety and experience

CN&EDoQ 3 3

Corporate objective 2 - To be an international leader in research and innovation which leads to direct patient benefits at all stages of the cancer journey

Gaps in assurance

Risk appetite

Principal Risks

Exec Lead

Key Control established

Key Gaps in Controls

Assurance

Likelihood

Impact

Current Risk Score 12 Weekly review of performance. All industry metrics reported through to the Research Divisional Board and Management Board. Strategic elements regulalry reviewed through the CRSC

Opening Position

Position at end of Q1

Position at end of Q2

Position at end of Q3

Position at end of Q4 Target risk score

Target date for completion

Performance management system in place to track real time delivery; set-up review group in place to make recommendations for improvements; regular review at weekly operational meetings; SLAs established with each service department involved in set up and delivery. Director of Research & Innovation appointed March 2021. Regular review of DG level pipeline. Regular dialogue with national funding organisations on potential impact; open dialogue with strategic pharma partners; strong academic investment strategy to retain and attract world leading academics. Reporting to NHSE/I as and when required. Engaging in national webinars and updates. Sign up to regulators alerts - legislative changes assimilated into local processes as they arise. Any associated risks discussed and communicated. Programme board established with UoM & CRUK. Funding plan agreed in principle. Preliminary review to Board in June 18. MoU finalised. Detail at each Board. Draft full business case (FBC) to November Board, FBC approval to Jan 19 Board. Additional board sessions to discuss complex case. Planning application will be considered in late August by Manchester City Council. Development agreement signed. GMP approval planned for November. Project Board working on affordability - progress on value engineering and VAT position. Full business case approved at November BoD. Development Agreement unconditional. Build continues on plan and budget.

Disruption to delivery of the Research strategy due to the impact of COVID 19 creating strategic, financial and operational risks

Uncertainty around impact of COVID-19

2.1

EMD 3 4

None identified Medium

4

Risk to research profile and output through reduced funding & changes to clinical trial legislation as a result of EU Exit

Oversight of potential legislative impact and consideration of any impact from COVID-19 pandemic

8 Levels of risk and mitigation reported through Research Division Board and Christie Research Strategy Committee None identified Medium

2.2

EMD 2 4

8

Uncertainty around impact of COVID-19.

EDoF&BD /

10 Regular reports to Board & Audit Committee

10

None identified Low

2.3 Failure to deliver the Paterson building replacement

EMD 2 5

128