Service Risk Register

					Source of risk
					Analysis of incidents, complaints, claims and staff absences	0
					Audits	1
					Corporate Objectives	2
					Exit interviews	3
					Healthcare Commission baseline assessments	4
					Incident, complaints and claims reporting	5
					Media
					National reports
					New legislation
					Patient and Public Involvement Forum
					Reports from external assessments/inspections by external bodies
					Risk Assessment
					SABS hazards and other alerts/safety notices
					Service reviews
					Service user satisfaction surveys
					Staff Surveys
					Team meetings
					Training
					Workplace surveys















Directorate:		Finance and	Informatics
Lead :		Lois Lere
Project Risk Log
Project Name: SUMMARY CARE RECORDS
Project Manager: David Payne

(Note: To create an easier view of the actions/ progress, you can create a new text line within a cell or insert a space between each item by pressing the 'Alt' and 'Enter' keys when typing or editing the text
						Original				Target				Current
Corporate Objective no.	RR no.	Date	Description of Risk	Impact Description	Source of risk	Org. Consequence	Org. Likelihood	Original Risk Rate	Actions being taken to reduce risks (Including date to be completed by)	Target Consequence	Target Likelihood	Target Risk Score	Progress on action including date updated	Current Consequence	Current Likelihood	Current Risk rating	Open/ Closed
	SCRR2	15.12.08	Delayed or inadequate Stakeholder Engagement will lead to a lack of uptake and awareness across the health economy	Lack of awareness across stakeholder groups will reduce patient awareness and ability to make informed choice and HealthSpace uptake	Risk Assessment	4	2	8	Approved Communications Plan and Communications Matrix Confirm/Organise stakeholder event. Further direct briefings. New revised Communications Plan.	2	2	4	Stakeholder mailout to 700 stakeholders completed 10.02.09 as part of PIP. 06.04.09 Pai Tang started as Engagement and Change Lead. 22.05.09 Communications Strategy issued for review, engagement activities ongoing.	3	2	6	Open
	SCRR3	15.12.08	Lack of clear messages from CfH regarding the consent model and other key messages will compromise clinical stakeholder engagement and uptake	Lack of uptake and willingness to participate by GPs. Confusion of messages to both clinicains and patients	Risk Assessment	4	3	12	Escalated to CfH lead and via SHA. Receipt of all available CfH documentation. Board and internal discussions. Sufficient clarity to progress to the Pilot PIP. Attendance at a Consent Model workshop 18th March 09. Escalation face to face meeting via SHA planned for 31.03.09 and Action Plan presented by CfH. Ongoing escalation to CfH via SHA.	2	2	4	Being escalated urgently via SHA to CfH. This is being raised on regular ongoing conference calls, most recent 23.03.09. Attended SHA consent workshop 18.03.09. Attended ttend SHA/CfH escalation meeting 31.03.09. Action Plan presented including agreement to produce a full written consent model. Still no clear document has been presented by CfH, detail remains very vague around the upload of more detailed supplementary data. 08.05.09 awaiting feedback from CfH via SHA. 21.05.09 Reported at the SHA Leads Forum that still awaiting a detailed written consent model.	4	4	16	Open
	SCR R5	05.01.09	Inadequate Executive ownership of the Project, at both PCT and SHA level, will cause inadequate ownership of risks, escalation of issues to CfH and provision of project resources	Poor project governance, management and escalation of risks and issues. Ineffective decision making.	Risk Assessment	5	1	5	Establish an effective Project Board and Governance structure, engage fully at K&M and SHA level with project groups.	1	1	1	Regular Board meetings and 1:1 meetings with SRO.	2	1	3	Open
	SCR R6	05.01.09	Indadequate Project resources and skills will delay and compromise effective delivery of all required workstreams	Inadequate project deliverables, delays, failure to meet quality standards	Risk Assessment	4	2	8	Ongoing review of requirements with SRO. Effective communication and working with IPO. Resource Plan drafted for SRO review. Recruitment of Engagement and Change Lead.	1	1	1	Resource Plan approved by SRO 06.03.09. Engagement and Change Lead started 06.04.09. RA Lead started 01.03.09. 22.05.09 LIS funding for the project identified as less than expected though no impact on staffing identified. Revised staff resourcing agreed with SRO.	2	1	2	Open
	SCR R7	07.01.09	Lack of successful communication to vulnerable and hard to reach patient groups may compromise the equity of roll out and mean all patients are not fully enagaged to inform the consent decision	Certain patient groups will not be given the opportunity of informed consent	Risk Assessment	3	2	6	Stakeholder engagement event, drop in sessions, further Communications planning	1	2	2	Mailout to external stakeholder groups and organisations 10.02.09 coincided with Patient Mailout. No current plan for an engagement event. 22.05.09 New Communications Strategy has been issued for final review..	2	2	4	Open
	SCR R8	07.01.09	Negative messages from the media both nationally and locally, concerning wider personal data security may impact on stakeholder perception and take up	Negative impact on internal and external and patient stakeholders	Risk Assessment	2	4	8	Proactive early engagement with media and PCT and CfH Communications Leads via Media Brief released 10.02.09.	1	2	3	No adverse media stories received following the PIP. Radio interview held 19.02.09. No current identified change.	2	3	6	Open
	SCR R9	19.01.09	Deceased Patients are not removed from the GP and Exeter systems until notification from Births Deaths and Marriages, this may lead to the mailout still being sent to deceased patients	Cause distress to deceased patient families, may cause negative publicity for the PCT and project	Risk Assessment	2	5	10	Discussed with Practice Managers, numbers idientified as low. Names were sought but it was not possible to remove names from the exeter download, explained to Practice Managers.	1	1	1	Being monitored for impact.	1	2	3	Open
	SCR R11	15.01.09	The patient letter may not be fully and correctly worded and approved to provide the correct messages and choices to patients	Ambiguity of messages, reduced opportunity for informed patient choice	Risk Assessment	3	2	5	Will review during the PIP to assess required improvements	1	1	1	Review to be planned.	3	1	3	Open
	SCR R12	22.01.09	Expected Benefits and Benefits realisation Planning may not be identified and planned to effectively measure the benefit outcomes	It will not be possible to measure the impact on patient care and deliver the full potential of this solution.	Risk Assessment	3	3	9	Further engagement and working with K&M and SHA leads. Ongoing review via Project Board. Stuart Slyfield from the K&M Programme Office to produce a workpackage for Benefits Realisation planning.	1	1	1	Reviewed at Project Board. Requirement for a Benefits Realisation Plan identified for post First Wave. Stuart Slyfield has produced a first Draft BRP though no longer in post. Further work planned via the SHA.	2	3	6	Open
	SCR R14	19.02.09	A number of GP Practices will not implement or gain IM&T DES acreditiation within the required project timescales i.e. > 2yrs. This will mean full roll out cannot be achieved.	SCR will not be implemented in these Practices, full rollout will not be achieved and all patients will not have a SCR created.	Risk Assessment	4	4	16	Detailed profile of likely dates for acreditation within each Practice. Ensure Project Board informed of status. Medway IM&T LES has been agreed for 2009/10	2	4	4	Escalated at the Project Board. Planning ongoing with IM&T DES Lead to identify problem areas. Discussions with Barbara Moscrop, IM&T DES Lead. 08.05.09 Detailed planning and assessment of risk practices ongoing via Barbara Moscrop. 22.05.09 Being monitored via Project Board.	3	4	12	Open
	SCR R16	27.02.09	Following an iSoft open day, it is now apparent that the current iSoft Syngery build for SCR is based on the original consent model and not the assumed 'consent for all information' model we are following.	The current build may not match the requirement of the consent model currently we are using. The functionality and user acceptance may be compromised and delayed.	Risk Assessment	4	4	16	This has been escalated to the SHA and CfH. Raised at the iSoft Primary Care Open Day. Request made to CfH for a position statement and resolution. Escalation face to face meeting via SHA planned for 31.03.09.	1	1	1	Attended face to face meeting via SHA 31.03.09, awaiting supporting documentation and revised concept training. A new Synergy build looks unlikely in the meduim term (up to 12 months). A document has been produced by CfH but this does not fully explain how the upload of supplementary data will be managed. 08.05.09 this remains escalated to CfH via the SHA. 22.05.09 iSoft training awareness session delivered 12.05.09, workarounds identified, though impact on ability to manage suplemntary uploads remains unclear.	4	4	16	Open
	SCR R17	27.02.09	Practices may be required to synchronise all patients with the spine's PDS service before SCRs can be uploaded	The practice may have to manually synchronise all their patients with the PDS service on the spine. This could cause the surgeries to delay the upload, or ask for resources to cope with the extra work.	Risk Assessment	3	4	12	Investigate the PDS Synchronisation process with Isoft to see if it can be avoided, or the potential impact reduced. Ongoing detailed review with iSoft of requirements. Estimate of resources made to support GP Practices.	1	1	1	Clarity sought from iSoft/CfH, regular Con Calls with SHA/CfH, most recent 06.04.09. Discussed with First Wave Practices, planning the preferred apparoch. Awaiting a PDS process document from iSoft (08.05.09 still outstanding). CfH resource visit Medway to run through process 29.04.09. PCT funding support confirmed to Practices 01.05.09. First Wave Practices have PDS awareness provided by Stephan Coupland, work now ongoing at Napier Rd and Parks, Walderslade Village have requested additional staff support from PCT. 22.05.09 Progressing well at Napier Rd and Parks with in house resource and should meet the required timescales.	3	3	9	Open
	SCR R18	20.04.09	Funding for an Adastra upgrade to enable PDS and SCR within MedOCC has not been agreed by CfH. Adastra have provided a quote but no clear guidance has been received by CfH as to central funding.	Delay to the SCR availability in MedOCC. This will delay benefits to end users and reduce the scope of the SCR Project. Loss of potential key end user buy in.	Risk Assessment	4	3	12	Quote received from Adastra,. Escalated to SHA and CfH. Reviewed at the project Board 17.04.09 where agreement in principle was given to seek local funding. An options appraisal document produced to justify local funding in advance of CfH funding.	1	2	2	Raised att he SHA leads meeting 21.04.09. Options Appraisal sent to Lois Lere/Karen Morgan for comment. A PO has been raised for 1 days work to cover RA requirements. The options paper is going to the May Informatics Board. 07.05.09 paper reviewed by HIB, no decision given yet. 22.05.09 this order has now been raised at risk.	1	1	1	Open
	SCR R19	08.05.09	If national swine view warning is raised to level 6 pandemic, the CRS Helpline to the PIP will close and their may be pressure to postpone the SCR PIPs. Alternative local arrangements may be required to proceed.	The PIP may be postponed or local arrangements for a helpline may be required.	National reports	4	2	8	Monitor the situation via NHS Direct/CfH. Raise at Project Board and review contingency plans.	2	2	4	To raise at Project Board. Escalated to SHA (Becky Gayler) and CfH (Matt Watson). 22.05.09 being monitored.	4	2	8	Open
	SCR R20	22.05.09	Walderslade Village Practice may delay upload activities whilst procurement route for new single system to support new acquired practices are clarified.	This practice may delay the upload unitl the procurement is clarified, possible further major delay if a new solution is procured.	Risk Assessment	3	3	9	Being moniotred via informatics management.	1	1	1	22.05.09 discussion with Sue Wanstall to identifiy the current staus.	3	3	9	Open

Closed Risks

Source of risk

Analysis of incidents, complaints, claims and staff absences

Audits

Corporate Objectives

Exit interviews

Healthcare Commission baseline assessments

Incident, complaints and claims reporting

Media

National reports

New legislation

Patient and Public Involvement Forum

Reports from external assessments/inspections by external bodies

Risk Assessment

SABS hazards and other alerts/safety notices

Service reviews

Service user satisfaction surveys

Staff Surveys

Team meetings

Training

Workplace surveys

Directorate:

Finance and

Informatics

Lead :

Lois Lere

Project Risk Log

Project Name: SUMMARY CARE RECORDS

Project Manager: David Payne

(Note: To create an easier view of the actions/ progress, you can create a new text line within a cell or insert a space between each item by pressing the 'Alt' and 'Enter' keys when typing or editing the text

Original

Target

Current

Corporate Objective no.

RR no.

Date

Description of Risk

Impact Description

Source of risk

Org. Consequence

Org. Likelihood

Original Risk Rate

Actions being taken to reduce risks (Including date to be completed by)

Target Consequence

Target Likelihood

Target Risk Score

Progress on action including date updated

Current Consequence

Current Likelihood

Current Risk rating

Open/ Closed

SCRR1

15.12.08

Engagement with First Wave Practices will be compromised with a lack of engagement with iSoft as to system readiness. There will be workflow impact which needs to be understood by the GP Practice

May reduce willingness of user uptake until understood. May cause time constraints on GP workflow which may be unacceptable to the GP

Risk Assessment

iSoft have an 'open day' planned for 23.02.09. iSoft will attend the March SHA Project meeting. Further investigation with early adopter sites and direct iSoft engagement.

Risk closed, iSoft engagement risk now identifed in SCRR15

Closed

SCRR4

05.01.09

Failure to gain agreement and buy in from the First Wave Practices will delay the First Wave PIP and compromise user uptake

First Wave Practices will not participate in the Pilot

Risk Assessment

Discussions with Practice Managers to explain process. Concept Training delivered. First wave PIP commenced.

PIP commenced 10.02.09

Closed

SCR R10

15.01.09

The arrangements for the mailout may not be organised to meet the planned PIP start date

Missed Milestone, reduced credibility of the project, confused stakeholder messages

Risk Assessment

Effctive planning of the Mailout via KPCA, discussions and lessons learnt from other sites (e.g. Stoke, SW Essex). Mailout 10.02.09. Mailout 10.02.09

PIP mailout complete

Closed

SCR R13

05.02.09

CfH Funding remains unclear. Conflicting messages have been received from CfH and the SHA as to the exact funding we may receive. It had been agreed at 12k, then 12k per Practice was suggested. CfH will not clarify.

It will be difficult to plan the local funding requirement until clarification and confirmation is gained from CfH. Should not prevent project resourcing.

Risk Assessment

Continue to escalate, review at March Project Board. Escalated at Project Board and separately via CfH and SHA. No direct risk identified to the project. Formal request sent on 13.03.09 to CfH.

Confirmation received from CfH of 12k funding in total to be payed in April 09.

Closed

SCR R15

27.02.09

Dealys to the urgently required iSoft kick off meeting to plan work for the configuration of iSoft GP Systems to enable the SCR upload following the PIP. iSoft are reluctant to engage until authorised by CfH.

We will not be able to commence meaningful planning of iSoft activities until this meeting occurs and iSoft are enagaged. This may delay the upload process.

Risk Assessment

This has been escalated to the SHA and CfH via the Project Board. Raised at the iSoft Primary Care Open Day, where a willingness to meet was expressed by iSoft. Regular requests continue to CfH.

Kick off meeting held 06.03.09

Closed

Example Register

Source of risk

Analysis of incidents, complaints, claims and staff absences

Audits

Corporate Objectives

Exit interviews

Healthcare Commission baseline assessments

Incident, complaints and claims reporting

Media

National reports

New legislation

Patient and Public Involvement Forum

Reports from external assessments/inspections by external bodies

Risk Assessment

SABS hazards and other alerts/safety notices

Service user satisfaction surveys

Staff Surveys

Training

Workplace surveys

Service Area

Speech and Language Therapy

Responsible Officer / Service Manager

Joe Bloggs

Original

Target

Current

Corporate Objective no.

RR no.

Date

Description of Risk

Source of risk

Org. Consequence

Org. Likelihood

Original Risk Rate

Actions being taken to reduce risks (Including date to be completed by)

Target Consequence

Target Likelihood

Target Risk Score

Progress on action including date updated

Current Consequence

Current Likelihood

Current Risk rating

39601 *

The SLT room in the HHT Therapy services dept is isolated which can be a problem as staff see clients on their own who may become aggressive or behave inappropriately due to their injury or illness

Risk Assessment

** 12

Supply Personal Alarm for each therapist by 20/06/08 SLT team select suitable patients for late afternoon appointments by 27/06/08 Identify new clinical treatment room in busy area to avoid lone working by 01/09/08

** 2

SLT team reviewed appointment process with afternoon appointments in mind - 15/06/08 Personal alarms to arrive next week - 15/06/08 Management team to meet 23/07 to discuss possible relocation

** 12

39601 *

The SLT room in the HHT Therapy services dept is isolated which can be a problem as staff see clients on their own who may become aggressive or behave inappropriately due to their injury or illness

Risk Assessment

** 12

** 2

SLT team implemented new afternoon appointment process - 23/06/08 Personal alarms supplied to each therapist - 22/06/08 Management team agree possible relocation to East wing or Room H117 beginning October 07 - 23/07/08 Facilities investigating temporary panic alarm -25/07/08

** 8

39601 *

The SLT room in the HHT Therapy services dept is isolated which can be a problem as staff see clients on their own who may become aggressive or behave inappropriately due to their injury or illness

Risk Assessment

** 12

** 2

SLT team implemented new afternoon appointment process - 23/06/08 Personal alarms supplied to each therapist - 22/06/08 Panic alarm fitted -10/08/08 Move to East wing scheduled 18/10/08

** 6

39601 *

The SLT room in the HHT Therapy services dept is isolated which can be a problem as staff see clients on their own who may become aggressive or behave inappropriately due to their injury or illness

Risk Assessment

** 12

** 2

SLT team implemented new afternoon appointment process - 23/06/08 Personal alarms supplied to each therapist - 22/06/08 Panic alarm fitted -10/08/08 Move to East wing completed 10/10/08

** 2

** 0

Corporate Objectives


No	*Objective*	*Action to be Taken*	*Outcome*	*Timescale*	*Lead Director/ Officer*
1	To establish a World Class Commissioning (WCC) Development Programme	1.1 To undertake a self-assessment	1.1.1 Results known	Oct-08	Chief Executive
					Commissioning
					ALL
		1.2 To establish a Development Programme	1.2.1 Programme approved by the Board	Nov-08	Chief Executive
					Commissioning
					ALL
		1.3 To establish and manage the WCC Assurance Framework	1.3.1 Good rating achieved	Feb-09	Company Secretary
		1.3 To establish and manage the WCC Assurance Framework	1.3.1 Good rating achieved	Feb-09	ALL
2	To maintain a dynamic 5 year Strategic Commissioning Plan (SCP)	2.1 To refresh the 2007-12 5 year Plan	2.1.1 Update approved by the Board	Sep-08	Commissioning
		2.1 To refresh the 2007-12 5 year Plan	2.1.1 Update approved by the Board	Sep-08	ALL
		2.2 To participate in the national pilot SCP development programme	2.2.1 PCT’s plan meets national requirements	Sep-08	Commissioning
			2.2.1 PCT’s plan meets national requirements	Sep-08	ALL
3	To achieve the priorities in the NHS Operating Framework 2008/09.	3.1 To implement the PCT’s Operational Plan 2008/09:	3.1.1 All key targets achieved in line with vital signs trajectories and Local Area Agreement indicators	Mar-09	Chief Executive
		-�� Improving access;			ALL
		-�� Keeping adults and children well
		-�� Experience, satisfaction and engagement
		-�� Emergency preparedness
		-�� Cleanliness and healthcare associated infections
		3.2 To establish an Operational Plan for 2009/10	3.2.1 To clarify priorities for implementation and expenditure (board approved plan)	March 2009	Commissioning
					Finance
					ALL
4	To review and maintain the PCT’s financial model for medium term financial stability	4.1 To match projected capital and revenue budgets to five year and annual plans	4.1.1 Clear matching of service and financial plans	On-going	Finance
					Commissioning
					ALL
5	To develop a strategy in relation to health needs which informs commissioning intentions and Medway Renaissance planning	5.1 To complete a Joint Strategic Needs Assessment (JSNA)	5.1.1 JSNA agreed by Medway PCT and Council	July-08	Public Health
		5.1 To complete a Joint Strategic Needs Assessment (JSNA)	5.1.1 JSNA agreed by Medway PCT and Council	July-08	ALL
		5.2 To establish a prioritisation process for health and healthcare investment and dis-investment	5.2.1 Priority process agreed by the PCT and Council	Sep-08	Public Health
			5.2.1 Priority process agreed by the PCT and Council	Sep-08	ALL
		5.3 To develop a high level programme budgeting framework.	5.3.1 Expenditure and outcomes known across 23 disease groups	Nov-08	Public Health
					Finance
					Commissioning
		5.4 To develop a spatial framework mapping health need, service provision and estate to local areas	5.4.1 Health need mapped at local level	Nov-08	Public Health
					Finance
					ALL
			5.4.2 Spatial framework for estates based on health mapping	Feb-09	Finance
			5.4.2 Spatial framework for estates based on health mapping	Feb-09	Provider Development
		5.5 To agree local process for health impact assessments for regeneration	5.5.1 Process agreed	Sep-08	Public Health
			5.5.2 Improved integration with Renaissance Team	Aug-08	Provider Development
6	To undertake a ‘Choosing Health’ work programme to keep adults and children well	6.1 To establish smoking cessation QOF validation process	6.1.1 Increased referrals to Stop Smoking Service (SSS)	April 2008	Public Health
		6.2 To complete the Stop Smoking Service Strategy	6.2.1 Action Plan agreed	June 2008	Public Health
			Milestones met	On-going	Public Health
	– to achieve smoking quitters target	6.3 To implement the ‘Stop before the Op’ programme	6.3.1 Increased referrals to the SSS	Sept 2008	Public Health
		6.4 To deliver targeted intervention for ethnic minorities	6.4.1 Increased use of services by non-English speakers	Sept 2008	Public Health
		6.5 To deliver and evaluate a pilot mini MEND programme	6.5.1 To inform roll out of mini MEND programme	Sept 2008	Public Health
	- tackling obesity	6.6 To develop a project plan for early years interventions	6.6.1 Action plan agreed	Sept 2008	Public Health
		6.6 To develop a project plan for early years interventions	Milestones met	On-going	Public Health
		6.7 To evaluate ‘Tipping the Balance’ programme	6.7.1 Informed development of the programme	March 2009	Public Health
		6.8 To expand ‘4 Life’ to two new areas	6.8.1 Increase members by 150	March 2009	Public Health
	- teenage conceptions	6.9 To refresh Medway’s self-assessment of teenage conceptions	6.9.1 Action plan agreed	May 2008	Public Health
			Milestones met	On-going	Public Health
		6.10 To develop systematic data across agencies for programme monitoring	6.10.1 Better targeting of actions by monitoring being in place	June 2008	Public Health
	- Chlamydia screening	6.11 To promote and provide screening through primary care and sexual health services	6.11.1 Achieve target of 17% 15-24 year olds being screened	March 2009	Public Health
	- reducing alcohol-related admissions	6.12 To establish an alcohol focused health promotion programme	6.12.1 Action planned agreed	Sept 2008	Public Health
			Milestones met	On-going	Public Health
7.	To improve access to primary medical care (Fair Access to Primary Care Programme)	7.1 To procure 3 additional GP practices	7.1.1 Contracts awarded	Dec 2008	Provider Development
		7.1 To procure 3 additional GP practices	7.1.2 Services in place	March 2009	Provider Development
		7.2 To establish a GP-led Health Centre	7.2.1 Contract awarded	Dec 2008	Provider Development
		7.2 To establish a GP-led Health Centre	7.2.2 Services in place	March 2009	Provider Development
		7.3 To develop support systems to enable flexible hours working	7.3.1 50% of practices offering flexible hours	March 2009	Provider Development
			7.3.1 50% of practices offering flexible hours	March 2009	Medical Director
8.	To ensure the average waiting time for primary community and secondary care services is reduced to no more than 7 weeks by 2012.	8.1 To review all commissioned services and identify a waiting times reduction programme	8.1.1 Reduction programme identified to inform 2009/10 Operational Plan	Oct 2008	Commissioning
				Oct 2008	Provider Development
		8.2 To take immediate action on ‘hot spots’ in 2008/09	8.2.1 Specific projects commissioned	July 2008	Commissioning
			8.2.1 Specific projects commissioned	July 2008	Provider Development
			8.2.2 18 weeks referral to treatment target achieved	Sept 2008	Commissioning
			8.2.2 18 weeks referral to treatment target achieved	Sept 2008	Provider Development
9.	To extend choice of services	9.1 To develop an implementation plan for Maternity Matters	9.1.1 Plans agreed by local partners	July 2008	Commissioning
9.	To extend choice of services	9.1 To develop an implementation plan for Maternity Matters	Milestones met	On-going	Commissioning
10.	To establish and implement work programmes in a number of care pathway areas	10.1 To oversee the Kent and Medway Cancer Network Business Plan Objectives 2008/09	10.1.1 To provide an assurance framework for delivery of the plan	June 2008	Director of Commissioning, Kent and Medway Cancer Network
					Company Secretary

	- Cancer	10.2 To develop and implement an action plan to deliver the Cancer Reform Strategy in Medway	10.2.1 Plan agreed	July 2008	Commissioning
			Milestones met	On-going	Commissioning
	- Stroke Services	10.3 To develop stroke services to meet the National Stroke Pathway	10.3.1 Improvement in:		Provider Development
		(also ref 10. 20)	- 7 day therapy service	Nov 2008
			- 80% admissions to stroke ward within 24 hours
			- Thrombolysis service extended hours
			- Daily rapid access TIA service	July 2008
			- Targeted patients managed in primary care	On-going to
			- Improved provision of post-stroke services	March 2009
	- Cardiovascular Disease	10.4 Develop and deliver a work programme for cardiovascular	10.4.1 Work programme agreed	July 2008	Commissioning
			Milestones met	On-going	Provider Development
	- Renal Services	10.5 Develop and deliver a work programme for renal services	10.5.1 Work programme agreed	July 2008	Commissioning
	- Kent and Medway Specialised Services (FFF)		Milestones met	On-going

	- Urgent and Emergency Care	10.6 To deliver the Urgent and Emergency Care Board Work Programme (20 workstreams)	10.6.1 Urgent Care Board programme delivered	March 2009	Provider Development
			10.6.1 Urgent Care Board programme delivered	On-going	Commissioning
	- Services for Children and Young People	10.7 To deliver the Children’s and Young People’s Integrated Improvement Programme	10.7.1 Review of CAMHS completed	July 2008	Commissioning
					Provider Development
			10.7.2 Implementation of CAMHS review	On-going	As above
			Milestones met
			10.7.3 Implementation of children with disability review. Milestones met	On-going	As above
			10.7.4 Development of locality-based integrated children’s teams	Sept 2008	Provider Development
	- Older People	10.8 To develop and implement a work programme for older people	10.8.1 Work programme agreed	Sept 2008	Commissioning
			Milestones met	On-going	Commissioning
			10.8.2 Review of intermediate care strategy completed and bed requirement identified	Aug 2008	Provider Development
			10.8.3�� Commissioning Strategy for OPMHN implemented	On-going	Commissioning
			Milestones met	On-going	Commissioning
	- Mental Health	10.9 To oversee the Kent and Medway Mental Health Commissioning Business Plan Objectives for 2008/09	10.9.1 To provide an assurance framework for delivery of the plan	June 2008	Commissioning
					Kent and Medway Mental Health Services
					Company Secretary
		10.10 To complete the work on the Community Support Scheme	10.10.1 Residents placed in accordance with person-centred plans	June 2008	Commissioning
		10.10 To complete the work on the Community Support Scheme		June 2008	Kent and Medway Mental Health Services
		10.11 To develop and implement a work programme for Medway mental health services	10.11.1 Improvements in:	March 2009	Commissioning
			- Psychological therapy services		Kent and Medway Mental Health Services
			- Reduced A&E attendance
			- Requirement for ‘A Block’
			beds identified
			- Primary Care Mental Health services
	- Offender Health	10.12 To develop a commissioning strategy for offender health and commence implementation programme	10.12.1 Strategy agreed by the Board	May 2008	Commissioning
			Milestones met	On-going	Commissioning
		10.13 To review and update the Commissioning Strategy for People with a Learning Disability and commence implementation programme	10.13.1 Strategy refreshed, milestones met	Sept 2008	Commissioning
			10.13.1 Strategy refreshed, milestones met	On-going	Commissioning
	-�� Learning Disabilities	10.14 To implement the recommendations from the audit of the Section 31 agreement	10.14.1 Robust systems and processes in place	Sept 2008	Finance
			10.14.1 Robust systems and processes in place	Sept 2008	Commissioning
	- Physical Disabilities	10.15 To review the assessment service and supply of specialised wheelchairs	10.15.1 Review Complete	July 2008	Commissioning
			10.15.2 Improvements in access and delivery rates	March 2009	Commissioning
	- End of life care	10.16 To develop an implementation plan for End of Life Care	10.16.1 Plan agreed by local partners	Sept 2008	Commissioning
			Milestones met	On-going	Provider Development
	- Drug Misuse and Alcohol Services	10.17 To establish a Medway Drugs and Alcohol Board	10.17.1 Medway Drugs and Alcohol Board in place	July 2008	Chief Executive
					Commissioning - Mental Health
					Public Health
		10.18 To review the substance misuse work programme to deliver the national Substance Misuse Strategy in Medway	10.18.1 Plan agreed	September 2008	Kent Drug and Alcohol Team Manager, KCC
				On-going	Commissioning, Kent and Medway Mental Health Services
			Milestones met
		10.19 To develop a work programme to implement the Medway Alcohol Strategy	10.19.1 Plan agreed	Sept 2008	Commissioning Kent and Medway Mental Health Services
			Milestones met	On-going	Public Health
		10.20 To implement the recommendations from the Urology Evaluation Panel	10.20.1 - Multi-disciplinary Team (MDT) for West Kent and Medway	July 2008	Chief Executive
			- Proposals for single surgical site identified and consulted on	July 2008	Director of Commissioning, Kent and Medway Cancer Network
			- Implementation of surgical site solution	March 2009
			- Pan Kent and Medway MDT audit function in place	Oct 2008
			- Workforce plans in place	March 2009
	10.21�� To implement/support proposals for:	10.21.1 Kent and Medway service plans in place	On-going	Commissioning
	-�� Stroke			Provider Development
	-�� Vascular
	-�� Cardiology
	-�� Trauma
11	To ensure that the PCT can demonstrate resilience and compliance with the Civil Contingencies Act	11.1 To establish an Emergency Planning Committee	11.1.1 Committee in place	May-08	Provider Development
		11.1 To establish an Emergency Planning Committee	11.1.1 Committee in place	May-08	Public Health
		11.2 To develop Business Continuity Plans	11.2.1 Plans agreed by the Board	Sep-08	Provider Development
		11.2 To develop Business Continuity Plans	11.2.1 Plans agreed by the Board	Sep-08	Public Health
		11.3 To develop a Major Incident Plan agreed by the board incorporating a mass casualty plan	11.3.1 Plan agreed by the Board	Nov-08	Provider Development
			11.3.1 Plan agreed by the Board	Nov-08	Public Health
		11.4 To develop and deliver a training and testing programme with partners across Medway	11.4.1 Interim testing exercise undertaken	July-08	Provider Development
			11.4.1 Interim testing exercise undertaken	July-08	Public Health
		11.5 To incorporate appropriate response standards in contracts with all providers where appropriate	11.5.1 Contract standards agreed	Mar-09	Commissioning
			11.5.1 Contract standards agreed	Mar-09	Finance
		11.6 To Develop a pandemic flu plan	11.6.1 Flu Pandemic plan agreed by the Board	Nov-08	Public Health
		11.6 To Develop a pandemic flu plan	11.6.1 Flu Pandemic plan agreed by the Board	Nov-08	Provider Development
12	To improve patient and public experience, satisfaction and engagement	12.1 To publish a PCT prospectus setting out the Operational Plan 2008/09	12.1.1 Prospectus sent to key stakeholders	June-08	Commissioning
					Communications
					ALL
		12.2 To develop a PCT Communications and Engagement Framework	12.2.1 Structure and standards agreed by the Board	May-08	Communications
			12.2.1 Structure and standards agreed by the Board	May-08	ALL
		12.3 To develop a specific engagement strategy for Commissioning	12.3.1 Strategy agreed by the Board	Nov-08	Commissioning
			Milestones met	On-going	Communications
		12.4 To develop patient measures to be included in contracts with NHS providers; involving patients, public and staff	12.4.1 Patient satisfaction measures developed	Dec-08	Commissioning
			12.4.1 Patient satisfaction measures developed	Dec-08	Communications
			12.4.2 Contracts agreed	Feb-09	Commissioning
			12.4.2 Contracts agreed	Feb-09	Communications
		12.5 To establish a Patient Advice and Liaison Service	12.5.1 Service in place	July-08	Company Secretary
13	To ensure Equality and Diversity good practice is embedded throughout the organisation	13.1 To develop a strategy and action plan	13.1.1 Strategy agreed by the Board	May-08	Human Resources
		13.1 To develop a strategy and action plan	13.1.1 Strategy agreed by the Board	May-08	ALL
		13.2 To develop an Equality Impact Assessment Tool	13.2.1 Tool implemented throughout the organisation	Sep-08	Human Resources
			13.2.1 Tool implemented throughout the organisation	Sep-08	ALL
			13.2.2 Tool embedded in the commissioning process	Mar-09	Human Resources
			13.2.2 Tool embedded in the commissioning process	Mar-09	ALL
		13.3 To develop a single equality scheme	13.3.1 Single scheme in place	Mar-09	Human Resources
		13.3 To develop a single equality scheme	13.3.1 Single scheme in place	Mar-09	ALL
14	To ensure that the PCT has an effective quality assurance process and achieves optimum patient safety	14.1 To implement the clinical quality performance framework	14.1.1 Implementation in place:		Clinical Performance/ Nursing/ Medical Director
			- Medway Maritime Hospital	May 2008
			- PCT provider Services	Sept 2008
			- Mental Health	July 2008
			- Prisons	June 2008
			- Independent contractors	March 2009
		14.2 To review existing quality standards in NHS contracts and to agree new standards for 2009/10 contracts	14.2.1 Quality standards agreed	Dec 2008	Commissioning
					Clinical Performance/
					Nursing/
					Medical Director
			14.2.2 Contracts agreed	Feb 2009	Commissioning
					Clinical Performance/
					Nursing/
					Medical Director
		14.3 To agree evidence-based service specific outcome measures for 2009/10	14.3.1 Outcome measures agreed	Dec 2008	Clinical Performance/
					Nursing/
					Medical Director
					Public Health
		14.4 To ensure appropriate procedures are in place for safeguarding adults and children	14.4.1 All procedures reviewed and updated as necessary	June 2008	Provider Development
					Clinical Performance/
					Nursing/
					Medical Director
		14.5 To deliver improvements in QOF performance	14.5.1 Average scores improved	March 2009	Medical Director
		14.5 To deliver improvements in QOF performance	14.5.1 Average scores improved	March 2009	Provider Development
15.	To ensure cleanliness and the reduction of healthcare associated infections	15.1 To ensure all providers have systems in place to comply with the Code of Practice for the Prevention and Control of Healthcare Associated Infections (HCAIs)	15.1.1 Systems in place	June 2008	Clinical Performance/
			15.1.1 Systems in place	June 2008	Nursing
		15.2 To ensure HCAI and forthcoming cleanliness strategy is implemented	15.2.1 Plans in place	Sept 2008	Clinical Performance/
				On-going	Nursing
			Milestones met
		15.3 To ensure PCT provider services achieve targets to improve hand hygiene standards and infection control training	15.3.1 Targets achieved	On-going to March 2009	Provider Development
			15.3.1 Targets achieved	On-going to March 2009	Public Health
		15.4 To ensure Medway Maritime Hospital has plans to screen all emergency admissions	15.4.1 Screening in place	March 2009	Clinical Performance/
			15.4.1 Screening in place	March 2009	Nursing
		15.5 To implement the local health improvement plan for infection control	15.5.1 Trajectories met for 2008/09	March 2009	Clinical Performance/
			15.5.1 Trajectories met for 2008/09	March 2009	Nursing
16.	To develop further a robust commissioning function within the PCT and across South East Coast (SEC)	16.1 To develop the SEC Commissioning Rules Panel programme to address quality and benchmarking	16.1.1 Work programme agreed	July 2008	Chief Executive
			Milestones met	On-going	Chief Executive
		16.2 To examine proposals for further integrated commissioning of Health and Social Care in Medway	16.2.1 Proposals developed	Sept 2008	Chief Executive
			16.2.1 Proposals developed	Sept 2008	Commissioning
			16.2.2 Plans implemented	March 2009	Chief Executive
			16.2.2 Plans implemented	March 2009	Commissioning
		16.3 To identify specifications across care pathways	16.3.1 Contract specifications established for:	March 2009	Commissioning
			- COPD		Provider Development
			- Stroke
			- Diabetes
			- Dementia
		16.4 To develop detailed programme budgeting across care pathways	16.4.1 Programme budgets established for:	March 2009	Finance
			- COPD		Commissioning
			- Stroke		Provider Development
			- Diabetes
			- Dementia
		16.5 To develop specifications for PCT provider services	16.5.1 Specifications developed	March 2009	Commissioning
		16.5 To develop specifications for PCT provider services	16.5.1 Specifications developed	March 2009	Provider Development
		16.6 To develop detailed programme budgeting for PCT provider services	16.6.1 Programme budgets established	Dec 2008	Finance
					Commissioning
					Provider Development
		16.7 To improve the use of commissioning information for interpretation and ‘intelligence’	16.7.1 Improved suite of indicators in use	Sept 2008	Commissioning
			16.7.1 Improved suite of indicators in use	Sept 2008	ALL
		16.8 To develop a market management approach to commissioning plans	16.8.1 Strategy implemented	Dec 2008	Provider Development
			16.8.1 Strategy implemented	Dec 2008	Commissioning
		16.9 To ensure contracts for 2009/10 have updated key performance indicators (KPIs)	16.9.1 KPIs agreed	Feb 2009	Commissioning
					Provider Development
					ALL
		16.10 To review Practice-based Commissioning arrangements in line with Darzi Next Stage Review	16.10.1 Clinician engagement improved	On-going	Commissioning
			16.10.1 Clinician engagement improved	On-going	ALL
			16.10.2�� Recommendations agreed	Dec 2008	Commissioning
			Milestones met	On-going	Commissioning
		16.11 To establish a Practice-based Commissioning Board accountable to the PCT Board	16.11.1 Governance arrangements in place	May 2008	Commissioning
17.	To develop PCT Provider Services to support arms-length provision	17.1 To establish a Provider Services Board accountable to the PCT Board	17.1.1 Governance arrangements in place	Aug 2008	Provider Development
		17.2 To provide an annual plan, including three year projections, based on current planning assumptions	17.2.1 Plan agreed	June 2008	Provider Development
					Commissioning
					Finance
		17.3 To implement a programme of performance monitoring and management of provider services	17.3.1 Performance framework in place	Sept 2008	Provider Development
			17.3.1 Performance framework in place	Sept 2008	ALL
		17.4 To ensure the support mechanisms for arms-length provision are fit for purpose	17.4.1 Appropriateness and capacity of services assessed, eg Finance, HR, IM&T	Sept 2008	Provider Development
				Sept 2008	ALL
		17.5 To identify the allocation of overheads between commissioning and provider services	17.5.1 Allocations clear	June 2008	Finance
					Provider Development
					ALL
		17.6 To develop and implement a marketing strategy for provider services core business in line with Darzi Next Stage Review	17.6.1 Strategy developed	Sept 2008	Provider Development

			Milestones met
				On-going
18.	To improve quality, efficiency and effectiveness of PCT provider services	18.1 To undertake a programme to improve access, productivity and effectiveness.	18.1.1 Improvements in:	On-going to work stream timescales	Provider Development
			- Reduced waiting times and increased choice
			- Extended hours of working
			- Decrease in Did Not Attends (DNAs)
			- Improved patient experience
			- Reduction in complaints
			- Reduced admissions to hospital
		18.2 To establish effective systems to ensure patient safety.	18.2.1 Provider Governance structure in place	Sept 2008	Provider Development
			18.2.1 Provider Governance structure in place	Sept 2008	Clinical Performance/ Nursing
			18.2.2 St Bartholomew’s action plan complete	As shown in action plan	Provider Development
			Milestones met		Clinical Performance/
					Nursing
		18.3 To undertake an external review of governance processes.	18.3.1 Recommendations are implemented	July 2008	Provider Development
			18.3.1 Recommendations are implemented	July 2008	Company Secretary
19.	To implement the PCT Primary Care Strategy for GPs, Dentists, Optometrists and Pharmacists	19.1 To deliver a stronger workforce in general practice and community services	19.1.1 Improved recruitment of GPs and primary care development scheme in place	On-going	Provider Development
					Medical Director
					Human Resources
		19.2 To establish plans for further co-location of services in line with service redesign programmes	19.2.1 Improved use of Healthy Living Centres for local populations	On-going to work stream timescales	Provider Development
			19.2.2 Lease arrangements for internal usage reviewed	March 2009	Commissioning
					Provider Development Finance
		19.3 To produce a strategy to expand the range of service provided by MedOCC	19.3.1 Strategy agreed	June 2008	Provider Development
			Milestones met	On-going	Provider Development
		19.4 To strengthen and improve access to dental services	19.4.1 Oral health survey completed	Dec 2008	Public Health
			19.4.1 Oral health survey completed	Dec 2008	Provider Development
			19.4.2 Dental services awareness campaign undertaken	March 2009	Communications
				On-going	Provider Development
					Public Health
			19.4.3 Improved monitoring of access and waiting times	June 2008	Provider Development
			19.4.4 Accredited Clinical Governance Scheme for General Dental Practitioners in place	March 2009	Provider Development
				For 2008/09 target	Medical Director
		19.5 To establish a development programme for optometrists in line with national contract and local need.	19.5.1 Service portfolio extended.	March 2009	Provider Development
			19.5.1 Service portfolio extended.	March 2009	Commissioning
		19.6 To agree and implement a work programme for the Medicines Management Strategy	19.6.1 Programme in place	On-going to work stream timescales	Provider Development
			19.6.2�� Implementation of the community pharmacy action plan	On-going	Provider Development
			Milestones met
				On-going
20.	To improve the performance management and assurance framework of the PCT	20.1 To improve integrated governance arrangements	20.1.1 Improvements in whole organisational risk management processes.	Sept 2008	Finance
					Company Secretary
					ALL
		20.2 To implement a plan to achieve an ‘excellent’ rating the Annual Health Check	20.2.1 ‘Excellent’ rating achieved for 2008/09 assessment	March 2009	Company Secretary
			20.2.1 ‘Excellent’ rating achieved for 2008/09 assessment	March 2009	ALL
		20.3 To establish a cross-cutting performance framework for the PCT	20.3.1 Clear monitoring and reporting lines in place, including Integrated Service Improvement Plan (ISIP) Board and Local Area Agreement (LAA) progress reporting	July 2008	Commissioning
				July 2008	Company Secretary
21.	To ensure that the PCT continues to develop as an organisation with an engaged and appropriately skilled workforce	21.1 To agree a Medway Workforce Development Plan	21.1.1 Plan agreed with Health and Social Care partners	May 2008	Human Resources
		21.2 To set the programme for 3 Local Health Economy service workstreams	21.2.1 Detailed plans identified for:	Ongoing according to work stream	Human Resources
			- midwifery		Commissioning
			- Planned care examples		Commissioning, Kent and Medway Mental Health Services
			- psychological therapies		Provider Development
			Milestones met
		21.3 To implement the education commissioning arrangements in the context of workforce needs	21.3.1 Contracts agreed	March 2009	Human Resources
			21.3.1 Contracts agreed	March 2009	ALL
		21.4 To establish a Human Resources Staff Support Plan	21.4.1 Improvements based on:	On-going to work stream targets	Human Resources
			- Staff Survey		ALL
			- Medway partners
			healthy workplan
			- Stress project
			Milestones met
		21.5 To undertake an HR operational improvements plan	21.5.1 Improvements in:	On-going to work stream timescales	Human Resources
			- Processes to deliver HR policies
			- Team building in provider services
			- Electronic Staff Record (ESR) processes and use of data
			- Recruitment processes
			- Sickness absence rates
		21.6 To implement the Organisational Development Plan for 2008/09	21.6.1 Leadership programme for Band 7s and 8s in place	May 2008	Human Resources
			21.6.2� Undertaken skills mapping for Bands 1-4	July 2008	Human Resources


			21.6.3�� Training and development needs addressed	March 2009
			21.6.4�� Re-established first line managers programme for Bands 5 and 6	Sept 2008	Human Resources
			21.6.5 Support second wave South East Coast Aspirant Directors’ assessment	March 2009	Human Resources
			21.6.6 Rolled out further Lean 6 Sigma programme	June 2008	Human Resources
					Provider Development
					Commissioning
22.	To manage the finances of the PCT in line with Department of Health requirements	22.1�� To achieve financial targets relating to:	22.1.1 Targets achieved	Mar-09	Finance
		-�� 1.4% surplus
		-�� capital spend
		-�� cash limit
		22.2 To improve Auditors Local Evaluation (ALE) scores from 2007/08 achievement	22.2.1 ALE scores of 3 or above	Mar-09	Finance
		22.3 To ensure internal financial control is at best practice levels	22.3.1 Clean statement of internal control achieved	Mar-09	Finance


23	To progress the use of IM&T to support commissioning and provider services	23.1 To undertake 2008/09 actions in support of the National Programme for Information Technology (NPfIT) (NCRS)	23.1.1 Informatics programme board in place	Apr-08	Finance
			23.1.1 Informatics programme board in place	Apr-08	Finance
			23.1.2 PCT provider services action plan implemented	May-08	Finance
			Milestones met	On-going	Provider Development
			23.1.3 Commissioning data warehouse established	Sep-08	Finance
			23.1.3 Commissioning data warehouse established	Sep-08	Commissioning
			23.1.4 ESR readiness assessment 5 complete	Mar-09	Human Resources
			23.1.4 ESR readiness assessment 5 complete	Mar-09	Finance
		23.2 To improve the level of engagement and support to the effective running of PCT informatics and IT systems	23.2.1 Improvement against internal performance targets	Sep-08	Finance
24	To manage effectively current PCT estate and plan for future access and service re-design	24.1 To improve scores and benchmark position for PCT estate management	24.1.1 Improve achievement against national targets – usage, unit cost per meter squared and condition	Jan-09	Provider Development
				Jan-09	Finance
		24.2 To develop an Energy Strategy	24.2.1 Strategy agreed	Sep-08
		24.2 To develop an Energy Strategy	Milestones met	On-going
		24.3 To review provision of shared services’ contracts	24.3.1 Shared services contracts reviewed and re-let where appropriate	June-08	Provider Development
					Finance

		24.4 To complete 2008/09 plans to improve primary care estate	24.4.1 To ensure temporary accommodation for primary care ‘fair access’ programme and plans for permanent sites agreed	Mar-09	Provider Development
				Mar-09	Finance
			24.4.2 LIFT Procurement process reviewed	Sep-08	Finance
			24.4.2 LIFT Procurement process reviewed	Sep-08	Provider Development
			24.4.3 Plans for Balmoral Gardens and Canterbury Street implemented further	Mar-09	Provider Development
				Mar-09	Finance
			24.4.4 Option appraisal completed for relocation of St Bartholomew’s hospital	Oct-08	Provider Development
				Oct-08	Finance
			24.4.5 Specific plans for Rochester Riverside agreed	Mar-09	Provider Development
		24.5 To implement plans for Headquarters’ accommodation	24.5.1 Revised plans for Units 2, 5, 7 and 8 in place	July-08	Provider Development

Consequence Scoring

Using the consequence tab below, choose the most appropriate domain for the identified risk from the left hand side of the table Then work along the columns in same row to assess the severity of the risk on the scale of 1 to 5 to determine the consequence score, which is the number given at the top of the column. NOTE: A single risk area may have multiple potential consequences, and these may require separate assessment. It is also important to consider from whose perspective the risk is being assessed (organisation, member of staff, patient) because this may affect the assessment of the risk itself, its consequences and the subsequent action taken. It is important that the risk description reflects this.

Consequence score (severity levels) and examples of descriptors

Domains

Insignificant

Minor

Moderate

Major

Catastrophic

Impact on the safety of patients, staff or public (physical/psychological harm)

Minimal injury requiring no/minimal intervention or treatment.

Minor injury or illness, requiring minor intervention

Moderate injury requiring professional intervention

Major injury leading to long-term incapacity/disability

Incident leading to death

No time off work

Requiring time off work for >3 days

Requiring time off work for 4-14 days

Requiring time off work for >14 days

Multiple permanent injuries or irreversible health effects

Increase in length of hospital stay by 1-3 days

Increase in length of hospital stay by 4-15 days

Increase in length of hospital stay by >15 days

An event which impacts on a large number of patients

RIDDOR/agency reportable incident

Mismanagement of patient care with long-term effects

An event which impacts on a small number of patients

Quality/complaints/audit

Peripheral element of treatment or service suboptimal

Overall treatment or service suboptimal

Treatment or service has significantly reduced effectiveness

Non-compliance with national standards with significant risk to patients if unresolved

Totally unacceptable level or quality of treatment/service

Informal complaint/inquiry

Formal complaint (stage 1)

Formal complaint (stage 2) complaint

Multiple complaints/ independent review

Gross failure of patient safety if findings not acted on

Local resolution

Local resolution (with potential to go to independent review)

Low performance rating

Inquest/ombudsman inquiry

Single failure to meet internal standards

Repeated failure to meet internal standards

Critical report

Gross failure to meet national standards

Minor implications for patient safety if unresolved

Major patient safety implications if findings are not acted on

Reduced performance rating if unresolved

Human resources/ organisational development/staffing/ competence

Short-term low staffing level that temporarily reduces service quality (< 1 day)

Low staffing level that reduces the service quality

Late delivery of key objective/ service due to lack of staff

Uncertain delivery of key objective/service due to lack of staff

Non-delivery of key objective/service due to lack of staff

Unsafe staffing level or competence (>1 day)

Unsafe staffing level or competence (>5 days)

Ongoing unsafe staffing levels or competence

Low staff morale

Loss of key staff

Loss of several key staff

Poor staff attendance for mandatory/key training

Very low staff morale

No staff attending mandatory training /key training on an ongoing basis

No staff attending mandatory/ key training

Statutory duty/ inspections

No or minimal impact or breech of guidance/ statutory duty

Breech of statutory legislation

Single breech in statutory duty

Enforcement action

Multiple breeches in statutory duty

Reduced performance rating if unresolved

Challenging external recommendations/ improvement notice

Multiple breeches in statutory duty

Prosecution

Improvement notices

Complete systems change required

Low performance rating

Zero performance rating

Critical report

Severely critical report

Adverse publicity/ reputation

Rumours

Local media coverage –

National media coverage with <3 days service well below reasonable public expectation

National media coverage with >3 days service well below reasonable public expectation. MP concerned (questions in the House)

Potential for public concern

short-term reduction in public confidence

long-term reduction in public confidence

Total loss of public confidence

Elements of public expectation not being met

Business objectives/ projects

Insignificant cost increase/ schedule slippage

<5 per cent over project budget

5–10 per cent over project budget

Non-compliance with national 10–25 per cent over project budget

Incident leading >25 per cent over project budget

Schedule slippage

Key objectives not met

Finance including claims

Small loss Risk of claim remote

Loss of 0.1–0.25 per cent of budget

Loss of 0.25–0.5 per cent of budget

Uncertain delivery of key objective/Loss of 0.5–1.0 per cent of budget

Non-delivery of key objective/ Loss of >1 per cent of budget

Claim less than �10,000

Claim(s) between �10,000 and �100,000

Claim(s) between �100,000 and �1 million

Failure to meet specification/ slippage

Purchasers failing to pay on time

Loss of contract / payment by results

Claim(s) >�1 million

Service/business interruption Environmental impact

Loss/interruption of >1 hour

Loss/interruption of >8 hours

Loss/interruption of >1 day

Loss/interruption of >1 week

Permanent loss of service or facility

Minimal or no impact on the environment

Minor impact on environment

Moderate impact on environment

Major impact on environment

Catastrophic impact on environment

Additional examples

Incorrect medication dispensed but not taken

Wrong drug or dosage administered, with no adverse effects

Wrong drug or dosage administered with potential adverse effects

Wrong drug or dosage administered with adverse effects

Unexpected death

Incident resulting in a bruise/graze

Physical attack such as pushing, shoving or pinching, causing minor injury

Physical attack causing moderate injury

Physical attack resulting in serious injury

Self-harm resulting in minor injuries

Self-harm requiring medical attention

Suicide of a patient known to the service in the past 12 months

Homicide committed by a mental health patient

Grade 1 pressure ulcer

Grade 2/3 pressure ulcer

Grade 4 pressure ulcer

Laceration, sprain, anxiety requiring occupational health counselling (no time off work required)

Healthcare-acquired infection (HCAI)

Long-term HCAI

Large-scale cervical screening errors

Incorrect or inadequate information /communication on transfer of care

Retained instruments/material after surgery requiring further intervention

Removal of wrong body part leading to death or permanent incapacity

Delay in routine transport for patient

Vehicle carrying patient involved in a road traffic accident

Haemolytic transfusion reaction

Slip/fall resulting in injury such as a sprain

Slip/fall resulting in injury such as dislocation/fracture/blow to the head

Loss of a limb

Post-traumatic stress disorder

Failure to follow up and administer vaccine to baby born to a mother with hepatitis B

Incident leading to paralysis

Incident leading to long-term mental health problem

Rape/serious sexual assault

Liklihood Scoring


When assessing likelihood, it is important to take into consideration the controls already in place. The likelihood score is a reflection of how likely it is that the adverse consequence described will occur. Likelihood can be scored by considering: • frequency (how many times will the adverse consequence being assessed actually be realised?) or • probability (what is the chance the adverse consequence will occur in a given reference period?)

Likelihood score	1	2	3	4	5
Descriptor	Rare	Unlikely	Possible	Likely	Almost certain
STANDARD DESCRIPTOR
Frequency How often might it/ does it happen	This will probably never happen/recur	Do not expect it to happen/recur but it is possible it may do so	Might happen or recur occasionally	Will probably happen/recur but it is not a persisting issue	Will undoubtedly happen/recur,possibly frequently

TIME FRAMED DESCRIPTOR
Frequency	Not expected to occur for years	Expected to occur at least annually	Expected to occur at least monthly	Expected to occur at least weekly	Expected to occur at least daily

PROBABLITY DESCRIPTOR
Probability Will it happen or not?	<0.1 per cent	0.1–1 per cent	1–10 per cent	10–50 per cent	>50 per cent

5 X 5 Matrix


		Likelihood score
		1	2	3	4	5
		Rare	Unlikely	Possible	Likely	Almost certain
Consequence	5 Catastrophic	5	10	15	20	25
	4 Major	4	8	12	16	20
	3 Moderate	3	6	9	12	15
	2 Minor	2	4	6	8	10
	1 Negligible	1	2	3	4	5


		1–3 Low risk	Can be managed by routine procedures to be implemented by team leaders, ward managers or a designated individual with operational responsibility for the area affected.
		4–6 Moderate risk	Specific responsibility for risk assessment and action planning must be allocated by a senior manager to a named person in that manager’s team. Usually, deadline for completion will be within 6 to 24 months and will depend on resource availability.
		8–12 High risk	Urgent senior management attention needed. Within one month an appropriate action point must be agreed, usually with a deadline for completion of no more than 6 months.
		15–25 Extreme risk	Immediate action required. A Director must be informed and he/she will take responsibility for immediately planning action.

(Unknown Page)

Corporate Risk Register

Version 11: April 2008

Risks <12

Area

No.

Corporate Objective no.

Dept.RR no.

Source of Risk

Date

Description of Risk

Consequence

Likelihood

Risk Rate

Last Review Date

Owner

Mitigating Actions

Likelihood

Consequence

Residual Risk Score

Progress on Action

Strategy

5.1

39282 *

Poor buy in by user departments to engage in the development of the Estates Strategy.

** 9

39281 *

Jonathan Bates

Management team leading the process. First phase of the Estates Strategy commissioned

** 8

IM&T

6.1

39282 *

Lack of clarity on national IT implementation results (NPfiT) will limit value of strategy

** 9

39281 *

Jonathan Bates

Timetable for implementation agreed and being implemented

** 6

Equality and Diversity

8.1

39282 *

High day to day workload preventing the overview of compliance with best practice in equality and diversity

** 9

39281 *

Cheryl Clements

Equality and Diversity Strategy being developed

** 9

PPI

9.1

39282 *

PCT needs analysis regarding public expectation needs further work.

** 9

39281 *

Collette Glasson

Work programme in place. Patient survey being commissioned with Medway council.

** 6

Partnership

10.2

39315 *

LAA and LSP community plan not met

** 9

39315 *

Sally Ann Ironmonger

PCT and Council are reviewing current position

** 9

Commissioning

11.1

39282 *

Slow completion of commissioning strategy

** 9

39281 *

Louise Parker

Executive Team & Reference Group working on commissioning strategy

** 9

Strategy being currently developed

Performance

14.1

39282 *

Shortage of hospital capacity for key specialties in local area. Shortage of management and clinical capacity to develop primary care

** 9

39281 *

Louise Parker /Martin Riley

Assistant Director of Commissioning and Hospital general managers and close involvement of Kent and Medway Acute have made sound progress on achieving 18 week wait for acute care.

** 9

Commissioning

15.1

39282 *

Inappropriate admissions by hospital.

** 9

39482 *

Martin Riley/ Louise Parker

Assistant Director of Commissioning and Hospital general managers and close involvement Medway Hospitals NHS Trust have regular meetings to review performance Project Co-ordinator being appointed to facilitate workstreams achieving deadlines

** 6

20 Urgent Care workstreams established reporting to the Urgent Care Board.

Governance

16.1

39282 *

Lack of timely response to known areas of concern. New arrangements for performance process not yet fully bedded in, especially around Performance Advisory Groups (PAG).

** 6

39429 *

Martin Riley

Primary Care Team working closely with contractors with problem areas and an internal audit program. New Decision Making Group (DMG) process underway.

** 3

DMG / PAG process established. GP lead for PAGs to be identified

Human Resources

19.1

39282 *

Current skills/leadership gaps causing potential risk to achievement.

** 9

39281 *

Cheryl Clements

Executive team and new HR Director has reviewed OD and HR Structures. OD strategy to go to Board in September 2007.

** 4

Provider Services

21.1

39282 *

Lack of certainty on Department of health views on way forward e.g. tariff

** 9

39281 *

Martin Riley

In collaboration with external partners planning to develop a model for assessing effectiveness and efficiency of provider services

** 6

Strategy

23.1

39282 *

Slow implementation of action plans. Difficult recruitment to vacant posts

** 9

39281 *

Jonathan Bates

Action plan in place and regular reporting to Risk Management Committee.

** 0

Financial Planning

25.1

39282 *

Unidentified cost pressures discovered late in financial year. Difficulty in recruiting high calibre staff.

** 9

39281 *

Jonathan Bates

Month 3 return to Department of health on target. Clean external Audit report for previous year. Monthly reporting to Board and SHA

** 0

IM&T

26.1

39282 *

Local and National IT implementation may fall behind schedule. Complex and expensive solution to effective joint working with social services

** 9

39281 *

Jonathan Bates

IM & T Manager reports regularly to Director of Finance and Assurance. Key directors involved. GP IT service moved to Health Informatics Service. Information needs for provider services being reviewed.

** 0

Clinical Effectiveness

28.1

39282 *

Lack of medicines management strategy. High demand on service which may cause lack of support to General Practice

** 9

39532 *

Martin Riley

Updated arrangements for medicines management being developed.

** 4

Strategy been written

Clinical Effectiveness

29.1

39282 *

Lack of completed baseline assessment

** 9

39532 *

Martin Riley

Community pharmacy strategy being developed

** 6

Strategy been written

Clinical Effectiveness

30.1

39282 *

Completed commissioning plan not in place leading to potential lack of service

** 9

39532 *

Martin Riley

Community pharmacy strategy being developed

** 6

Staffing structure now agreed and acting HoMM in post

Governance

24.3

39302 *

Volume of outstanding issues and cases related to independent practitioners

** 6

39429 *

Martin Riley

DMG process reviewed.Officer within the PCT responsible for ensuring actions are completed now appointed.

** 6

Process now in progress to address this by holding a number of case reviews.

Strategy

1.1

39282 *

Slow completion of supporting strategies causing delay to overall PCT strategy.

** 8

39281 *

Marion Dunwoodie

Programme of action in place for all strategies

** 8

Strategy

3.1

39282 *

Slow completion of supporting strategies causing delay to overall financial strategy.

** 8

39281 *

Jonathan Bates

Draft Financial Strategy being finalised. Detailed strategy to follow

** 8

Strategy

4.1

39282 *

High day to day workload preventing development of the Workforce Strategy

** 8

39281 *

Cheryl Clements

Preparatory work in process.

** 8

Support Services

27.1

39282 *

Absence of detailed specification of shared services causing potential lack of service

** 8

39281 *

Martin Riley

Contract monitoring of Shared services complete. New contract specification being provided to core services.

** 4

Performance

15.3

39302 *

Risk that a contracted provider will be unable to fulfill their contract

** 8

39302 *

Louise Parker

Regular performance review with all providers

** 8

Partnership

10.1

39282 *

Health impact assessment not completed

** 4

39281 *

Sally Ann Ironmonger

Rapid health impact assessment completed

** 4

Strategy

22.1

39282 *

Incomplete implementation of action plan

** 4

39281 *

Marion Dunwoodie

Project Manager in place managing delivery of action plan with Executive Team.

** 0

Governance

24.2

39464 *

Complaints management arrangements not robust causing potential for escalation of complaints

** 9

39464 *

Marion Dinwoodie

Review by Patient Safety Group and Board strengthened. Procedures reviewed to ensure further robustnesss.

** 6

Complaints policy including habitual/vexatious complaints section in final draft format. To be agreed at Risk Management Committee 31 January 2008.

Human Resources

12.1

39282 *

Difficulty in recruiting high calibre staff to remaining posts

** 9

39460 *

Louise Parker

PEC and Commissioning Sub Committee revising staffing structure as part of LDP and recruitment now progressing well. Readvertising all posts then if not successful review all job descriptions and bandings

** 15

Some progress in appointing key staff in particular the Head of Performance.. Some posts remain unfilled.Improved position. Still a few key posts to fill.

(Unknown Page)

Area

No.

Corporate Objective no.

Dept.RR no.

Source of Risk

Date

Description of Risk

Consequence

Likelihood

Risk Rate

Last Review Date

Owner

Mitigating Actions

Likelihood

Consequence

Residual Risk Score

Progress on Action

Independent Practitioners

17.1

7-19-07

Poor response to tender

** 9

7-18-07

Martin Riley

Executive Team review progress. APMS tender drafted

Target achieved Risk closed

Strategy

7.1

39282 *

Director of Public Health post vacant preventing the development of the knowledge management strategy.

** 12

39464 *

Sally Ann Ironmonger / Louise Parker

Recruitment process in progress. Interviews 19/07/07. alternative knowledge management approach being followed

** 8

Appointment made post holder to start in March 2008.Initial work on knowledge managemnt strategy being followed.

Public Health

2.1

39282 *

Vacancy of Public Health Director resulting in constraints in carrying out health equity audits.

** 12

39464 *

Sally Ann Ironmonger

Recruitment process in progress. Interviews 19/07/07

** 4

Appointment made, post holder now commenced. a number of health equity audits have now been carried out.

Performance

14.1

39668 *

Gaps in general practice in Medway. Shortage of management and clinical capacity to develop primary care.

** 12

39464 *

Martin Riley

Development of a Buddy system to allow patients to access neighbouring practices if access is an issue. Reviewing the role of SDT centre to consider offering for routine appointments

** 4

Proposal now in place to improve GP access, including extended hours

Spreadsheet's Author: amy.paton
Last Updated with Excel 97

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