Balanced Scorecard Review Project Proposed measures, format and process

Transcription

1 Item 14 Council 05 October 2016 Balanced Scorecard Review Project Proposed measures, format and process Purpose of paper Action Corporate Strategy Business Plan 2016 Decision Trail To present to the Council the output of phase two of the Balanced Scorecard review project and seek approval for the newly designed reporting framework For approval Objective 1: To improve our performance across all our functions so that we are highly effective as a regulator. Objective 2: To improve our management of resources so that we become a more efficient regulator. Objective 3: To be transparent about our performance so that the public, patients, professionals and our partners can have confidence in our approach. Project Management Office (PMO) Balanced Scorecard Review Project In December 2015, the Council discussed the need to carry out a review of the balanced scorecard to check its ongoing fitness for purpose some 18 months after implementation. At the meeting of the Finance & Performance Committee (FPC) in February 2016, preliminary ideas for a redeveloped scorecard were discussed, with the Committee asking the executive team to carry out further work in advance of its May 2016 meeting. In April 2016, the EMT noted the direction of travel of the new report format and provided its feedback. In July, a prototype of the new scorecard was discussed at a Council workshop with feedback received from its members. At the meeting of FPC in September, the Committee approved the newly proposed reporting framework and verified its readiness for Council review Page 1

2 Next step Recommendations Authorship of paper and further information The PMO will finalise preparation of all performance measures and continue towards delivery of the revised balanced scorecard in January 2017 (Q performance) The Council is asked to: approve the revised format of the balanced scorecard report; approve the set of performance measures proposed to be reported within the revised balanced scorecard report; and, approve the terms and reporting arrangements for the revised balanced scorecard report. Gurvinder Soomal Director of Registration and Operational Excellence Tim Wright Head of PMO and Reporting Matt Dunphy Project and Reporting Manager Alex Gooding Business Planning & Reporting Manager Appendices Appendix 1: Nine key quality requirements and the Cranfield model Appendix 2: Glossary of (draft) performance measures Appendix 3: Blank template revised balanced scorecard format Appendix 4: Key terms and reporting arrangements document Page 2

3 Executive summary 1. This paper and its appendices summarise the output of phase two of the Balanced Scorecard review project. This phase of the project has involved; Engagement with all directorates to identify a set of proposed key performance indicators suitable for inclusion to the revised scorecard report, which have been compiled into a glossary The completion of a revised format for the new report (following the work to develop a prototype during phase one), and; The development of a guidance document to clarify proposed reporting process arrangements. 2. A set of 61 key performance indicators have been identified which are presented at Appendix 2, and are summarised within this cover paper for ease of reference (set out at tables 1 to 5 below). At this stage, the Council are requested to review the performance measures primarily to consider whether the right areas of performance have been identified for inclusion as organisational key performance indicators (KPI s). Some work is still required to refine certain measures to make them more SMART, and this is currently being carried out through liaison with leads around the organisation. 3. A blank version of the proposed report template is provided at Appendix 3. This follows the style and principles that were demonstrated to Council during engagement activity in July. A summary of the principles of the format is provided in this cover paper at paragraphs 22 to The proposed reporting process is set out in Appendix 4. This provides clarity on key procedural matters in report compilation and review, including arrangements for; proposing a new or revised KPI, generating performance narrative and the process for selecting measures for the high priority dashboard. A summary of the most notable parts of the process guidance is set out in this cover paper at paragraphs 26 to 34 below. 5. The EMT approved this paper and the contents of appendices at its board meeting in August, followed by the FPC at its meeting in September. Pending Council approval of the principle of the reporting framework and the draft measures, the PMO will continue to work with leads for each measure to develop them in further detail and prepare them for operational readiness. Introduction and background 6. In mid-2014, the Council approved the introduction of a balanced scorecard performance report to be presented to Council meetings on a quarterly basis. The performance report presents the Council with performance across the business in the standard balanced scorecard themes of customer service, internal process, finance and HR. Reports have been produced on an ongoing basis to the EMT, the FPC and the Council since the introduction of the report. At the Council meeting in December 2015, the Council noted it would be good practice to undertake a post implementation review of the scorecard some 18 months after its introduction to ensure that the model and its measures remain fit for purpose. 7. The PMO has subsequently commenced a project to carry out this review. Engagement activity has been undertaken with EMT, FPC, Council and heads of department stakeholders in Q1 and Q2 this year. Workshop and meeting discussions have been held with the project s senior stakeholders to re-define the organisation s perspective on its key performance measures with a balanced scorecard approach linked to business planning and risk management. Heads of department have spent time within teams working to establish their own key performance measures and to consider how target setting and action planning in these areas will drive future success. Page 3

4 8. The PMO supported this process with advice and meeting facilitation, before collating the glossary of draft performance measures for review. Output 1 Draft set of organisational Key Performance Indicators 9. Through discussion with senior stakeholders, and by reviewing the detailed memorandum from the FPC to the executive on 1 March 2016, the PMO identified a set of nine key quality requirements for delivery as part of the balanced scorecard review project. These key requirements are outlined in Appendix 1 of this paper. 10. A Cranfield School of Management model on target setting was used to support heads of department and managers in the creation of performance measures and targets across all GDC directorates. The model employs a ten step target setting process to evaluate the impact of measures which deliver success on behalf of an organisation s major stakeholders. The model s ten step process is also outlined in Appendix Engagement with managers from across the organisation related to focusing on the specific nature of success and performance in each area and how vital it is to create measures that have real impact and a tangible meaning for staff and managers. The PMO supported discussions with specific advice on target setting, particularly in areas where the measurement of success is challenging to define. 12. The glossary of performance measures collated by the PMO will form an audit trail for those initial measures subject to EMT, FPC and Council approval and will also help to monitor changes made in future: where measures are proposed and approved for inclusion after the project go live date, or where measures are approved for removal, the glossary will be updated to reflect this. 13. The glossary of draft performance measures is available in Appendix 2 to this paper. For ease of reference, tables 1-5 below list the title of each of the proposed measures from each of the directorates. 14. At this stage, the Council is requested to review the performance measures primarily to consider whether the right areas of performance have been identified for inclusion as organisational KPIs. 15. The PMO are continuing to work with leads for each measure to develop them in further detail, refining them where necessary to make them more SMART and prepare them for operational readiness. The glossary at Appendix 2 will be amended with supplementary information in advance of a final review for operational readiness by the EMT during Q The main benefits of applying the Cranfield model at the GDC are that it has allowed the organisation to consider which of its performance measures are critical to success on behalf of major stakeholders. It also allows better ownership of measures and performance management in each area. The approach also provides a firm governance structure for performance monitoring and action planning based on the regular reviews of the scorecard by EMT, FPC and Council. 17. Proposed Fitness to Practise directorate measures are listed within table 1. These contain the key timeliness, quality and cost measures identified by the management team as of the utmost importance for the management of the core function, as well as for the Illegal Practice, Corporate Legal and Data Security areas. Page 4

5 Table 1 Summary of proposed Fitness to Practise key performance indicators BSC/FTP/001-85% of cases to be appropriately assessed within 17 weeks of receipt BSC/FTP/002-85% of cases to have substantive case examiner decision within 9 weeks of referral BSC/FTP/003-85% of prosecution cases heard within 9 months of referral for prosecution BSC/FTP/004-85% of prosecution cases (ELP s) heard within 9 months of referral for prosecution BSC/FTP/007-80% of the English and Welsh cases in the Illegal Practice team will have a charging decision made within 9 months of receipt of the complaint BSC/FTP/010 - Budget for legal costs for interim order, prosecution and resumed matters controlled (including external legal spend and monitoring of ILPS/ELPS referrals split) BSC/FTP/013-90% positive feedback on corporate legal customer surveys BSC/FTP/016 - The GDC effectively reports, records and learns from Data Security Incidents. (Further detail of lessons learnt arrangements to be added) BSC/FTP/005 - Composite measure: Initial Interim Orders heard within recognised time limits and without loss of jurisdiction. BSC/FTP/008 - In 100% of cases which are listed by the IP team for prosecution in England and Wales a full costs award shall be sought BSC/FTP/011-95% of Corporate Legal matters responded to within required time limits BSC/FTP/014-95% of Data Security Incident cases to be appropriately assessed within time limits BSC/FTP/006-95% of cases requiring review are monitored appropriately and in accordance with standard operating procedures BSC/FTP/009 - Composite measure of process robustness and adherence across the stages of FTP taking into account outcomes and peer review status (further detail to be defined) BSC/FTP/012 - Reduction in number of Corporate Legal matters dealt with externally and in line with budget 9further detail to be defined) BSC/FTP/ % GDC staff receive regular training in respect of FOI/DPA and data security (Further detail of exact training arrangements to be added) 18. Proposed Registration directorate measures are listed within table 2. They provide coverage of key performance in the areas of registration application timeliness/productivity/quality, call centre productivity, registration customer service, applicant income and PMO/compliance and project delivery quality. Table 2 Summary of proposed Registration key performance indicators BSC/REG/001 - The average overall time taken for processing Registration applications is lower than: 1) The internal SLA 2) The statutory requirement BSC/REG/004-80% of respondents either strongly agreeing or agreeing with the statement I was satisfied with the customer service I received from the GDC. BSC/REG/007 Composite measure to demonstrate performance in relation to Minimum Acceptable Productivity (MAPs) levels (Further detail to be defined) BSC/REG/002 - The average time taken with days on-hold removed for processing Registration applications is lower than: 1) The internal SLA 2)The statutory requirement BSC/REG/005 - The amount in of application income collected vs the target amount in. BSC/REG/008 - Placeholder measure pending recommencement of Registration audit process 100% of Registration Audits result in a pass rating BSC/REG/003-85% of those calls presented to the Customer Advice and Information Team are answered BSC/REG/006 - The amount of applications processed vs the target amount. BSC/REG/009-85% or greater responses received in the positive sections of the PMO customer service survey Page 5

6 BSC/REG/010 - Placeholder measure Compliance effectiveness measure to be developed following the repositioning of the team into second line risk defence activity BSC/REG/011 - All projects outlined in the 2016 operational plan are initiated and delivered in line with stakeholder expectations 19. Proposed Strategy directorate measures are listed within table 3. They provide coverage of key performance in the areas of Communications, Standards, QA & Education and the DCS. Table 3 Summary of proposed Strategy key performance indicators BSC/STR/001 - Communications - Key opinion formers and stakeholders reflecting the improvement work at the GDC and reflecting this at conferences, in the trade press and in social media at least 6 instances per quarter BSC/STR/004 - Communications - The number of GDC Twitter account followers to increase by 5% per quarter BSC/STR/007 - Standards - All projects and research outlined in the Policy & Research board signed off work plan are initiated, and in the projected timeframe and all GDC research is published and disseminated BSC/STR/010 - Quality Assurance & Education - Delivery of QA of specialty training, including process for internal review and improvement. Implementation of process and approval of specialty curricula including process for revision. BSC/STR/002 - Communications - GDC proactively engages with stakeholders at meetings, events and conferences and this engagement is coordinated by the communications team to ensure spokespeople are speaking with one voice at least 24 instances per quarter BSC/STR/005 - Standards - All queries in relations to the GDC s Standards are answered in full within a 2 week timeframe BSC/STR/008 - QA & Education - Keeping QA stakeholders informed and involved in a timely manner. Attending meetings and events and contributing to developments. Raising awareness of developments at the GDC. 75% (TBC) attendance of specified meetings. BSC/STR/011 - Dental Complaints Service - Achieving 90% and above in the excellent and good categories for feedback received from both patients and dental professionals BSC/STR/003 - Communications 12 newsletters to be published to internal staff on an annual basis to be opened by at least 40% of staff BSC/STR/006 - Standards - The Standards team attends stakeholder events in which we provide high impact on the outcomes/purpose of the events, or in which we improve our reputation and relationships by being there (further detail being defined) BSC/STR/009 - Quality Assurance & Education - Delivering all QA inspections according to agreed 2016/7 timetable on time and to a high quality. Deliver monitoring activity to BSC/STR/012 - Dental Complaints Service - All enquiries and complaints acknowledged and progressed within agreed timeliness SLA s (Composite measure with further SLA detail to be added to glossary) 20. Proposed Finance & Corporate Services directorate measures are listed within table 4. They provide coverage of key performance in the areas of Finance, IT and Facilities. Table 4 Summary of proposed Finance & Corporate Services key performance indicators BSC/FCS/001 Finance Total organisational income is 100% or greater of budgeted level BSC/FCS/004 Finance The DB pension scheme funding position, where the value of the scheme s assets is compared to the value of its liabilities, is funded to 100% BSC/FCS/002 Finance Total Fitness to Practise spend is within acceptable tolerance (-/+2%) of budgeted level BSC/FCS/005 Finance Internal financial reports to be submitted on or prior to the deadline in 10 or more months out of 12 BSC/FCS/003 Finance Total organisational spend is within acceptable tolerance (-/+2%) of budgeted level BSC/FCS/006 Finance Composite timeliness measure for; associates fees and expenses, staff expenses, invoices and refunds Page 6

7 BSC/FCS/007 Finance 100% of invoices have a valid purchase order number on them (in instances when a PO would be expected) BSC/FCS/010 Facilities Composite measure to aim for: 0 major breaches of health and safety, 0 serious accidents, 0 Improvement of Prohibition Notices issues by Health and Safety Executive BSC/FCS/008 IT Exceeding 95% compliance against IT Service Level Agreement Exceeding 95% customer satisfaction against submitted customer service surveys ( ed to requestor at point of service ticket closure) BSC/FCS/011 Facilities Building lifts are available for 100% of time during the month (excluding scheduled maintenance events) BSC/FCS/009 IT Exceeding 99.7% uptime on each of the key IT systems 21. Proposed HR & Governance directorate measures are listed within table 5. Table 5 Summary of proposed HR & Governance key performance indicators BSC/HRG/001 - HR - To complete the recruitment campaign from start (date of online requisition) to finish (candidate appointed) within 6 weeks Keeping the average cost per hire below 2,500 for employee and middle managers For 90% of roles recruited first time round BSC/HRG/004 - HR - To have an appropriate number of disciplinary cases and grievances (placeholder measure - exact metric and target level pending further EMT discussion) BSC/HRG/007 - Quarterly pulse surveys around leadership behaviours show an average score 4 or above for the chosen Leadership Behaviour heading BSC/HRG/010 - Governance - No more than two sets of minutes each quarter being sent to director more than 4 working days after meeting. BSC/HRG/002 - HR - Number of sickness days taken by employees being below national average of 7.9 days per annum BSC/HRG/005 - Annual 360 feedback for staff shows average score of 4 or above for each of the 4 Staff Behaviour headings BSC/HRG/008 - Governance - 90% satisfaction level from EMT and Council members in relation to meeting support BSC/HRG/011 - Governance - 95% of papers to be shared in accordance to planned deadlines in advance of meetings BSC/HRG/003 - HR - Natural turnover being below 4.3% (industry average) Overall turnover being below 11.9 % BSC/HRG/006 - Annual 360 feedback for managers shows average score of 4 or above for each of the 5 Leadership Behaviour headings BSC/HRG/009 - Governance - Meeting costs are 100% or less than budgeted levels Output 2 - Proposed scorecard format 22. The PMO has developed the prototype version of a revised scorecard report with the aim of meeting the nine key quality requirements set out at appendix Following the incorporation of EMT, FPC and Council feedback, the current version of the report template has been finalised. 24. The report has been designed in four distinct modules, which are as follows: 25.1 Executive Summary: The one page executive summary would pick out a limited number of key noteworthy points from throughout the report. Page 7

8 Narrative would be more concise than in the current format and would have increased emphasis on actual or potential impact of emerging performance issues, and focus on steps that management are taking in response. In order to provide clear focus to the executive summary, narrative would be provided under each of the following sections: key performance issues, notable performance successes, key links with corporate risk reporting, key links with business plan reporting, horizon scanning and key actions proposed following initial EMT review. This section is particularly designed to meet key requirements E, F, G and H as listed in Appendix Section 1: This is an overall dashboard for measures of the utmost organisational importance, including major cost drivers. It is envisaged that this would be the EMT and Council level dashboard and has been designed to provide visibility of those for those issues that are most in need of board attention. The selection of individual measures in this section would be due to their potential to lead to significant reputational or in some instances patient safety risks. It is proposed, however, that there would be flexibility to escalate or de-escalate measures to and from this level based on current business context. This would allow content to be refined over time to ensure that the dashboard continues to present boards with the most pertinent measures at the time of the report. In order to mitigate the risk that this approach may limit sufficient detailed Council scrutiny of holistic departmental performance, it is proposed that the FPC carry out a deep dive review of one directorates full measures at each of its meetings (along similar lines to the approach taken by ARC in review of the strategic risk register). This section is particularly designed to meet key requirement A, D and E as listed in Appendix Section 2: This section provides specific supplementary reporting for the FTP and Registration directorates. FPC have indicated the need for these departments to be reported upon in detail at each stage of the functional processes. The need for focussed reporting in this area is due to their nature as operational departments which have established key performance indicators, the effective management of which is vital to fulfil key statutory operational duties and avoid potential backlogs at any process stages. This section is particularly designed to meet key requirements B, C, D, E and G as listed in Appendix Section 3: This section is designed as a summary section for escalated measures from around the rest of the business. This page is demonstrated on page 16 of appendix one. It is proposed that the PMO would continue to collect full data sets from data owners around the rest of the business. However, measures would only feature in the report by exception only based on the PMO liaising with the Heads of each department to identify measures that needed EMT/Council level visibility. This is intended to help focus discussion in key areas, and serve to trim some of the currently lengthy content from the report. Work will also be carried out to review the fitness for purpose of existing measures in these parts of the organisation, which are recognised to be in need of revision in certain areas. Page 8

9 This section is particularly designed to meet key requirement E as listed in Appendix The current blank template of the revised balanced scorecard, which includes indicative notes of how it would be filled in, is found in Appendix 3 of this paper. Output 3 Balanced Scorecard key terms and reporting arrangements document 26. The project has included a review of the process by which the scorecard is created each period and how recommendations and actions are made at all reporting points up to and including Council. 27. Two key quality requirements for the project were a closer link to action planning based on performance reports each period and a clearer governance structure for managing scorecard measures and information. These requirements led to the proposal of a document detailing key terms and reporting arrangements which should become a shared point of reference across all stakeholders. 28. The document, provided at annex 4, covers five main areas: The purpose of the balanced scorecard. The report production process and reporting arrangements. The report usages, including key roles and responsibilities for the different audiences within the GDC. The KPI development process, including how KPIs are approved and by whom. The KPI prioritisation process, outlining the arrangements and methodology for how KPIs are selected and escalated/de-escalated. 29. A number of elements of the previous production process by the MI function within the PMO are proposed to continue, alongside a number of new features to the scorecard framework. The main new features of the report, to note are summarised as follows: 30. Performance narrative: At the month end the PMO will seek commentary from areas of the business on the latest performance across all key measures. A summary of this information will then be presented to the EMT at its monthly board meeting. These updates will facilitate the creation of a quarterly performance narrative to be generated and agreed by each director for inclusion in the quarterly scorecard. An executive summary will be created using the EMT s agreed narrative each quarter. This will incorporate the business insight and performance commentary received from across the organisation. Prominence will be given to areas that has required the EMT s focussed attention during the reporting quarter either as key issues experienced or key areas of success. The quarterly executive summary will be signed off and agreed by the EMT before being included in the quarterly BSC due for review by the FPC and the Council. 31. Proposing a new or amended KPI: Any member manager or committee member can propose a new or revised performance measure. However, the performance measure must be sponsored by a Director to bring to EMT for approval, before it is recommended to the FPC and the Council. The business area where there is a proposal for a revised measure will complete a PMO performance measure template including rationale about the purpose of the measure and what area of performance it will drive. Page 9

10 New or revised performance measures will need to be reviewed and signed off by the EMT, included in the annex of the BSC report. The EMT will recommend the new measure to the FPC for approval and the Council for endorsement. New proposed measures will be annexed in the latest report to both the FPC and the Council. 32. Selection of KPI s for the top priority dashboard: An initial EMT workshop is to be scheduled in Q to determine the priority measures proposed for inclusion to the top level dashboard on the BSC. However, the BSC is flexible to adapt to changing business needs, seasonal performance measures (such as ARF collection) and responding to the external environment In order for a measure to be escalated or de-escalated to or from top-priority a Director will need to sponsor the proposed change and notify the PMO. Measures proposed to be escalated or de-escalated will be brought to the EMT Board meeting as an appendix to the report for discussion and approval, with the Director sponsoring the change acting as advocate. Any changes to the positioning of a measure will be annexed to subsequent reports to notify the Council and the FPC of the changes. 33. Other notable points within the key terms and reporting arrangements document: A BSC action plan will be generated and monitored by the PMO to ensure that actions that come out of the report are captured and monitored. There is a clear reporting schedule laid out, including deadlines for when updates and business insight must be returned to the PMO to ensure the overall report deadline is met. The schedule also details the deadline dates for each part of the process, including quality assuring and sign off points. The governance of the report is clearly outlined, following the committee and Council schedule established by the Governance team. The report is approved at EMT, before being presented to the FPC to be recommend to the Council (with the current schedule and governance procedure the Council will receive performance updates on average 10 weeks in lieu following quarter end). There is a clear process and schedule map, including a feedback loop for the EMT and the Council. There will be a user survey on a quarterly basis to gather customer feedback about the report. The BSC will be shared routinely with report contributors and all staff to an agreed schedule. Broadly, it is intended that; a red status will be an indicator of significant organisational concern, an amber status will be an indicator of either a manageable departure from performance, or an emerging risk to performance and, a green status will indicate that performance is on track. 34. Please see appendix 4 below for the draft key terms and reporting arrangements document. Next Steps 35. Following the FPC s approval and feedback at this meeting, the PMO will return to heads of function for finalisation of discrete performance measures and the full glossary as required. Development work will be undertaken on the underlying data structure for the new scorecard format and on all new reporting arrangements. Finalised information will be referred to the Council for its approval on 5 October Page 10

11 36. All final preparation will then be made ahead of the project s delivery date in January A version of the report in the new format will be completed including actual Q data, alongside a version of the report in the old format for the purpose of continuity. Recommendations 37. The Council is asked to: approve the revised format of the balanced scorecard report; approve the set of performance measures proposed to be reported within the revised balanced scorecard report; and, approve the terms of reference for the revised balanced scorecard report. Appendices 38. Appendix 1: Nine key quality requirements for the revised scorecard and the Cranfield Model 39. Appendix 2: Glossary of draft performance measures 40. Appendix 3: Blank template revised balanced scorecard format 41. Appendix 4: Key terms and reporting arrangements document Page 11