Organisational Development Action Plan for Cumbria

Transcription

1 Organisational Development Action Plan for Cumbria Organisational Development Strategy Actions to deliver the vision of providing person centred world class quality healthcare against the Trusts Strategic Objectives / Master Change Plan (Priority Measures): 1. Building the Platform necessary for long term sustainable delivery 2. Continuous quality and safety improvement 3. Consistent achievement of all NHS constitutional standards, national and local performance targets 4. Ensuring workforce capability and capacity 5. Delivering long term financial stability 1

2 Work Stream 1 - Board Development Ref What Description of what is to be done Why Include the reasons for completing this work e.g. reference to national guidelines etc. Who / How How is it to be delivered When Start / End date Measure MCP / Strategic Obj. RAG Ratin g 1.1 Increase Non-Executive visibility in the Trust. 1.2 Determine an organisational narrative for cascade during board visits. 1.3 Update the Board Development Plan using an independent advisor and set a baseline to measure progress. To increase staff engagement and visible leadership. To ensure consistency and reinforcement key messages to all staff To maintain board awareness and knowledge of key areas for strategic focus. GT Create a calendar for Non- Executive visit programme to hospital areas AF/GT/CR Prepare a crib sheet to be used on visits ensuring same story is being relayed and received by all staff. JT/PS From the baseline set, determine and commission a refreshed board development programme, including evaluation. Create an internal and external evaluation schedule for the board and build into annual board cycle. Oct 14 Oct 14 Sept 14 Programme dates set and feedback reported to the Trust Board. Staff understand the direction of travel of the trust. Questionnaires collated and results received. Board Development Programme completed and agreed by Board. 1.1, , , 1.1, 5.1 2

3 Develop strong sustainable relationships with partners further 1.4 Align all enabling strategies in the Trust via the Integrated Business Plan approved by the Board. Performance reports to the Board to ensure compliance and give assurance of delivery. 1.5 Ensure board champions are identified for each key governance committee. 1.6 Coaching relationships with board members to be discussed with CEO / Chair during personal development planning meetings. 1.7 Work with the Acquiring trust to develop a people / OD focused plan for the transition. 1.8 Board commitment to a standardised Trust Improvement Methodology (CLIC). 1.9 Refresh the 2014/15 Board Development plan. Ensure alignment with partners Provide leadership and governance to the Trust Governance reporting and consistency Developing Board Skills and Performance Preparing for acquisition - to support a smooth transition post acquisition Developing Board Skills and performance Development plan updated following feedback form CQC inspection April 14 AF/GT Contribute to system level groups and developments. CEO / DS / DF Strategies completed Review and progress monitored HRD AF / GT Specialist programmes accessed where appropriate AF GT Board to undertake training and agree their role in promoting and supporting the CLIC improvement methodology throughout the whole Trust. JS Plan updated with reference to key documents From April 14 Oct 2014 Oct 2014 As per annual board dev. cycle When transiti on date agreed Oct 14 onwar d Recognition of proactive system leadership. Report to Board. Key priorities managed via Master Change Plan evidenced by regular performance reports. Reports received, acted upon and agreed by Board. Reports received, acted upon and agreed by Board. Coaches and timescales agreed and in place where appropriate. Plan delivered by agreed date. CLIC improvement methodologies used to drive improvement in all clinical business units and corporate departments. 1.1, 5.1 MCP , , , Oct 14 Plan updated

4 Work Stream 2 Leadership and Employee Engagement Ref What Description of what is to be done Why Include the reasons for completing this work e.g. reference to national guidelines etc. Who/How Who is responsible for delivery &How is it to be delivered When Measure MCP / Strategi c Obj RAG Rating Business Unit Development Programme supporting Collective Leadership 2.1 Develop the collective leadership model. Identify how many leaders are needed, of what kind, in which positions, with which skills and define the way in which they should behave both individually and collectively. PHASE ONE: To identify the desired future collective leadership capabilities and leadership culture Based upon diagnostic tools for individual and team assessment and will align with NHS Leadership Framework HR and AIS Undertake a strategic directions leadership and managerial profile against 22 leadership behaviours with Executive Directors, senior clinical leaders, plus other e.g. BUDs deputy BUDs,GMs Matrons OSMs Jan 2015 Identification and prioritisation of the key behaviour set for leaders and creation of suitable and appropriate development plans to improve performance. Objectives and appraisals at 95% reflecting the Values of the organisation and a quality improvement directly linked to an organisational priority. 4.1, 2.2 4

5 2.2 Clear specific outline of what the business unit directorate team is accountable for based on the Unit Business Plan 2.3 Individual diagnostics using predictive analytics tool which consists of business and managerial competencies, psychological profiling (critical business thinking and emotional intelligence / resilience) This will also be based upon the values and cultural ethos work PHASE TWO: A clear understanding of what the business unit directorate team is accountable for PHASE THREE: baseline assessment for individuals and the team HR JR GN - Determine BU Obj: o Safe and sustainable services within available finances o Opportunities for growth o Understand financial drivers to achieve balanced budget and CIP o Clear standards of service to patients within recognisable improvements in clinical practice o Performance standards e.g. A&E, Cancer, Referral to treatment 18 weeks and other specific targets o Role clarification GM, CD, OSM, Matron AIS Helen Ray Executive Directors and BUDs Individual Assessment against analysis of competencies Competency self-assessment of Predictive Analytics completed Feb 2015 March 2015 Business Plan SMART objectives agreed Align personal 360 degree feedback with agreed strategic behaviour profile Completion of appraisals and PDPs Individual Appraisals and personal development plans with feedback on strengths and priority areas to develop agreed with executive Leadership mentoring Coaching 4.1, ,2.2 5

6 2.4 Team inventory and profile based on the diagnostics. o Working together to resolve problems o Identifying how to be more effective as a team o Delegation, empowerment and accountability o Motivating teams and individuals to engage o Business plan and Performance review 2.5 Review of the effectiveness of the team Review of business plan Review of team processes Review of engagement and empowerment Identifying on-going team development Evaluation of programme PHASE FOUR: facilitated impact events with the team PHASE FIVE: review and sustainability AIS and Team Four events focused upon team coaching facilitation of the development of the business plan o Executive Directors AIS and team Executive Directors and participants Executive Leader Review of progress Matrons Programme Leadership April 2015 May20 15 Business Plan clear measurable goals and timelines Demonstration of working as a collective team Have team strategies and skills to engage people in the process Increased staff satisfaction survey results Review meeting Feedback Pre and post evaluation using core objectives Workforce related metrics, improved outcome measures 4.1, , Whilst in the main this is a practical skills based programme there will also be Inspirational Master class input where staff will; understand and operate effectively using a leadership for coaching approach develop the core skills for difficult conversations develop the core skills of leaders as coaches to motivate teams This programme builds upon the Matrons skills and experience and helps them to mature and develop a style of leadership based upon solution focused coaching. 6 Day programme designed to enable matrons to build upon their skills and experience. April Dec 2014 Increased selfawareness of own leadership style and developed this through increased use of coaching leading to achievement of compliance targets and patient experience scores. 2.2, 4.1 6

7 Coaching and Mentoring Leadership 2.7 Ensuring that coaching interventions are not delivered as a standalone approach and are linked to development programmes and the translation of learning and development into practice. Providing valuable insights and practical solutions adding greater value to individuals and the organisation. Target audience: Executive Directors, Senior Managers, Matrons and Ward Managers Coaching and mentoring interventions are intrinsically linked to individual and/or team development. On-going within current programmes A programme of diagnostics and psychometrics used to underpin coaching and mentoring conversations, and the practical, and on-going application of learning. Bespoke 360 degree diagnostics for teams/individuals. Effective self-assessment diagnostics with effective follow up and feedback with outcomes fortifying existing personal development and professional growth interventions. On - going Measure improvements in performance metrics and staff survey results. Report on number of coaching interventions Increase support for staff. Raised self - awareness. More effective and cohesive individual and team working. Ability to motivate and develop others. Increased staff survey satisfaction ratings. Higher levels of staff engagement 2.2, 4.1 Strategic Leadership Development Programme Listening, Open and Supportive Management 2.8 Delivery of a 1 year multiagency, multidisciplinary programme series which is underpinned by central overarching aims of increased leadership capability and capacity.. Target Audience: Clinical Directors, Senior Managers, Clinical Leads, GP s, Practice Managers, CCG Leads, Social Care Senior Managers Aligned to strategic priorities and organisational values. Executive support and input to embed trust values between medical staff and the Executive Directors and Senior Managers AIS and Facilitators Introductory 2 day residential 8 master classes monthly Final 2 day residential Provision of annual rolling senior leadership development programme. o Pre-programme 360 diagnostic o Understanding personal behaviour & effectiveness. o Expert national and local input and facilitation. o Individual improvement Sept 2014 June 2015 March 2015 Feb 2016 Outcome: Evidence of Increased confidence in senior leadership Strengthened leadership capacity. Improved staff survey and medical engagement results Continuous improvement of service standards Observed shift in culture of values & behaviours 2.2, 4.1 7

8 projects. o Coaching and support 1:1 2.9 Facilitation of Clinical Policy Group - Engage senior leaders by debating and making decisions about improvement and delivery of patient services through the Clinical Policy Group Creating ownership of the agreed strategic direction and implementation. COO MD DON From Nov 2012 CPG minutes show agreed way forward on all clinical strategies. Values and Behaviours Engagement Process Listening, Open and Supportive Senior Management 1.1, , The promotion of consistent leadership and management behaviours is required to meet this challenge. Clarity of the expectations of staff leaders and managers play in embedding Trust values. The priority areas are: Acute Medicine strategy across North Cumbria Obstetrics strategy across North Cumbria Paediatric strategy across North Cumbria More elective treatment across North Cumbria Values And Behaviours - To achieve a consistent engagement in the delivery and demonstration of the trusts values and behaviours. To meet the strategic goal to recruit and retain a skilled and motivated workforce we must develop a more open, transparent and actionorientated culture through communication training and role modelling; Values and behaviours discussions will be included in all development programmes as a core unit This is designed to generate engagement through discussion and case studies connecting the values with everyday practice. Staff encouraged to work in multidisciplinary teams Time out provided 1/4ly to design strategic direction of their service Priority areas identified On - going All staff are clear about the organisational values and behaviours. Values and behaviours are embedded across clinical and nonclinical practices. Staff survey results improved Patient satisfaction scores improved Staff can articulate the values and behaviours of the trust Values and behaviours are modelled at every level of the organization Strategic direction and implementation plan designed by staff. Improved patient outcomes in line with NICE and national 2.2,4.1 8

9 New Consultant 5 Day Programme - Leadership peer results 2.11 This 5 day leadership programme introduces consultants who are new to the Trust to management and leadership issues in both a practical and theoretical sense. A Programme designed for both newly qualified and newly appointed Consultants to NCUH providing skills to deliver improved performance and engagement in Trust strategy, values and behaviours. Consultants newly qualified and Consultants new to the Trust Featuring key elements such as: National and local NHS policy and strategic direction Managing Self and Others - Myers Briggs Type Indicator Service Improvement Techniques NHS Structure, Commissioning and Governance Understanding NHS Finance and PbR Leadership and Management Legal Aspects of Medical Records & Other Medic - Legal Issues Difficult Conversations SAS Leadership Programme - Leadership Sept 2014 Jan 2015 Supporting the creation of clinical and managerial leadership qualities An understanding of the strategic, financial and operational agenda of the Trust Knowledge of the challenges facing the changing NHS and wider public sector environment Improvement in performance & management practices This comprehensive programme aims to bring to life the core management and leadership competencies by equipping doctors with the knowledge, skills and experience to lead others in their day to day work in the delivery of excellent care. A Programme designed for SAS Doctors providing skills to deliver improved performance and engagement in Trust strategy, values and Delivered programme through which they will achieve: Updated knowledge about national and local NHS policy, plans, strategic direction NHCT Dec 14 Apr 15 Develop knowledge relating to national and local NHS policy, plans, strategic direction NHCT Safety & qualityputting safety first, 4.1 9

10 behaviours. A greater understanding of the strategic, financial and operational agenda of the Trust Understanding the leadership context in relation to their role within the organisation, change management and personal effectiveness Ability to deal with challenging situations Enhanced confidence in leadership skills Management Actions delivering improvements in Engagement improving patient outcomes improved management practices Improve patient experience scores Enhanced communication skills and styles 2.13 Increase Executive Director support by creating a buddy system with the Clinical Business Units to support them making decisions using the Trust Values Commence regular staff drop in sessions led by the Executive Directors Delivering skills and actions to demonstrate a more listening, open and supportive senior management team. Sept 14 From Sept 2014 Staff survey recognises the support by senior managers. Staff are encouraged to share their concerns in a supportive culture and they are addressed Time is taken to listen to staff to develop strategies to focus on North Cumbria: Nursing and Midwifery strategy Quality Strategy Medical workforce strategy July 14 to Nov 2014 Staff survey results demonstrate an improved engagement Senior Managers walk onto their areas of responsibility daily and engage with staff about what they are proud of and how they can support them to do the right thing, every time. From Oct 14 Improved performance against service delivery metrics and patient experience 10

11 2.17 Medical Staff Culture and Engagement MES Survey complete. Instrument utilised and completed by NCUH medical staff. External support specifically engaged to provide further support for medical engagement Identifying areas for improvement through linking findings to strategic planning, workforce engagement strategy, clinical strategy, quality strategy and organisational development strategy and will be used to influence current and future engagement developments Output demonstrated a predominant low level of medical engagement across all domains. Review of current findings of initial survey: Undertaken a range of Focus Groups to further understand the Medical Engagement Score s findings through discussion with the medical workforce. Focus groups held to generate engagement and accountability, and a solution focused perspective. June 2014 July 14 Aug 14 Sept 14 Oct 14 Working in Collaborative Culture Having a purpose and direction Being Valued and Empowered Climate for Positive Learning Good Interpersonal relationships Appraisal and rewards appropriately aligned Participation in decision making and change Work Satisfaction Outcome focused action plan agreed with Exec Directors Develop improved partnership working practices with Staff Side representatives 2.19 Patient Experience Time out sessions focus on motivating teams and individuals to work effectively. To increase staff engagement through the demonstration of effective partnership Aim is to support the personal and professional development of team members Identify appropriate range of programmes and events to develop and enhance partnership working Align staff behaviours with overarching organisational goals and values 658 staff attended sessions to July 61 sessions scheduled for Sept - Dec Dec 15 Jan Dec 14 Reduction in grievances and disciplinaries Effective major change processes 2 way communication process supportive of Trust strategies. Outcomes: Attitude & Behavioural changes in staff members Process changes & systems performance identified by teams Patient Experience data improvements

12 Emerging changes to culture 12

13 Work Stream 3 Building Workforce Capability and Capacity Ref What Description of what is to be done Why Include the reasons for completing this work e.g. reference to national guidelines etc. Who/How Who is responsible for delivery &How is it to be delivered When Measure MCP / Strategi cobj RAG Rating Workforce Planning Talent Management 3.1 Medical Workforce strategy to support a workforce planning model 3.2 Nurse Practitioners to be recruited and trained in time for the removal of the F1 Doctors at WCH 3.3 Complete review of nursing establishments with acuity tool and start the same process for non-ward staff. 3.4 Develop workforce planning skills within the Clinical Business Units. 3.5 Increase training cohorts for RGN students to ensure there is a greater supply of locally Identifying future workforce needs to support the strategy for the Trust Transition from reliance upon F1 Doctors to Nurse Practitioners to create a sustainable service Acuity tool used to define establishment requirements to meet service delivery. Facilitate workforce planning skills across the senior operational management team Ensure cohesive relationships Workforce strategy to be written and agreed by the Board led by Medical Director Recruitment plan to be developed by Director of Nursing and Midwifery and Medical Director Completed acuity to be delivered by Director of Nursing and Midwifery. This would include birthrate plus commissioned & outcomes actioned. Facilitation of suitable training programme to deliver skills for workforce planning HRD/DoF Recruitment team to ensure strong relationships built and effective Nov 14 July 14 July 15 Oct 14 Oct 15 July 15 Board receive and approve strategy Required number of Nurse Practitioners in post Results to October Board. 4.2 Each Clinical Business Unit has its own workforce plan. 4.2 Dec 14 More nurses trained from

14 trained staff. between Trust and University to achieve employer of choice for students to facilitate recruitment pipeline communication processes in place working with Nursing leaders Human Resources Director Leading Patient Safety Core Business Patient safety days for multiple clinical teams representing the patient pathway in a hospital to reflect on the Trust Values, Receive training in key areas and give time to teams to focus on a quality improvement that is a priority to them. Patient Safety & Quality Improvement must be developed across all disciplines. Target audience: Multidisciplinary ward teams Rolling face to face patient safety days incorporating a core patient safety focus. Provide understanding in both theoretical and practical application improvement methodology. Training and awareness of Human Factors Team based development Shared learning and clearly defined best practice models. Empowering staff to lead patient safety within their own team Biannual ly Improved staff survey results. Increase levels of excellence in patient care and clinical outcomes Encourage closely integrated pathways Undertake Mapsaf safety culture survey as part an annual snapshot of progression Improvement in patient experience scores Team Development Core Business 3.7 Team development sessions with profiling e.g. Belbin, MBTI, Insights, Team building, Mediation, Individual diagnostics 360 feedback, Neo /Hogan psychometrics Providing the backdrop to enable further development of team skills and capabilities to improve performance Initial team assessment through discussion then appropriate diagnostics e.g. Aston team Inventory /Team Health check Leadership style of the team Shared purpose Personal responsibilities Holding to account Setting and managing team priorities ongoin g Values and behaviours embedded Improved team working Standards agreed and upheld Increased staff satisfaction scores Reports of team intervention outputs Individual feedback

15 linked to PDPs Training and Development as Core Business 3.8 Develop line manager skills training programme to cover all basic operational line management processes in accordance with policies 3.9 Develop & implement a staff health & wellbeing strategy. Ensure that there is appropriate understanding and capability of all line management processes to enable effective and efficient outcomes in line with trust policies. Continued support for staff reduce and prevent sickness absence 3.10 Introduction of care certificate. Improvement in the skilling and Work with training team to develop and implement a comprehensive training programme of practical skills for line managers including: ESR, Recruitment, Appraisals, Managing Sickness, Grievances, Disciplinaries, planning completion of team stat and Man training in accordance with delivery schedule Develop OSMs, matrons & ward managers to use improvement tools also raise awareness through patient safety days. Work with the Health and Wellbeing committee to provide good governance and information in respect of risk areas and inform strategic plan. Planning and delivery of relevant training programmes via training Dec 15 Dec 17 Improved compliance with Stat and Mandatory training. Reported through Workforce Committee with recovery plans if required. Appraisal completion rate improved Reduction in time taken to complete investigations Reduction in suspensions (cost) Sickness Rate reduction to 4% (2015) & 3.5% (2016). Effective use of mediation recorded number of mediations used and where to identify potential hot spots CLIC improvement methodology used to improve patient safety Health and Wellbeing strategy to be in place and approved through Board. 4.1, , , Dec 15 No of certificates. 4.1,

16 3.11 Support the secondment of HCAs to qualified status Preceptorship programme for all new qualified nurses Effective and comprehensive induction programme appropriate to the needs of all staff and specific to specialities where relevant. Emphasising values and behaviours already assessed through recruitment. Specific to clinical and non-clinical roles recognition of training for patient facing staff. Development opportunities for nursing staff at all levels supporting continuous improvement To continue to develop staff awareness of values and provide a comprehensive portfolio of knowledge at the start of the employment relationship to ensure all staff are as effective as soon as possible in their roles team. DNM to provide report on progress and ensure programmes are in place and to satisfactory standard Continual development of induction programmes and utilisation of all mediums to ensure understanding, safety and compliance from Day One. Dec14 Sep14 Dec 14 ongoin g Management Skills Programme building Managerial Capability and Capacity EMT approval. Performance reviews and increase in internal nursing recruitment pipeline Audit/Check all new band 5 files Monitor through Workforce Committee. Feedback from new starters on induction programmes Retention of employees Delivery of multidisciplinary programme series which is underpinned by overarching aims of increased management capability and capacity. Core development includes; Leadership and management Corporate and human dimensions of change Provides assurance across the organisation that managers are equipped with the required knowledge and skills to deliver effective service AIS Organisational and External presenters This is a 5 day programme designed to provide delegates with core management skills Feb 2015 Workforce compliance targets are met Evidence of stronger management teams driving and delivering the change required. Delivery of compliance

17 Service Improvement Engaging your staff Managing teams Managing performance Communication skills Appraisal process Managing Governance and risk Finance requirements. Aligned to strategic priorities and organisational values. development. Target audience: Managers Band 6/ 7 and above. against set targets in: Clinical Safety Quality Governance Workforce Financial Nurse Leadership Programme Building Ward Managers and Nursing staff capability and capacity 3.15 Achieving excellence in clinical outcomes, patient care and integrated pathways, whilst delivering on quality, safety and regulatory compliance. Multi-disciplinary ward teams and managers of all staff grades working together to focus on the importance of patient experience as an indicator of safety and quality Motivating and leading teams to develop the ethos of team working, the impact of behaviours and communication skills on the delivery of compassionate care. Organisational workforce capability and capacity to lead improvements in Patient Safety and Quality Improvement across all disciplines. Getting the best from our Teams improving patient experience and working environment AP Structured Time Out Sessions for Wards Half day or full day programme - Ward Managers, and multidisciplinary teams Patient Experience Understanding ourselves : implications for team working & communication using insights profiling agreeing our way forward Human factors : supporting our safety culture Stop the Line: preventing errors Formalise & communicate nurse CPD arrangements PC 2 Day Programme: Each participant is supported in this process of development with subsequent 1:1 subsequent coaching sessions. Target audience: Band 5& 6 Nurses 2014 Ward Accreditation Improved patient experience scores Increased confidence in leading skills for practical application of knowledge to deliver visible outputs in practice Maintaining high standards of care Enhanced leadership and management capability of frontline nurse managers Improved time management and goal setting Increased staff satisfaction scores Reduction in SUI s & Never Events 2.2,

18 Work Stream 4 Aligning Systems and Processes Ref What Description of what is to be done Why Include the reasons for completing this work e.g. reference to national guidelines etc. Who/How Who is responsible for delivery &How is it to be delivered When Measure MCP / Strategi c Obj. RAG Rating Consultant Recruitment Panel Training 4.1 Monthly delivery of a 1-day Consultant Recruitment Panel Training process. Programme designed to generate a pool of capable and competent consultant interview panel members, equipped with the relevant knowledge and skills to complete the appointment process. This is a compulsory programme which all consultant interview panel members must complete prior to sitting as a panel member. Target audience: Executive Directors, Consultants, Senior Nurses Ongoing 1/mth To increase clinical leadership capacity and capability from new recruitment Impacting on reduce costs of locum cover Number of panel members trained High quality candidates employed in the trust Increased number of consultant appointments

19 Recruitment and Retention Management Actions 4.2 Establishment and utilisation of recruitment tracker system for all medical recruitment by all operational managers involved in this process 4.3 Adopt NHFT brand & secondment & overseas recruitment. 4.4 Transfer or terminate medical locum staff not on Master Vendor/NHS locum rates. 4.5 Rigorously replace locums with substantive appointments. 4.6 Introduce values based recruitment for staff in direct clinical care posts. 4.7 Extend consultant recruitment process to include VBR psychometric tool. Measures of control and management of all medical recruitment. Medical recruitment & retention baseline for Consultants and non-consultant staff. Includes costed establishment control for filling all vacancies. Integrating trust values through all practices starts with the recruitment process and indicates compatibility at the earliest stage of the employee/employer relationship Tracker system designed/created and then maintained by recruitment team but referred to by all operational managers prior to recruiting medical staff either substantive or locum Medical recruitment now managed through NHCFT recruitment team Managed transfer/termination programme. Recruitment team NHCFT Ongoing recruitment programme using both focussed campaigns and regular advertising. VBR project piloted for HCA staff then rolled out once successfully adapted to NCUH. Further development of VBR process all recruited consultant posts currently subject to competency based psychometrics. Jun 14 Nov14 Establishment for Consultants CEO approved. Establishment for nonconsultant posts CEO approved Tracker system fully implemented and maintained 4.2 Apr 14 % Vacancies reduction. 4.2 Dec 14 Cost savings on rate of pay. 4.2 Dec 15 SLA in place. 4.2 Mar15 Pilot completed and VBR process available for all staff. All recruiting staff trained in VBR interview skils. 2.2 Mar16 2.2,4.2 19

20 4.8 Introduce aptitude and psychometric tools as part of normal recruitment process and review policy accordingly Ensure standardisation of recruitment and further inform development and training needs Utilisation of occupational psychologists for delivery and interpretation Dec 15 % recruited using tests. 2.2,

21 Revalidation and Appraisal Skills Development Programme 4.9 In order to meet the priorities for improving and achieving quality and safety all members of staff require clear objectives staff must understand their contribution to organisational success and the knowledge and skills to ensure they can complete their role safely and to the required standard. The importance of good appraisals is to engage staff, increase job satisfaction and motivation to perform well in their roles. This is a rolling programme of training for all doctors. AIS Programme includes introduction of the Clarity appraisal toolkit that combines on line appraisal recording to support Revalidation. Consultants must provide quality strengthened medical appraisal for revalidation; including active listening and giving feedback Appraisal and Development Management Actions Ongoing 1/mth Streamlined process. Clear revalidation and appraisal process framework. Competent trained appraisers All appraisals of Doctors completed annually and in accordance with compliance requirements Roll out of new appraisal work book for all staff and demonstrate link between Trust Values and performance. Ensure Policy is updated accordingly. Continuation of embedding the values of the trust into people processes throughout the organisation. Programme of training and support for appraising managers to deliver quality appraisal process and link to values and behaviours. Mar 16 o Delivery of improved performance metrics through alignment of values and behaviours. o Completion of appraisals 95% recorded on ESR in accordance with planned delivery dates o Improved staff survey scores relating to quality of appraisals. o All senior managers have core objectives & PDP following appraisal. o All staff have clear objectives following 2.2,

22 4.11 Move medical staff to Clarity appraisal system for job planning purpose Review executive director appraisal arrangements via Remuneration Committee Review people policies to ensure that they underpin the Values in accordance with review timetable 4.14 Review effectiveness of communications systems including team brief Complete roll out of manager, supervisor and employee self-serve on ESR. Consistency and transparency of process. Qualitative executive appraisals to be completed and linked to trust values and behaviours Supporting the integration of values and behaviours in all processes. To continually improve the effectiveness and relevance of communication processes throughout the trust. To improve the effectiveness of management information system and provide timely and accurate information to managers Ensure appropriate training given to remuneration committee involved in appraisal process Policy review group to ensure values are supported appropriate training and guidance to be provided to review group. Review communication methodologies in line with technology and ensure all staff are able to access trust information appropriately ad with ease. Complete roll out programme and continue with a comprehensive follow up training process to ensure ongoing upskilling Oct 14 Dec15 Dec 15 Nov 14 Dec 14 on going appraisal 100% of Consultants are job planned. CEO sign off. All executives to have received a quality appraisal in accordance with the delivery timescale Clear objectives to be outlined and agreed Policies reference values and behaviours. Effective team briefs held with all staff feedback received and upward communication Report monthly on utilisation by manager to identify any areas that are to using effectively Provide accurate reports for workforce committee , ,

23 Work Stream 5 Improvement Methodology Ref What Description of what is to be done Why Include the reasons for completing this work e.g. reference to national guidelines etc. Who/How Who is responsible for delivery &How is it to be delivered When Measure MCP / Strategi c Obj. RAG Rating 5.1 Senior staff to have an understanding of CLIC and improvement methodology. Develop a common improvement approach that partners across organizations understand, share and is sustainable over time. Help staff to further develop knowledge and skills in service improvement that already exist and apply them to improve patient care. Help staff to improve their own jobs as they design improved pathways of care. Assist staff to understand and spread good practice. Focus efforts on service priorities Awareness of improvement methodologies agreed as part of continuous performance improvements Improvement methodologies - commenced development sessions with CLIC 30 people attended so far, to be rolled out across the organisation. 12 attendees on Executive Director Dev sessions 2 Attendees on Master class session value stream mapping: learning to see and measure value 17 attendees on Cumbria Production Systems: Awareness Session Oct 14 CLIC improvement methodologies used to drive improvement in all clinical business units and corporate departments. Improved performance against metrics and patient care pathways. Agree and record cascade system to embed improvement methodologies into the Clinical Business Units to facilitate change and improvements within the Clinical Business Units ,

24 5.2 Agree with Clinical Business Units their priorities for staff undergoing CLIC improvement methodology training. 5.3 Evaluate and address any capacity issues in conjunction with CLIC to ensure delivery of training in improvement methodologies is widespread. Awareness of improvement methodologies agreed as part of continuous performance improvements Behaviours are linked to our Trust Values. Staff in multi-disciplinary teams focus on using the Cumbria Learning and Improvement Methodology to enhance four priority quality improvements. 1: Theatre checklists and debrief 2: Discharge checklists 3: Early warning scores 4: Records Management Define and agree a roll out training programme to share the skills of improvement methodology Dec 15 Outcomes from priority quality improvement projects. o Learn the Trust standardised improvement methodology. o Learn to behave in teams to design and implement o Improved clinical processes. o Improved staff survey results. Monitor attendees on CLIC training programmes 2.1, Active transformation programme in place. To ensure continuous reevaluation of processes and improvement efficiencies 5.5 Develop tools & techniques of continuous improvement with link to patient experience: support small scale improvement initiatives. Building on the work achieved through patient experience days Utilisation of skilled staff in transformation processes Follow up work to patient experience 2016 Establish a transformation team that can support the implementation of improvements Dec 15 Include improvement methodology into patient experience days Identify small scale projects Support the development of key training initiatives for staff learning from incidents and complaints and refresh the training To ensure all staff are aware of the positive benefits of Ensure that these techniques are included in all relevant development and training Dec 15 Evidence of modules included in relevant training & development 2.2,

25 plan accordingly e.g. NEWS, dementia. learning from experience and encourage openness in reporting. programmes. programmes Improved incident and complaint levels 25

26 Development Programme Overview Sept October 2014 (Exc. CLIC) Programme Quality Improvement Improvement Methodologies Patient Experience Strategic Priorities Corporate Governance HR Practices Leadership Total hours Learning 1 4 Day Engagement Programme Anaesthetics Team Day Consultant 5 Day Consultant Recruitment Panel Healthcare Acquired Infection High Performing Clinical Leaders Junior Doctors Leadership Management Skills Programme Cumbria Matrons Medical Engagement Team Days Medical Engagement Focus Groups 12 Nurse Leadership Development NLD 121s Revalidation and Appraisal Skills SAS Trust 14 Leadership Development Trust 15 Leadership Development Trust 16 Leadership Development TOTAL: Overall Total:

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