Public Board of Directors papers 27.01.22

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0 Board agenda 27.01.22	1
01-22c Draft Board minutes 25.11.21	2
Safe	4
Responsive / Access	4
Effective	5
Well – Led	5
01-22d Action plan rolling programme	10 - 11
2021-22	10 - 11
01-22d(ii) Action log - Public items	14 - 15
02-22b Rapid Review Board final paper	16
02-22bi Letter_Chris Outram_The Christie	42
02-22bii Christie Rapid Review V1 FINAL 20211115 (002)	43
1 Background 1-2	44
2 The Review Team’s response to the Terms of Reference 2	44
2.1 ToR 1 How the Trust responded to the review conducted by Wendy Fisher, which highlighted issues in management and culture within the R&I Division in 2018.	44
2.2 ToR 2 How the Trust handled the review into concerns raised about the R&I3 Division in 2020, including whether the people that raised concerns suffered detriment as a result of speaking up.	44
2.3 ToR 3 How the Trust handled allegations concerning the sharing of patient 7 data with Roche through the Foundation Medicine (FM) programme and Flatiron in and around 2018-date. Including whether people that raised concerns suffered detriment as a ...	44
2.4 ToR 4 Whether there was a failure at the Trust to engage with clinicians 7	44
in relation to commercial partnerships to ensure that:	44
4. ToR 6 In the context of these issues consider what learning the Trust should 17-18	45
1. Background	46
2. The review team’s response to the Terms of Reference	47
2.1.1 Recommendations	47
2.2 ToR 2 How the Trust handled the review into concerns raised about the R&I division in 2020, including whether the people that raised concerns suffered detriment as a result of speaking up.	48
2.2.1 Collective concerns raised with the Freedom to Speak Up Guardian (FTSUG) in February 2020	48
2.2.2 Other contacts with the FTSUG	49
2.2.3 Observations on the FTSU process	50
2.2.4 Recommendations regarding the FTSU process	50
2.2.5 The general matter of raising concerns and suffering detriment	50
2.2.6 The types of concerns that had been raised by staff	51
2.2.7 Perceptions on the way concerns were handled	51
2.2.8 Perceived detriments as result of speaking up	51
2.2.9 Observations on raising concerns	51
2.2.10 Recommendations regarding raising concerns	51
2.3 ToR 3 How the Trust handled allegations concerning the sharing of patient data with Roche through the Foundation Medicine (FM) programme and Flatiron in and around 2018-date. Including whether people that raised concerns suffered detriment as a re...	52
2.3.1 Observations	52
2.3.2 Recommendation	52
2.4 ToR 4 Whether there was a failure at the Trust to engage with clinicians in relation to commercial partnerships to ensure that:	52
2.4.1 Background	52
2.4.2 Project management	53
2.4.3 Comments and reactions to this partnership have been received from a number of sources:	54
2.4.3.1 ’Concerns in the R & I Division’ (February 2020)	54
2.4.3.2 Comments in correspondence and meetings with medical oncologists May 2020 onwards	54
2.4.3.3 Non-Executive Director’s “Freedom to Speak Up – a Review June 2, 2020”	54
2.4.3.4 ’Independent Assessment of the Progression of Real-World Evidence/Big Data Partnership Opportunities at The Christie 2018-2020’ (December 2020)	55
2.4.3.5 Report to The Christie Management Board by a Medical Director – 24 September 2020	55
2.4.4 Allegations of financial irregularity in relation to the commercial partnership	56
2.4.5 Observations	56
2.4.6 Recommendations	56
2.5 TOR 5 The appropriateness of recruitment decisions within the R&I Division during this period.	57
2.5.1 Jobs not advertised appropriately	57
2.5.2 Acting up/paying higher grades	57
2.5.3 Contract renewal issues	57
2.5.4 Staffing levels and skill mix	57
2.5.5 Turnover in the R&I Division	57
2.5.6 Recommendations	58
3. Matters not included in the rapid review’s Terms of Reference	58
3.1 Leadership of the R&I Division	58
3.1.2 Research strategy	58
3.1.2.1 Observation	58
3.1.2.2 Recommendation	58
3.1.3 Reconfiguration of clinical research management	58
3.1.3.1 Observation	59
3.1.4 Relationships and behaviours in the R&I Division	59
3.1.4.1 Observations	59
3.1.4.2 Recommendations	59
3.2 Bullying and harassment	60
3.2.1 Types of incidences	60
3.2.2 Observation	60
3.2.3 Recommendations	60
3.3 Concerns about racist behaviours	60
3.3.1 Recommendations	61
3.4 Board of Directors’ oversight	61
3.4.1 Observation	61
3.4.2 Recommendations	61
3.4.3 Important Note:	62
4. ToR 6 In the context of these issues consider what learning the Trust should consider and make recommendations in that respect.	62
5. Acknowledgements	63
03-22a RM strategy cover paper	64
03-22ai Risk Management Strategy Framework 2021 Draft v04	66
1.0 Associated documents	69
2.0 Introduction	69
2.1 Statement of intent	69
2.1.1 Risk appetite	70
2.2 Equality Impact Assessment	70
2.3 Good Corporate Citizen	70
2.4 The Christie Commitment	70
2.5 Purpose	70
2.6 Scope	71
3.0 Definitions	71
4.0 STRATEGY	73
4.1 Objectives of this strategy 2021-2024	73
SECTION TWO RISK MANAGEMENT POLICY	80
5.0 Duties	80
5.1 Board of Directors	80
5.2 Chief Executive	80
5.3 Executive Directors	80
5.4 Non-Executive Directors	80
5.5 Individuals with specific responsibilities for risk management	80
5.5.2 Divisional Teams	80
5.5.3 Health, Safety and Emergency Planning Lead, Patient Safety and Risk Lead and Patient Experience Lead	81
5.5.4 Patient Safety and Risk Team	81
5.5.5 Divisional Governance Leads	81
5.5.6 Responsibility of all Employees, Agency and Contractors (“Staff”)	81
6.0 Committees and sub committees with risk management responsibilities	81
6.1 Quality Assurance Committee	81
6.2 Audit Committee	81
6.3 Management Board	82
6.4 Risk and Quality Governance Committee (R&QGC)	82
6.5 Patient Safety Committee	82
6.6 Patient Experience Committee	82
6.7 Clinical & Research Effectiveness Committee	82
7.0 SUPPORTING POLICY	83
7.1 Board Assurance Framework	83
8.0 LEVELS OF RISK MANAGEMENT ACROSS THE TRUST	83
8.1 Board & corporate level	83
8.2 Divisional level	83
8.3 Clinical and non-clinical departmental level	83
9.0 ACCOUNTABILITY AND REPORTING STRUCTURES	84
10.0 RISK MANAGEMENT APPROACH	84
10.1 Just Culture	84
10.2 Duty of Candour	84
10.3 Reporting Concerns	84
11.0 Process for the Management of Risk	84
11.1 Proactive risk processes	84
11.2 Reactive risk processes	85
12.0 systematic risk assessment approach	86
12.1 Risk Identification and Categories of Risk	86
12.2 Risk quantification & assessment	87
12.3 Risk evaluation	87
12.4 Risk ranking, risk acceptability and management responsibility	88
13.0 RISK REGISTER	89
13.1 Corporate risk register	90
13.2 Divisional and Departmental risk registers	90
13.3 Review of the organisation-wide risk register	90
13.4 Escalation of Risk	90
14.0 Aggregating data and learning from incidents, complaints and claims	90
14.1 Monthly report to Board of Directors and Management Board	91
14.2 Quarterly aggregated patient safety & experience report	91
14.3 Process for communicating reports/learning points	92
15.0 Consultation, approval and ratification process	92
16.0 Dissemination & implementation	92
16.1 Dissemination	92
16.2 Implementation	92
16.3 Training/Awareness	92
17.0 PROCESS FOR MONITORING EFFECTIVE IMPLEMENTATION OF THE STRATEGY	93
18.0 Version control sheet	95
19:0 APPENDICIES	98 - 99
Appendix 1: Risk management strategy	98 - 99
Appendix 2: Trust accountability structure – 2021	100 - 101
Appendix 3: Trust Organogram - 2021	102 - 103
Appendix 4: Annual Audit of Committee effectiveness template	104
Appendix 5 – Incident and risk grading Tool	107
04-22a IPC BAF cover paper.pdf	111
04-22a IPC BAF without evidence	112 - 113
04-22b IPQFR December 2021v2	198 - 199
Slide Number 1	198 - 199
CONTENTS	200 - 201
EXECUTIVE SUMMARY	202 - 203
SUMMARY DASHBOARD	204 - 205
SUMMARY DASHBOARD	206 - 207
1.1 - Incident Reporting	208 - 209
1.2 - Serious Incidents and Never Events	210 - 211
1.3 – Moderate+ Incidents	212 - 213
1.4 – Learning - Patient Safety Incidents	214 - 215
1.5 - Radiation Incidents	216 - 217
1.6 – Harm Free Care	218 - 219
Slide Number 12	220 - 221
Slide Number 13	222 - 223
Slide Number 14	224 - 225
Slide Number 15	226 - 227
3.1 - Cancer Standards	228 - 229
3.2 – Referrals Analysis	230 - 231
3.3 – Length of Stay	232 - 233
3.4 – Activity	234 - 235
3.4 – Activity	236 - 237
3.5 - Complaints	238 - 239
3.5 - PALS	240 - 241
3.6 - Inquests	242 - 243
3.7 - Claims	244 - 245
4.1 - Healthcare Associated Infections	246 - 247
4.1 - Healthcare Associated Infections	248 - 249
4.2 – COVID-19 Testing	250 - 251
4.3 - Mortality Indicators & Survival Rates	252 - 253
4.4 - Quality Improvement & Clinical Audit	254 - 255
4.5 - NICE Guidance	256 - 257
4.6 - HR Metrics (Sickness)	258 - 259
4.7 - HR Metrics (PDRs & Essential Training)	260 - 261
4.8 - Workforce Metrics	262 - 263
5.1 - Finance (Executive Summary)	264 - 265
5.2 - Finance (Income)	266 - 267
5.3 - Finance (Expenditure)	268 - 269
5.4 - Finance (Capital)	270 - 271
04-22c BAF cover paper	272
04-22ci BAF	274 - 275
Sheet1	274 - 275

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