One traceable chain from a frontline event to board assurance — Event → Theme → Systemic Issue → Risk → Objective (BAF) — where every promotion carries its evidence, every risk drills back to the events that made it, and de-escalation is earned by assurance and signal abatement, never the calendar.
Operational, corporate and board (BAF) are not three registers — they are three lenses over ONE Risk source of truth. The chain promotes a frontline event up to a board objective, and a mitigation spine runs the other way, closing the loop with live data.
Thread Explorer, Signal Engine and the Register & BAF Lens — bidirectional trace, human-confirmed theme promotion, and ONE risk list seen through Operational / Corporate / BAF toggles.
Incident Reporting (severity ≥ moderate → Auto-CAPA + Duty of Candour auto-trigger), Near-Miss, Complaints, FTSU and Mortality Review all promote evidence into the chain.
Risks ≥12 escalate from the Corporate Risk Register into the BAF; principal risks, strategic objectives and three-lines assurance flow to the board portal and the 5×5 governance visual boards.
The thread begins where the harm, near-miss or concern is reported. Nothing is re-typed on the way up; each step carries its evidence links forward under a §8 governance gate.
An incident of severity ≥ moderate automatically raises an Auto-CAPA badge and link (PSIRF-aligned), and auto-triggers Duty of Candour (CQC Reg 20) into its 24-hour verbal / 10-day written SLA. The event is de-identified — patient initials and reporter role only.
The Signal Engine watches for patterns: a rule threshold, an SPC special-cause point, or triangulation across sources. Each candidate theme's trigger chips drill straight back to the evidence — the exact events behind it.
A candidate is never auto-promoted. A governance-lead gate confirms candidate → theme, and the promotion carries its evidence links. From theme to systemic issue to risk, every edge records who, when, the §8 gate and the evidence carried.
The systemic issue is promoted to a Risk — the single source of truth. It still drills down to its constituent events with reconciling counts: the risk's evidence count equals the drilled set. Controls link to /policy-to-process and /learn.
The same risk that started as an event is now a principal risk on the board's assurance framework. No parallel register: the Operational, Corporate and BAF views are toggles over the one record.
A risk scoring ≥12 escalates from the Corporate Risk Register to the Board Assurance Framework, landing in the board acknowledgement queue against a strategic objective — inherent, residual and target scores intact.
The lens reads objective → principal risk → controls → assurance by the three lines of defence → gaps in control → GAP IN ASSURANCE → actions with % complete. Every cell is expandable to its evidence; the risk row drills back to systemic issue → theme → events.
The board portal carries a live BAF risk summary, and the Governance Visual Boards plot the risk on a 5×5 map with a residual → target movement arrow — so a non-executive sees direction of travel, not just a number.
Closing or de-scoring a risk requires assurance plus signal abatement — the SPC signal returning to common-cause and the assurance gap closed — never the calendar. Evidence-based de-scoring (e.g. 12 → 6) only after both are met.
Because the chain carries links rather than re-keying, the board risk and the frontline event are two ends of the same object. Here is where the event enters — and how the signal that promoted it stays visible.
| Step in the thread | Module | Route | Model / API | Status |
|---|---|---|---|---|
| Event captured · Auto-CAPA · DoC auto-trigger | Incident Reporting | /incident-reporting | linked_capa_ref · auto_triggered_from | ● Live |
| Near-miss & complaints feed | Near-Miss · Complaints | /near-miss · /complaints | PSIRF · PHSO timescales | ● Live |
| Speak-up & mortality signals | FTSU · Mortality Review | /ftsu · /mortality-review | Guardian cases · ME/LeDeR | ● Live |
| Corrective action | CAPA Workflow | /capa | CAPA record · PSIRF | ● Live |
| Duty of Candour (CQC Reg 20) | Duty of Candour | /duty-of-candour | verbal 24h / written 10d SLA | ● Live |
| Signal → Theme (SPC / rule / triangulation) | Golden Thread · Signal Engine | /golden-thread | human-confirm gate · §19 worked example | ◍ Demonstrated |
| Thread Explorer (bidirectional trace) | Golden Thread | /golden-thread | promotion edges (who/when/§8/evidence) | ◍ Demonstrated |
| ONE Risk source of truth | Corporate Risk Register | /corporate-risk | escalate ≥12 → BAF | ● Live |
| Board Assurance Framework | BAF · Register & BAF Lens | /board-assurance-framework | /baf/ · principal risks · 3-lines assurance | ● Live |
| BAF summary on the board portal | Board Management | /board-management | acknowledgement queue · portal API /board/ · reads live /baf/ | ● Live |
| 5×5 risk bubble map (residual → target) | Governance Visual Boards | /governance-boards | likelihood × impact · movement arrows | ◍ Demonstrated |
| Controls (policy & competency) | Policy-to-Process · commvita Learn | /policy-to-process · /learn | process steps · competency sign-off | ● Live |