Response to Hard Truths - Action Plan Update Quarter 4 (March 26 th 2014)

Transcription

1 Response to Hard Truths Action Plan Update Quarter 4 (March 26 th 204). Prevent problems person (a) Culture and Patient Respond to staff survey results and develop an action plan as required Respond to quality walkarounds programme Respond to station visits programme Implement micro surveys Review staff exit interview process Develop and monitor suite of cultural indicators Measure Patient Culture and develop plans around improvement QC and patient, 0 & March 204 March 205 Review how all cultural indicators will be recorded, assessed and reported under review, awaiting national guidance on cultural indicators, due in Spring 204. Annual Staff Survey results reported to. Action plans reported to Equality and monitored by Organisational Development Group. Small scale/more frequent staff surveys being piloted. Exit interview process reviewed, revised processes being implemented. Cultural indicator task and finish group developing potential dashboard linked to national project. Organisational Development Strategy agreement MapSaf patient safety culture action plan to be reviewed and closed out Source new patient safety culture tool and benchmark culture to establish a baseline Progress against 202 Staff Survey Action Plan monitored by group Dec 203. Next review March 204 No national Guidance published to date MapSaf plan reviewed and closed out as now out of date from 200. Looking at more recent models to assess patient safety culture. Assess organisations Patient safety culture Maintain ECLIPS system of reporting and learning from incidents/complaints Maintain effective reporting to Ensure robust policies are in place and regularly reviewed and compliance monitored Manage risks effectively using trust risk management system / level committees/ Team and board level committees & 2 & 3 & 0 June 204 ECLIPS system maintained and lessons learned shared and actioned and reported to and Quality Review Group reports to be reviewed and metrics provided to support assurances Clinical policies regularly reviewed and updated through policy review group and Clinical advisory group review policy management processes Robust process for reporting incidents, near misses, complaints under review to improve use of Ulysses system and enable reporting of themes and trends Establishment of service line clinical governance meetings with dashboard review on performance and quality. Ensure Essential Annual Training contains up to date clinical best practice and issues on accountability. Risk management on Ulysses system to improve review and measurement tracking. Current processes being reviewed, 2 day kaizen event held and reported to ET. Reviewed process to be developed and agreed. Concept discussed with service line business manager and agreed. Dashboards under development In progress complete Policy for writing policies being reviewed and Policy Review group also being reviewed. QPulse quality system project to be progressed. policy compliance into board committees being introduced Incident investigation capacity reviewed and reported to ET (b) Openness and Candour Report Serious Incidents and learning to Clinical Commissioning Groups and Quality Review Group / / Quality Review Group & 2 Report learning on website Enhance internal reporting arrangements Provide prompt, honest and proactive responses to errors Duty of Candour QC 6 August 204 In Place Reporting on trust website under development Duty of candour included in the current standard contract since April 203 And is being reported Family Liaison s now trained and available to Process under review Implement government recommendations on duty of candour and open and honest hospitals New recommendations for duty of candour paper produced for QC and

2 . Prevent problems person support families. WEC awaiting government response (c ) Listening to Patients, Learning from Complaints Monitor incidents Engage with PALS Engage with patient focus groups Implement Equality Delivery System Ensure a robust and responsive complaints system Maximise learning from complaints Implement strategic engagement plan Establish mechanisms to share knowledge and raise issues Respond to annual staff survey results Equality Maintain Clinical Team reporting Develop and monitor net promoter score (d) Safe Staffing Trends and themes from incidents to be reported and lessons learned to prevent recurrence Clinical directorate engaged with regional PALS group Patient Engagement Strategy under development by Associate Communications March March 204 Complaints service planned to undergo review to improve systems and processes Systems in place to maximise learning from complaints Being further developed Under review Complaints team engaged with PALS and process changes have been made regarding customer feedback and complaint referrals to PALS. Good working relationships established and understanding from both NEAS and PALS regarding patient needs for feedback and complaint handling Complaint process completely reviewed and now all managed via electronic Ulysses system. Monthly reports sent to service lines on compliance with policies around complaints and reported into QC & 0 Awaiting results of staff survey 203 Results reported to 27/3/4. Action Plan outline report to in April 204.,6,7 Reporting matrix under development to feed into New clinical risks and incidents reports being monitored through Quality Implement establishment control systems Implement effective workforce planning Implement effective workforce management Implement effective resource scheduling systems Apply protected time Workforce planning Paramedic registration / CPD Develop effective CPD for wider NEAS workforce Apply principle of patient care paramount for all NEAS workforce Equality operating 3, 4, 7, 0 203/4 Improved establishment control arrangements introduced.4.3 Improved workforce planning arrangements introduced.4.3 Workforce analysis and recommendations reported to Team July Workforce planning strategy and plan reported to Team Sept. Workforce management system introduced to Contact Centre. 3, 0 203/4 Role and protected time arrangements of Emergency Care Team er under review. Workforce analysis and recommendations reported to Team July Workforce planning strategy and plan reported to Team Sept., 0 204/5 Awaiting further information Workforce Development 204 / /5 Awaiting further information Workforce Development 204 / 205 Report to March meeting of BIG, ET and Audit. 2. Detect problems quickly 2 (a) Care Quality Commission (CQC) inspections to look more closely at records Review CQC expectations and assessment arrangements March 204 Preliminary assessment undertaken of consultation information. Plan full review of Care Quality Commission expectations of ambulance services when available Full review of patient records and policies associated with same being undertaken Processes for safe transfer of paper records being developed to improve IG Mandatory use of epcr from st march 204 being monitored 2 (b) Fundamental Standards and Enhanced Quality Standards 2

3 2. Detect problems quickly Monitor proposals when published Continue monitoring and benchmarking and quality improvement of Ambulance Quality Indicators (AQIs) / / / Consultant Paramedic,2 Establish ways on improving communicating Ambulance Quality Indicators and performance against same is communicated to front line staff consultant paramedic to work with teams where clinical audit requires improvement in clinical outcomes In progress Awaiting publishing of new fundamental standards Continued reporting to and Governance & Risk Safeguarding arrangements and training Specialist training Equality 203/4 204/5 Safeguarding and specialist training inyear Workforce Development Programme 204/5 Plan in progress to include within EAT Quality committee agenda, TOR and cycle of business reviewed. New assurances and risks reports established to go live in April (c) Working Together Active participation with Quality Review Group Active participation with Clinical Commissioning Groups Active participation with Urgent Care s / Associate Strategy & Performance & 2 (d) Quality Surveillance Groups Develop and embed Quality Review Group Continue to provide Quality Report Continue to provide Annual Report Maintain governance transparency / / Team & 2 7 & 2 Quality review group now established and minutes reported into Quality 2 (e) Speaking Out Safely Reenforce arrangements Compromise agreement clause revised 2 (f) Clear Strong Governance: Role of s Equality / / 0 March 204 Whistleblowing Policy and arrangements under review. Formal wording determined with legal advice for inclusion in compromise agreements. Whistle blowing policy annual report to WEC Wording amended in standard agreement Monitor proposals to extend / enhance sanctions Respond to consultations on proposals Ensure compliance with license Ensure compliance with Monitor Quality Governance Framework Chairman / Governance & Risk March 204 Review individual contractual requirements for and Non Directors. Review and implement annual development programme Apply Competency framework for members Apply performance review for members Undertake / Governor development and engagement sessions / Chairman 0 January 204 Annual review development programme under review by & Head of Workforce Development for consultation with Chairman. To be integrated into Workforce Development Plan. Development of competency framework aligned to workforce competency framework in progress. Performance review process for and non Directors in place. Governor development and engagement programme in place. reviewed development needs at annual event in December, Ongoing action with board Report to be presented to Seminar on 27 th March 204 3

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5 3. Taking Action Promptly Person 3 (a) Clear and Meaningful Ratings Development of Integrated Quality Performance Report (IQPR) / Audit Associate Director Strategy & Performance In progress Associate Strategy and Performance developing dashboard 3 (b) Clear Risk Based Interventions Robust investigation process for incidents and complaints to enable the process of learning and identification of themes needing immediate action Improve accountability of service lines Monitor proposals Respond to consultation Risk and Governance Business Investment & Finance / Governance & Risk and all Maintain Referral / Close Out Process (up/across/down) s Service Improvement Processes Improvement Steering Group Finance ALL March 204 Current process being reviewed 2 day scoping event held in November 203 Rapid Improvement Plan Workshop planned 5 Ongoing Ongoing monitoring of service improvement project plan and progress against plan undertaken by ISG. In Progress, automated alerts for review now in place, training and prompt sheet in development 4. Ensuring Robust Accountability 4 (a) Levels of Accountability Ensure accountability clear for all responsibilities and s 4 (b) Holding to Account Chairman / team, March 204 Review all and Non roles and clarify accountability. Ensure all levels of staff are clear on accountability and responsibilities Ensure /senior managers are aware of accountability responsibilities Continue to apply capability policy Continue to apply disciplinary policy Develop Holding to Account meetings for service lines to report on performance against target s and clinical outcomes linked to clinical governance, performance and quality Equality Quality Audit 203/4 To be included in development programme and great line management training programme leadership at every level 0 No immediate actions. Capability Policy and Disciplinary Policy reviews scheduled in Policy Review Programme 4 (c ) High Professional Standards / Professional Regulation Monitor proposals and respond to consultation Implement any new regulation(s) 4 (d) Fit and Proper Test for Level Appointments TBD Awaiting further information re professional regulation. Review job descriptions, terms & conditions Improve setting and performance review process 4 (e) Internal Scrutiny and Challenge Chairman / 0 203/4 Job descriptions reviewed 203. Review setting and performance review process for members Ensure governance arrangements enable scrutiny and challenge May 204 Review s governance arrangements specifically in relation to scrutiny and challenge arrangements. 5

6 4. Ensuring Robust Accountability Ensure individuals are skilled and confident to undertake scrutiny and challenge role Equality 0 March 205 Review competency framework in relation to scrutiny and challenge skills and confidence in 204 / 205 service plan Provide appropriate training and/or support. Review frequency and impact of scrutiny and challenge Scheduled for 204/5 service plan 5. Ensure staff are trained & motivated 5 (a) Staff Engagement Implement health, safety & wellbeing strategies Implement rewards & recognition strategies Implement work/life balance strategies Implement equality & diversity strategies Equality 0 203/4 Health, & Wellbeing Strategy agreed by Equality.0.3. Seminar January 204 Organisational Development Strategy agreed by October Staff Survey Action and Service Line action plans progressing Treat Us Right Campaign launched Health and Wellbeing Strategy endorsed by board January 4 strategy endorsed by board November 3 Ongoing monitoring of action plan by group Campaign launched and reviewed, on going Treat Us Right Campaign launched and reviewed. Implement reward & recognition strategies 0 204/5 Implement staff communication strategies 6 203/4 Communications Strategy Action Plan ind into new Develop and implement Employee voice mechanisms Organisational Development Strategy for consideration by WEC Oct 203. Develop Trade union engagement and support JCC approved review of Partnership Agreement and staff engagements arrangements Sept 203 Respond to annual staff survey results & 0 Awaiting results of staff survey 203 External facilitation appointed work started Staff Survey results being reported to March meeting. Outline action plan will be reported in April (b) Education and Training Workforce development plan and programmes in expected values Equality 0 January 204 Workforce Development Plan and programmes in 2045 will include valuesbased s 5 (c) Support Workers Training and Development Workforce development plan and programme for all nonregistered frontline staff Equality 0 January 204 Workforce Development Plan and programme 2034 in place Workforce Development Plan and programmes in 2045 being drafted Workforce Development Plan and programmes in 204 / 205 prepared. 5 (d) ership Culture Review Team er role, recruitment, s Apply Team er/service manager competency framework Implement Team er/service Manager development & support programme Apply protected time arrangements for team leaders Implement internal talent management and development Engage in regional, national and international leadership programmes Network with world class organisations Equality /Exec utive team, 0, January 204 Emergency Care Team er role and protected time requirements under review by emergency Care Business Manager Talent Management programme identified personal, team and wide management development needs and reflected in Workforce Development Plan /4 Cohort Talent Management programme implemented. Feedback provided to individuals, Directorates and. Cohort 2 commenced Autumn 203. Maximum participation in funded national and regional leadership programmes. Emergency Care Business Managers currently consulting on proposals On going 5 (e ) Compassionate Care Equality, 0 204/5 Organisational Development Strategy agreed and being implemented 6 Resources to implement actions being

7 5. Ensure staff are trained & motivated Develop programme of personal exposure to patient safety / patient experience for workforce Apply wide performance review re care Clinical Care and Patient Clinical care and patient safety Implement the 6 C s in clinical practice recruited. Expected to be in place May C s to be added to the value based recruitment process. 5 (f) Value Based Recruitment Recruitment and selection processes based on expected values Effective performance review & Personal Development Programme (PDP) system Induction programme for new employees based on expected values Review Essential Annual Training (EAT) content and measure quality and outcomes of same Equality 0 203/4 January 204 Corporate and NHS values embedded in induction and recruitment process to a limited degree. Proposals for further investment in values based recruitment agreed November 203. New performance review process for Agenda for Change workforce implemented wef.7.3. Corporate performance review process includes evidence based care for all employees Corporate and NHS values embedded in induction and recruitment process to a limited degree with further development in progress. Revised induction programme for In W service plan. Workforce Development Plan and programmes in 2045 being drafted Workforce Development Plan and programmes in 204 / 205 drafted. 6 C s need to be included for 4/5 Scheduled for 4/5 service s 7