WELSH HEALTH CIRCULAR

Transcription

1 WHC (2005) 097 WELSH HEALTH CIRCULAR Parc Cathays Caerdydd CF10 3NQ Cathays Park Cardiff CF10 3NQ Issue Date: 22 December 2005 Status: FOR ACTION Title: The Introduction of the Delivery and Support Unit into NHS Wales For Action by: NHS Trust, Local Health Board Chief Executives and Health Commission Wales Action required See Sections 4-10 For Information to: See attached list Sender: John Hill-Tout / Stuart Marples, Joint Directors, Directorate of Performance and Operations National Assembly contact(s) : See Section 11 of this circular Enclosure(s): 1

2 STRENGTHENING THE PERFORMANCE IMPROVEMENT FRAMEWORK WITHIN NHS WALES THE INTRODUCTION OF THE NATIONAL DELIVERY AND SUPPORT UNIT 1. SUMMARY 1.1 The Minister for Health and Social Services is committed to improving the performance of health services within the NHS. Whilst progress has been made in some service areas, concerted improvement is required across the whole health community to deliver a service that meets the needs and expectations of the people of Wales. There is a need to focus on the improvement of services on a daily basis whilst also planning and delivering key priorities contained within Designed for Life, ensuring that the key building blocks are in place to allow the achievement of longer term objectives. 1.2 Significant progress has been made in the development and use of a Performance Improvement Framework in NHS Wales, in line with the key recommendations contained within the Review of Health and Social Care in Wales (Wanless) Report. 1.3 Designed for Life identifies the delivery of world class healthcare by 2015 and this is only achievable through the continuous improvement of performance and the supporting frameworks. 1.4 This circular introduces the Delivery and Support Unit (DSU) as the next incremental step in the further development of the Performance Improvement Framework within Wales. It sets out the Welsh Assembly Government s intentions for the Delivery and Support Unit and the role it will play in assisting and supporting NHS Wales in securing sustained performance improvement. This Circular sets out the broad functions of the new Delivery and Support Unit and its role in supporting the Regional Offices in managing and improving performance within NHS Wales. The circular is supplemented by a series of appendices: 2

3 Appendix 1 Appendix 2 Appendix 3 The Purpose and Role of the DSU DSU Operational Policy Key Stakeholder Relationships. 2. BACKGROUND 2.1 The Performance Improvement Framework within NHS Wales is now well established following the implementation of key actions identified within WHC (2003) 120. The framework takes account of a number of the key recommendations highlighted within the Review of Health and Social Care in Wales Report (2003). This included the use of a rigorous and comprehensive performance management framework, the use of the balanced scorecard, benchmarking against good practice and the need for improved incentives and stronger sanctions based on overall organisational performance. 2.2 The annual Service and Financial Framework (SaFF) planning process has supported a structured approach to the identification of annual priorities and management of performance in relation to the delivery of these priorities. The development of a performance reward and support framework and other related tools will further support the prioritised approach in identifying and delivering strategic priorities within NHS Wales. 2.3 WHC (2004) 047 was the second circular in the series and introduced the Balanced Scorecard as the strategic tool by which objectives could be identified, measured and more effectively managed. 2.4 This structured approach to performance management will be built upon by the capacity and expertise provided by the DSU to NHS Wales, strengthening the performance improvement framework. 2.5 A vision of the health service in Wales is provided by Designed for Life. Making the Connections supports the key principle of continued performance 3

4 improvement as being vital in enabling the achievement of world class healthcare that is designed and delivered around the patient. This is a vision that will be achieved by the delivery of high levels of performance in a sustained manner. 2.6 The Regional Offices are responsible for the oversight of the management of performance within individual organisations and the wider health community of Wales and the introduction of the DSU will assist them in driving continuous improvement to ensure a better level of service for users of NHS Wales. 3. CONTEXT 3.1 This circular is the third in the performance management series and its implementation will further strengthen the Performance Improvement Framework for NHS Wales. The strengthening of the framework is essential if the vision set out within Designed for Life is to be delivered by 2015, as performance improvement is one of the central components in achieving it. 3.2 To assist health communities and NHS organisations in achieving continuous performance improvement the DSU is being introduced into the performance management environment of NHS Wales. The primary role of the DSU will be to provide health communities with enhanced support, and performance management tools and techniques to enable the achievement of improved performance levels. 3.3 The DSU will provide the Welsh Assembly Government and the NHS with additional capacity and operational expertise in areas where the levels of performance expected by the Welsh Assembly Government are not being achieved. It will also provide expertise and advice to the Welsh Assembly Government on policy development matters, including the development of a wider suite of performance management and improvement tools and techniques. The DSU will also develop the template for delivery planning 4

5 which will be used in the Department of Health & Social Care and within the wider service. Delivery Plans are an essential factor in ensuring that policy as set out by the Welsh Assembly Government is transformed into service improvement and developments for patients using the NHS. 4. THE DELIVERY AND SUPPORT UNIT AND ITS ROLE WITHIN THE PERFORMANCE IMPROVEMENT FRAMEWORK FOR NHS WALES 4.1 Good progress has been made with the development of a framework for, and culture of, performance management within Wales, but there is more to be done to achieve the sustained levels of performance required. The Welsh Assembly Government requires that high levels of performance are achieved and sustained within the health service and public services in general. 4.2 The formation of the DSU will be a key element in continuing to drive the improvement of performance within the NHS. It will act as an agent for change for those organisations that fail to meet Ministerial Core Targets. The intended outcome of any DSU involvement will be improved levels of performance that are sustainable and provide a better patient experience. It will ensure that organisations are assisted in developing sufficient capacity to ensure that improved performance levels can be sustained, through the transfer of skills and knowledge into organisations. 4.3 The purpose, structure and key areas of work of the DSU are outlined in detail in Appendix KEY FUNCTIONS OF THE DELIVERY AND SUPPORT UNIT IN SUPPORTING THE IMPROVEMENT OF PERFORMANCE 5.1 The key functions of the DSU are as follows: 5

6 To provide enhanced support to facilitate the improvement of performance within NHS Wales; The provision of advice on performance management policy development; To develop a framework for effective delivery planning; and To design and deliver the 2009 Access project. Each of these functions is set out in greater detail. ENHANCED OPERATIONAL SUPPORT 5.11 The achievement of expected levels of performance and the continuous improvement of these levels within NHS Wales is an expectation of the Welsh Assembly Government. Where performance levels fall below those expected, action will be taken by organisations and health communities to resolve the issues in a timely and effective manner Where organisations continue to experience difficulties in achieving expected performance levels or where initial improvement actions are not successful, they are encouraged to contact the DSU. Following agreement, the DSU will provide them with an initial diagnostic report to identify the issues to be addressed. It will also provide assistance in developing the action plan required to deliver the expected levels of performance Regional Offices are responsible for the performance management of health communities. In this capacity, Regional Offices can request support from the DSU for any organisation or health community that would benefit from the involvement of the DSU. The current system of enhanced performance reporting, aligned to the Ministerial Core Targets, will be the basis for judging whether assistance is required. The current criteria of green, amber and red levels of performance will continue to be utilised. If an organisation is red against a certain criteria then the DSU will be asked by the Regional Office to 6

7 undertake a diagnostic report and, if necessary, provide enhanced support. The operational approach of the DSU is set out in Appendix NLIAH will continue to provide support to organisations through their all- Wales programmes. The DSU will provide enhanced support to those organisations that are faced with the greatest challenges in achieving the expected levels of service delivery. MINISTERIAL CORE TARGETS 5.15 The Minister for Health and Social Services is determined to improve the access to, and quality of services within the NHS and the wider health and social care communities of Wales. The improvement in services will focus on a number of key areas, with effective performance management being of significant importance. The Minister views the introduction of the DSU as a vital component in supporting Regional Offices in improving the delivery of services through performance management and facilitating the change that is required to achieve world class healthcare in It is an expectation of the Welsh Assembly Government that organisations organise themselves to deliver all targets identified by the Government without exception. All annual targets will continue to be performance managed by the Regional Offices to ensure that the expected levels of performance are consistently achieved. Performance will continue to be reported to the Regional Offices using the criteria set out within WHC (2005) 072. That circular sets out the performance management arrangements for NHS Wales, which is based upon the utilisation of the balanced scorecard at national and organisational level. The balanced scorecard is now the established performance management framework and will continue to be refined and developed in line with improvements within the management of performance within NHS Wales and the introduction of the strategic priorities contained within Designed for Life. 7

8 5.17 Whilst continued performance improvement is expected across the whole range of national targets there are a number of targets which are critical to the delivery of effective services. These will be known as Ministerial Core Targets and will predominantly emerge from the SaFF planning process. The Ministerial Core Targets will be communicated to the NHS on an annual basis through the annual planning guidance, which sets out the SaFF targets. As stated in the Annual Priorities and Planning Guidance for the Service and Financial Framework for Wales circular, WHC (2005) 088, this will occur from 2007 / In respect of 2006 / 2007 the Ministerial Core Targets will be communicated in January A threshold will be set for each of the Ministerial Core Targets through consultation between the Directorate of Performance and Operations, Regional Offices and the DSU. This threshold will determine the point at which enhanced support is required and deployed. The thresholds will build upon the current performance-reporting framework The setting of all thresholds for Ministerial Core Targets will be transparent to the service. All Ministerial Core Targets and the agreed thresholds will be identified and approved by the Minister for Health and Social Services The categorisation of organisational performance against the Ministerial Core Targets will be shared on a monthly basis across Wales Regional Offices have in place a number of methods which they utilise to assist the health community to manage performance that falls below expected levels The DSU will be asked to assist in improving performance levels where Ministerial Core Targets are not delivered. This form of action will be known as Enhanced Support. The request for assistance may come from the organisation or from the Regional Office. 8

9 5.23 The need for enhanced support will be triggered by the performance monitoring criteria currently used within the Performance Improvement Framework of NHS Wales. This is set out below. i. Organisations performing at green status no support or intervention required Organisations performing at green status against any of the Ministerial Core Targets will not receive any intervention from the DSU. The DSU should be informed of all good practice being utilised in order that it is shared with other organisations. It is likely that organisations delivering services identified as good practice will be participating in an all-wales programme facilitated by NLIAH. ii. Organisations performing at amber status optional diagnostic report & enhanced support provided Organisations operating at amber status against any of the Ministerial Core Targets will have an option of receiving a diagnostic report and subsequent support from the DSU. The organisations will also have the option of sharing information with the DSU. iii. Organisations performing at red status an automatic diagnostic report prepared by the DSU and, if necessary, enhanced support Organisations that are operating at red status against any of the Ministerial Core Targets will receive an automatic diagnostic report prepared by the DSU and, if necessary, enhanced support. The Regional Office, in partnership with the DSU, will monitor any subsequent action plan The support provided by the DSU to the health community will be tailored directly to their own particular need through effective partnership between all stakeholders The outcome of any enhanced support activity will be the identification of a robust and sustainable way forward through robust action planning. It will ensure that the transfer of sufficient skills and development of required 9

10 capacity within the organisation has been effectively planned. This is required to provide assurance that improved performance levels are sustainable Following the initial diagnostic activity an action plan will be produced by the organisation or health community outlining the key milestones to be achieved, timescales, responsibilities and required outcomes to resolve the poor performance. The Chief Executive Officer and the Board will sign off the action plan For organisations displaying red performance status the implementation of agreed Action Plans, following the intervention of the DSU, will be performance managed by the Regional Office with the assistance of the DSU. If the Regional Office or DSU still have concerns in relation to underachievement against the action plan, or doubts about the organisations ability to rectify the underlying difficulties, a decision will be made on the appropriate action required to drive the expected levels of performance. The Regional Office and DSU will be responsible for agreeing the required course of action The outcome of any period of enhanced support must be a significant and sustained improvement in the level of performance in the target area of concern. ESCALATION OF SUPPORT AND INTERVENTION 5.29 It is expected that the involvement of the DSU within health communities and NHS organisations will result in significantly improved levels of performance that are sustained. If sufficient improvement does not occur as a result of support and intervention by the DSU, the performance issues will be escalated to a point where there will be direct accountability discussions between the Welsh Assembly Government, and the Chair, Chief Executive and the Board of the organisation concerned. 10

11 5.30 The escalation process will consist of three stages and will enable discussion to occur between the Welsh Assembly Government and the health community in relation to expected levels of performance and the action required to achieve them. The escalation stages are as follows: Stage 1 Chief Executive Officer(s) and Chair(s) of organisation meet formally with Regional Directors supported by DSU Director. Stage 2 Chief Executive Officer(s) and Chair(s) of organisation meet formally with the Head of the Health and Social Care Department Stage 3 Chief Executive Officer(s) and Chair(s) of organisation meet formally with the Head of the Health and Social Care Department and Minister for Health and Social Care It is the responsibility of all Chairmen to report any DSU intervention to the Board of that organisation. The Chairman is also responsible for reporting any subsequent escalation of enhanced support that the organisation receives from the DSU A formal agreement will be reached at each stage of the escalation process in relation to the following components: expected levels of performance to be achieved by the organisation; the course of action to be taken by the organisation to achieve the expected levels of performance; the estimated resource requirements and timescales required to achieve the expected levels of performance; and 11

12 the specific role that the Regional Director and the DSU will play in providing further support and guidance to achieve expected levels of performance Escalation to a higher level will only be triggered if the Regional Director, together with the DSU does not feel satisfied that the expected levels of performance agreed with the Regional Office and DSU, have been achieved or are likely to be achieved based on the evidence provided by the organisation. 6. THE PROVISION OF ADVICE ON PERFORMANCE MANAGEMENT POLICY DEVELOPMENT 6.1 The DSU will provide advice and assistance to the Directorate of Performance and Operations in developing policy on performance management. 6.2 The DSU will develop and maintain a database of benchmarking information for use by NHS Wales and assist with the further development of tools and techniques which can be used by the Department of Health and Social Care. 6.3 The tools developed for use will target high performance, be timely and transparent and allow comparison between organisations so that good practice can be identified and shared across all organisations. 6.4 Initial policy development will be focused on the refinement of the balanced scorecard and the development of an incentives and performance reward and support framework. 6.5 The DSU will also develop a strong focus on the provision of robust and timely management information within organisations. The need for accurate, timely and accessible management information is critical in effective decisionmaking and management of performance. 12

13 7. THE DEVELOPMENT OF A FRAMEWORK FOR DELIVERY PLANNING 7.1 The practical implementation of policy within NHS Wales is imperative if world class healthcare is to be delivered by To assist organisations in implementing policy the DSU will develop the structure and techniques for delivery planning to be used within the Health and Social Care Department and in NHS Wales. 7.2 The DSU will create a support framework for delivery planning and assist in areas of policy where implementation has not been effective, in the view of the Regional Office. It will support policy leads in drawing up robust delivery plans and effective performance management frameworks to deliver the plans. 8. THE DELIVERY OF THE 2009 ACCESS PROJECT 8.1 The 2009 Access project will support the NHS to deliver a maximum inpatient and outpatient wait of 26 weeks from the receipt of the GP or dental referral (including diagnostics and therapies) to treatment. 8.2 The DSU will design the delivery plan and manage the work programme for the 2009 Access project through the activities of the supporting and primary clinical workstreams. It will report all progress to the Project Board. 8.3 It will lead on the capacity and demand modelling work for the Access 2009 programme and the further development of this type of modelling on an All- Wales basis. 8.4 DSU will provide the management framework for the Second Offer scheme working closely with Rhondda Cynon Taff Local Health Board, the host body for the scheme. It will evaluate the outcomes of the current second offer scheme. 13

14 8.5 The management of performance within the Access 2009 project will be undertaken utilising the frameworks, tools and techniques outlined within this circular. 9. RELATIONSHIPS WITH OTHER STAKEHOLDERS 9.1 The engagement of a broad range of stakeholders who can provide expertise and professional knowledge is important in developing a whole systems approach to the improvement of performance within NHS Wales. The DSU will actively engage and consult with stakeholders. 9.2 The DSU has compiled a list of approved contractors who may be invited to undertake work on behalf of the DSU. 9.3 The key relationship interfaces with NLIAH and Health Inspectorate Wales are detailed in Appendix The DSU will work closely with the Improving Healthcare programme and the Corporate Health Information Programme. 10. SHARING THE LEARNING 10.1 It is vital that lessons are learnt and knowledge is shared amongst all stakeholders following all enhanced support activity. DSU will provide direct feedback to organisations that have received enhanced support to assist with the development of their knowledge base and skills. The DSU will more widely communicate key findings to the service, in association with NLIAH The DSU will also learn from the intervention process by obtaining feedback from organisations it is involved with. All knowledge and learning will be shared via developmental events that will be held on a regular basis. 14

15 10.3 It is intended that all completed reports will be made fully available within the public domain, excepting those that meet the exemptions set out within the Data Protection Act (1998) and the Freedom of Information Act (2000). 11. QUERIES AND CORRESPONDENCE 11.1 An electronic copy of this circular can be found on the NHS Performance Management website: All queries about the contents of this guidance should be sent to: Carl James Head of NHS Performance Management Policy Development Welsh Assembly Government Cathays Park Cardiff CF10 3NQ Christine Miles Director of the Delivery and Support Unit Innovation House Bridgend Road Llanharan CF72 9RP Tel:

16 Yours sincerely John Hill-Tout / Stuart Marples Joint Directors of Performance and Operations Health and Social Care Department 16

17 Appendix 1: THE PURPOSE AND ROLE OF THE DELIVERY & SUPPORT UNIT 1. The purpose of the DSU is: To assist NHS Trusts and Local Health Boards (LHBs) in Wales to consistently achieve national priorities; and To embed a culture of performance and delivery throughout NHS Wales. Key Areas of Work 1.1 The work of the DSU will be focused in five main areas: Ensuring the delivery of Ministerial Core Targets by NHS Trusts and LHBs; Designing and delivering the 2009 Access targets project; Providing appropriate advice, enhanced support and intervention at a local level to ensure the delivery of Ministerial Core Targets; Supporting the Directorate of Performance and Operations and the Regional Directors of the Department of Health and Social Care in the development of performance management tools and techniques; and Providing appropriate support for NHS Wales to produce and implement delivery plans. The Structure of the DSU Board and Advisory Group 1.2 The DSU will be led by a Director who will oversee the work of the unit. The DSU will receive direction from and report progress to the DSU Board 1.3 The DSU Board is directly accountable to the Head of the Health and Social Care Department and consists of the following members: 17

18 Chief Executive Officer Bro Morgannwg NHS Trust (Chairman of DSU Board); Joint Directors of Performance and Operations, Health and Social Care Department; Regional Director, Health and Social Care Department; Director of Delivery and Support Unit; and Chief Executive Officer Rhondda Cynon Taff Local Health Board. 1.4 The Terms of Reference of the DSU Board are set out below. Strategic The DSU Board is accountable to the Head of the Health and Social Care Department and through that role to the Minister; To agree the strategic direction for the DSU; To agree the outcomes of policy development work undertaken by the DSU; To advise the Minister, via the Head of the Health and Social Care Department, on the Ministerial Core Targets; To advise the Minister, via the Head of the Health and Social Care Department, on the thresholds for the Ministerial Core Targets following consultation with the Regional Offices and to oversee the intervention programme in consultation with Regional Offices; To agree the annual work plan for DSU and to review the plan on a quarterly basis; To consider reports from the Advisory Board for future policy development; To receive reports on income and expenditure and approve it in line with governance arrangements and ensure DSU remains within the pay and nonpay budgets; To agree the Service Level Agreement between the DSU and Welsh Assembly Government; To agree the accountability agreement between the DSU and Bro Morgannwg Trust; 18

19 To monitor Corporate Governance arrangements and, in particular, to approve the mechanism for maintaining the approved list of contractors and undertake the necessary involvement as described in the Operational Policy; and To approve the communications plan. Operational To receive reports on support and intervention undertaken by the DSU; To receive evaluation of the support and intervention undertaken by the DSU; To agree the operational policies for the DSU; and To be involved in the approval of the staff establishment and the selection process of staff for the DSU. 1.6 An Advisory Group for performance management & improvement will support the DSU and DSU Board. The Advisory Board will be responsible for ensuring that the DSU is delivering innovative and leading edge thinking and solutions in the areas of performance management and enhanced support and intervention. Key Principles and Behaviour of the DSU 1.7 The DSU will utilise a number of central principles to undertake its work: Work closely with colleagues in the Health and Social Care Department, Regional Offices, Health Inspectorate Wales and NLIAH to ensure coherent and focused outcomes are identified and delivered; Build relationships with LHBs, Health Commission Wales and Trusts to ensure delivery against key targets and for the transfer of knowledge; Intervention and support must lead to improved patient experience and access; 19

20 Work with evidence-based data and knowledge to develop systems of intervention and performance management; Accurate and timely information will underpin all decision making; and Clinicians and front line staff will be involved in all enhanced support and intervention work. 1.8 The operating philosophy of the DSU is one of support, action planning and learning which will ensure that organisations and the wider health community are assisted in developing a broader knowledge base, new and improved skills and practical experience of achieving high levels of performance. The DSU will therefore be driven by three key behaviours: Lead not blame: take responsibility for actions; Work together not undermine each other seek out opportunities and also work out how to enable colleagues to deliver their goals; and Look for answers and not excuses spend time on identifying real solutions and not redefining the problem. 20

21 Appendix 2: DSU OPERATIONAL POLICY TASK GREEN performance AMBER performance RED performance Ministerial Core Targets identified by Minister and communicated to service Yes Yes Yes Thresholds will be set by the Minister on the advice of the DSU Board, which includes the Director of Performance and Operations and a nominated Regional Director Yes Yes Yes Performance monitored against thresholds by Regional Offices Yes Yes Yes 21

22 TASK GREEN performance AMBER performance RED performance Enhanced tailored support Terms of reference of tailored support Disclosure of information on previous support and outcomes None - but organisations can seek advice from DSU For examples of good practice only Organisations may invite DSU in at this stage to review action plans or provide other assistance RO may seek advice from DSU concerning the organisation s action plan If performance worsens further towards red then discussion will be held with RO and the action plan reviewed by DSU together with RO and the organisation Organisation may be encouraged to seek DSU assistance prior to it going into red Terms of reference drawn up by client i.e. the organisation that invited DSU into the service Terms of reference signed off by client and DSU and communicated to RO Yes - but organisation has to give permission for this Yes The DSU will undertake a diagnostic and provide tailored support if required. Support will be tailored to the specific needs of the organisation after discussion with RO and organisation The support will range from a minimum of a meeting with a review of the action plan through to a diagnostic report and more enhanced support Terms of reference drawn up by DSU after consultation with RO and organisation DSU, RO and organisation signs off terms of reference Yes - all intelligence is shared 22

23 TASK GREEN performance AMBER performance RED performance Review of current support and additional support N/A Current and potential additional support from agencies/consultants other than DSU for this target area to be disclosed in action plan All current and additional support outside DSU intervention to be agreed with DSU for this target area Support provided by NLIAH Support from NLIAH would continue DSU informed of NLIAH s relevant programmes in organisation and discussion held between NLIAH, DSU and organisation as to whether NLIAH support continues whilst DSU is onsite DSU may recommend additional NLIAH support to organisation Organisation or RO is the client depending which organisation invited DSU in DSU informed of existing relevant NLIAH support It is expected that NLIAH support will be discontinued for the time DSU is supporting the organisation RO is the client Client of report from diagnostic N/A 23

24 TASK GREEN performance AMBER performance RED performance Report sign off N/A Report goes to DSU to ensure terms of reference have been covered Report is sent to organisation(s) for points of accuracy and then to RO for points of accuracy. Report to be signed off /accepted by organisation(s) Report goes to Director DSU to ensure terms of reference have been covered. Report is sent to organisation(s) for points of accuracy and then to RO for points of accuracy. Report to be signed off /accepted by organisation(s) and RO. Report presented to organisation s board by DSU Wider communication of lessons learnt Yes - in line with Freedom of Information requirements Yes - in line with Freedom of Information requirements Yes - in line with Freedom of Information requirements Action plan production Presentation of workshop by DSU N/A N/A Current action plan signed off by DSU or new action plan produced with the assistance of the DSU Only if organisation requests Action plan drawn up with assistance from DSU and action plan to be signed off by organisation s Board Requirement to be undertaken with DSU involvement Performance management of action plan N/A By regional office unless RO delegates to DSU for Ministerial Core Targets DSU intervenes if performance is deteriorating The Action Plan will be jointly performance managed by the Regional Office together with the DSU 24

25 Operational policy for ad hoc requests or troubleshooting The operational policy for amber organisations will be followed REQUEST GENERATED BY REGIONAL OFFICE DSU BOARD ACTION Organisation or health community i.e. self referral Yes, regional office informed Makes final decision on whether DSU intervenes if outside Ministerial Core Targets. Director makes decision if within Ministerial Core Targets Organisation draws up terms of reference Diagnostic/support provided by DSU or organisation given access to approved list of contractors Regional office Initiated by regional office Would normally accept referral from RO unless there is an issue of resources All the rest of the procedures as per amber performance Terms of reference drawn up by RO and organisation RO is client. All the rest of the procedure is as per red performance 25

26 Appendix 3(i): KEY STAKEHOLDER RELATIONSHIPS The Interface with NILIAH The following protocol will govern NLIAH activity and its relationship with DSU TASK GREEN AMBER RED NLIAH existing support NLIAH new support N/A as DSU is unlikely to be supporting these organisations. However, if an organisation requests the support of DSU then NLIAH support will continue as well unless otherwise agreed between NLIAH and DSU NLIAH will continue to support these organisations if requested by the organisation Identification of existing relevant (to intervention) NLIAH support and discussion held between NLIAH and DSU as to the best approach for handling the NLIAH support and the DSU intervention. DSU may commission NLIAH to provide support either alone or with DSU. If so terms of reference will be agreed between NLIAH and DSU and organisation and DSU will receive a regular update on progress of work (frequency to be agreed) Identification of existing relevant (to intervention) NLIAH support and discussion held between NLIAH and DSU as to timescale for the handover of the work from NLIAH to DSU At the end of the DSU intervention, discussion held as to how the work programme is transferred back DSU may commission NLIAH to provide specific support either alone or with DSU. If so, terms of reference will be agreed between NLIAH, DSU and organisation, together with the Regional Office The DSU and Regional Office will receive a regular update on progress of work (frequency to be agreed) 26

27 Information Sharing It is vital that there is also a clear protocol for the sharing of information, that this owned by Chief Executive Officer s of Trusts and LHBs and that its use is transparent. The following approach will be followed. GREEN AMBER RED NLIAH DSU Information managed within programmes. No disclosure other than through board and other published reports. Share learning points from interventions with DSU As green but additional information disclosed as authorised by client CEO and/or to support any referral by NLIAH to RO Share learning points from interventions with NLIAH. NLIAH discloses all relevant information to DSU. CHKS data will not be disclosed by NLIAH Share learning points from interventions with NLIAH. Note: The red, amber and green bands relate directly to the current performance measurement framework used within the Balanced Scorecard within NHS Wales. The bands will be used to determine the involvement of the DSU in assisting organisations to achieve the Ministerial Core Targets. 27

28 Appendix 3(ii). The Interface with Health Inspectorate Wales (HIW) The DSU will interface with Healthcare Inspectorate Wales (HIW) at various levels, specifically: The general findings from the DSU intervention work may be used to inform the future programme of work for HIW; Following an inspection or an investigation, HIW may advise and recommend that the organisation(s) seek enhanced support from the DSU in specific areas; and The DSU will use the reports produced by HIW to identify examples of good practice and to highlight areas that may give rise to concern and impact on patient care and/or organisational performance in the future. 28