BOARD OF DIRECTORS: 1 st June 2018 AGENDA ITEM: 5.1 SUBJECT: Performance Management & Accountability Framework Rebecca Brown Chief Operating Officer

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1 BOARD OF DIRECTORS: 1 st June 2018 AGENDA ITEM: 5.1 SUBJECT: RESPONSIBLE DIRECTOR: AUTHOR: Performance Management & Accountability Framework Rebecca Brown Chief Operating Officer Rebecca Brown Chief Operating Officer PREVIOUSLY CONSIDERED BY: EGM, OMG and Divisional PRMs and as part of the Board Development Program EXECUTIVE SUMMARY: It is the Trust s intention to implement a clear Performance Management & Accountability Framework which sets out the overarching principles and approach to delivering a high performing organisation. The Performance Management Framework seeks to align information on clinical and non-clinical operational performance, activity, finance and quality to give an accurate organisational overview. The framework outlines key roles, reporting lines and accountability and is linked to the Organisational Development Strategy to ensure that the staffs have both the capacity and capability to deliver to the standards required. This framework has been reviewed extensively within the Trust at Divisional, Executive and Board level. ACTION REQUIRED BY THE BOARD The Board of Directors is asked to approve the OF DIRECTORS Performance Management & Accountability RISK TO THE TRUST (include reference to BAF or Corporate Risk Register) WORKFORCE ISSUES: (including training and education implications) FINANCIAL IMPLICATIONS: Specify No/Yes (Detailed within the report). COMMUNICATION/CONSULTATION ISSUES (including patient and public involvement) STRATEGIC OBJECTIVE: (specify trust strategic objective) Framework. Failure to implement the Performance Management & Accountability Framework could impact on the delivery of all the Trusts Strategic Risks. NIL The delivery of this framework will support the Finance Plan. NIL To be a clinically led and financially sustainable Organisation. CQC DOMAINS: safe. effective. caring. responsive to people s needs. well-led safe effective caring responsive Chairman: Alan Burns Chief Executive: Simon Weldon

2 PERFORMANCE MANAGEMENT & ACCOUNTABILITY FRAMEWORK 1. BACKGROUND 1.1 It is the Trust s intention to implement a clear Performance Management & Accountability Framework which sets out the overarching principles and approach to delivering a high performing organisation. It aims to support the Trust to foster a culture of responsibility and accountability for every member of staff at every level within the organisation. This framework aims to ensure that the Trust is successfully delivering national and internal standards for performance and contractual targets as agreed with commissioners. The Framework seeks to align information on clinical and non-clinical operational performance, activity, finance and quality to give an accurate organisational overview. The framework outlines key roles, reporting lines and accountability and is linked to the Organisational Development Strategy to ensure that the staff have both the capacity and capability to deliver to the standards required. 1.2 This framework has been reviewed extensively within the Trust at Divisional, Executive and Board level. It has been reviewed by the Divisional Leads and has been presented at the Operational Management Group (OMG) and the Executive Group Meeting (EGM). It has also been debated extensively at the last Board Development session led by NHS Providers. 2. POLICY 2.1 The Performance Management & Accountability Framework underpins the Governance Framework for the organisation and it closely linked to the Organisation Development Strategy and the Trust Disciplinary Policy and Procedures. 3. RISK 3.1 There is a risk in terms of well-led governance arrangements until a robust mechanism is in place and adhered too. 4. FINANCIAL IMPLICATIONS. 4.1 Failure to implement this framework could result in severe implications to the Trust overall performance which includes the financial performance. 5. ACTION REQUIRED BY THE BOARD 5.1 The Board is asked to approve the Performance Management & Accountability Framework and to request a further update within 6 months following role out of the Organisational Development Program and review of the Standing Financial Instructions. Rebecca Brown Chief Operating Officer Chairman: Alan Burns Chief Executive: Simon Weldon

3 Performance Management & Accountability Framework 2018/19 Version: 1 This version issued: May 2018 Review date: Nov 2018 Number of pages: 16 Author: Rebecca Brown Chief Operating Officer 1 P a g e

4 CONTENTS 1. Introduction 1.1 What is the Performance Management & Accountability Framework 2. Roles, Reporting Lines and Accountability 3. Meeting Structures 4. Individual Reporting Lines 5. Setting Standards, Targets and Monitoring Performance 6. Financial Targets 6.1 Defining Indicators, Quality Metrics and Targets 6.2 Quality Metrics 6.3 Risk Management 7. Information for Performance Management 7.1 Strategy Objective 8. Response to Adverse Performance 9. Promoting Excellent Performance 9.1 Understanding Development Needs 9.2 Meeting Development Needs 10. Corporate Function 2 P a g e

5 Performance Management & Accountability Framework 2018/19 1. Introduction It is the Trust s intention to implement a clear Performance Management & Accountability Framework which sets out the overarching principles and approach to delivering a high performing organisation. It aims to foster a culture of responsibility and accountability for every member of staff at every level within the organisation. This framework aims to ensure that Kettering General Hospital Foundation Trust is successfully delivering national standards, internal standards for performance and contractual targets as agreed with commissioners. The Trust is subject to external performance management by a number of bodies: Single Oversight Framework Care Quality Commission (CQC) Clinical Commissioning Groups (CCG) and other commissioners via contract standards The Trust has also set its Operational Objectives which relate to the achievement of the Strategy Objectives as set out in the Trust s Operational Plan. The Trusts Strategic objectives: 1. To provide high quality care to individuals, communities and the populations we serve. 2. To be a clinically and financial sustainable organisation. 3. To maintain a fulfilling and developmental working environment for our staff. 4. To be a strong and effective partner in the wider health and social care community. Divisional Objectives: Each Division will align their objectives to the Strategy and Operational Objectives. 3 P a g e

6 1.1 What is Performance Management? Plan - Setting clear priorities. Act - Establishing proper measures, agreeing specific actions that are required, implementing them Monitoring & Reviewing the outcome on a regular basis. 4 P a g e

7 Performance Management Cycle Outcomes of a successful Performance Management & Accountability Framework Implementing this Framework ensures that the Board of Directors, Divisional Triumvirates and individual staff are able to: 5 P a g e

8 Assess performance against clear targets and goals. Inform strategic decisions and support continuous improvement. Undertake exception based performance delivery tracking. Predict future performance and forecast outturn. Identify key actions. Put in place effective review meeting structures including intervention as necessary and appropriate. Focus resources and improvement efforts in required areas. Identify any systemic problems in the Trust. Evaluate the impact of new schemes and initiatives. 2. Roles, Reporting Lines and Accountability COMMITTEES Title Performance role Board of Directors Meets Monthly and Chaired by Trust Chair. Receiving, considering and challenging the executive on the performance as reported within the monthly Integrated Performance Report Quality & Safety Meets monthly and chaired by Non-Executive Director. Committee Delegated responsibilities from the Board for oversight of quality (safety, clinical effectiveness and patient experience) performance by assuring risks to quality Workforce & Development Committee Performance, Finance and Resources Committee Executive Group Meeting are mitigated. Meets monthly and chaired by Non-Executive Director. Delegated responsibilities from the Board for oversight of workforce performance by assuring risks to quality are mitigated. Meets monthly and Chaired by Non-Executive Director. Delegated responsibility from the Board for oversight of financial performance, planning and operational performance. Receives financial performance updates from the Finance Department and operational performance reports from the Operational Management Team. Meets 2 weekly and Chaired by the CEO. The Executive Group Meeting is for the Trust and its purpose is to resolve operational and/or financial performance issues ensuring that the Trust operates safely, effectively and efficiently and in a patient focussed way. Decision making. OMG Meets 2 weekly and chaired by the COO. OD & Performance Meets monthly (for each division) and Chaired by COO. Management Responsible for: Identification of appropriate measures for inclusion on the Trust Divisional Board Performance report; Performance Approving target setting. Reviews Monitoring of performance, quality and financial delivery. Actions to improve performance including effective cultural changes Quality assurance of action plans in response to adverse performance Annual plan delivery Divisions risk and mitigation Chief of the Division, Divisional Directors and Head of Nursing are held to account for Divisional performance. PTL Performance Monitoring performance weekly and taking appropriate action in between 6 P a g e

9 INDIVIDUALS Title RTT, Cancer & Diagnostic Divisional Business Meeting Specialty Business Meeting Performance role Performance Management Meetings. Meets monthly and chaired by Chief of the Divisions. Accountable to PF&R via the Divisional Performance Review Meetings and to the Executives for the Divisions performance. Assures Divisional performance and sets the Divisions Strategy. Holds Specialty Leads and Divisional Directors to account. Meets monthly and chaired by Divisional Directors Accountable to the Divisional Business meeting for Specialty Performance. Holds Clinical leads to account. Accountable to CEO for delivery of national KPIs and high quality patient care and experience. Chief Operating Officer (COO) Deputy COO On behalf of the COO is responsible for ensuring appropriate systems are in place for managing performance and supporting the co-ordination of response to adverse performance. Chiefs of Divisions Accountable to the COO for performance of the Division. Divisional Directors Accountable to the Chief of Division for performance of the Division. Divisional Heads of Nursing Finance Business Partner Accountable to the Divisional Directors for performance of the Division. Professionally accountable to the Director of Nursing & Quality for quality and professional elements within the Division. Accountable to the Director of Finance. Highlights adverse variances to the Division Management Team and attends Division Business meeting. HR Manager Accountable to the Director of HR Highlights adverse variances to the Division Management Team and attends Division Business meeting. Clinical Directors/Leads Deputy Directors of Divisions Accountable to the Chief of Division for the performance of their Division. Accountable to the Divisional Director within the Divisions for performance of the Divisions. Leading the response to adverse performance. Service Manager Accountable to the Divisional Director within the Divisions for performance of the Divisions. Lead Nurse (Matron) Accountable to the Head of Nursing within the Division for performance of the Divisions. Executive Directors Responsible for challenging and offering support to Chiefs at the monthly Performance Meeting. 7 P a g e

10 3. Meeting Structure The diagram below describes the Divisions and Directorate meeting structures. EXECUTIVE GROUP MEETING (Bi-Weekly)Chair: CEO OPERATIONAL MANAGEMENT GROUP (Bi-Weekly) Chair: Chief Operating Officer OD & Performance Management Divisional Performance reviews Medicine Surgery Family Health 8 P a g e

11 4. Individual Reporting Lines Chief Executive Officer (CEO) Chief Operating Officer (COO) Chief of Division Clinical Director Divisional Director Divisional Head of Nursing/Midwifery Service Managers Deputy Divisional Directors Lead Nurses (Matrons) The COO is accountable for performance across the three divisions and reports to the Chief Executive and the Board (as a Board Executive Director). The Director of Nursing & Quality and Medical Director are accountable for quality and report to the CEO and the Board (as Board Executive Directors). The Director of Finance is accountable for delivery of the Financial Plan and reports to the CEO and the Board (as a Board Executive Director). The Director of Human Resources & Organisational Development is accountable for the delivery of the Workforce Strategy and reports to the CEO and the Board (as Board Executive Director). Chief of Divisions are accountable for the performance of their division and report to the COO. They are supported in this role by Divisional Directors Divisional Head of Nursing/Midwifery. 5. Setting Standards, Targets and Monitoring Performance The Performance Management Framework seeks to align information on clinical and non-clinical operational performance, activity, finance and quality to give an accurate organisational overview. By drawing on a range of data sets and improving the analysis of information, the framework is 9 P a g e

12 designed to add value to different information sources and provide a comprehensive picture of the complex elements affecting the Trusts performance. By providing clarity about how information can be used, and clear roles and responsibilities for analysing and acting on the information it is envisaged that the framework will aid an evidence based culture; with the right level, type and presentation of information being provided to different areas of the organisation as appropriate. The Corporate and Divisional scorecards are made up of a number of metrics that provide the individual committees with at a glance RAG rated positions against key performance indicators including the quality, service performance, workforce and finance targets. The scorecard and exception performance reports will assist the Trust Board via the subcommittees in the assessment of achievement of the Corporate Objectives and Key Targets. The corporate scorecard is made up using the four domains within the 2018/19 Accountability Framework for NHS Trust Boards. The domains are: Quality Workforce Operational Finance The scorecards are designed at Directorate level with indicators feeding up to the Divisions level and then at corporate level. 6. Financial Targets Financial performance targets are agreed with Divisions through the budget setting process. Each Executive and Chief must adhere to the Trusts Standing Financial Instructions (SFIs). With respect to significantly adverse financial performance after 1 month, the option will be available for Divisions performance to be separately reviewed in more detail with the Director of Finance. The purpose of the meeting(s) would be: To scrutinise monthly, year to date and forecast financial performance against budget, including income and expenditure, workforce and CIPs. To provide constructive support, advice and feedback. To help the Divisions to be able provide assurance at its next performance review that it has a rigorous approach in place to ensuring it meets its financial performance targets. A recovery plan to be submitted to DOF for scrutiny. 6.1 Defining Indicators, Metrics and Targets The Divisional Performance Review meeting, chaired by the Chief Operating Officer, has overall responsibility for ensuring that appropriate performance measures are in place. 10 P a g e

13 In addition the Board of Directors, Quality and Workforce Sub-Committees of the Board have the power to recommend performance measures. There are two main sources for the identification of appropriate performance measures: Externally mandated or agreed indicators: All national (e.g. with DH) or locally (e.g. with commissioners) mandated metrics will form part of the Trust s performance framework external targets will constitute a minimum standard. Internally set performance metrics: in order to manage the achievement of strategic goals, KGH will put in place performance metrics. A trajectory will be set for each externally mandated indicator. 6.2 Quality Metrics Quality metrics will form part of the Corporate and Divisions scorecards. Compliant and performance against these metrics will feed into the quality and safety committee. The Audit Committee are responsible for ensuring on behalf of the Trust Board that there is an effective system of integrated governance, risk management, and internal control across the clinical activities of the organisation that support the organisation s objectives of delivering the best possible outcomes of care to patients. Divisions will be held account at the performance meeting. 6.3 Risk Management The Performance Management Framework supports the risk management process in the organisation by ensuring there is a forum at each level in the organisation where performance related risks can be reviewed and challenged. Each risk register is reviewed at divisional Business Management meetings. This allows for connected consideration and conversation around performance and risk management. 7. Information for Performance Management The Corporate and Divisions scorecards will be populated monthly by the Information Team and be ready no later than the 10 th working day of the month (this will only include discharge data for finance purposes). At Divisions Specialty level the full Specialty scorecard must be presented with detailed exception reports for the areas which are under target (red & amber RAG rated). The Clinical Lead will hold the Divisions to account for performance at this meeting and will request remedial action if performance is below standard. At Divisional level meetings the full Divisions scorecard must be presented with detailed exception reports for the areas which are under target (red RAG rated). The Chief of Divisions will hold the Clinical Leads to account for performance at this meeting and will request remedial action if performance is below standard. 11 P a g e

14 At the monthly Divisions Performance Review meetings the scorecard should be presented in full and red areas discussed and challenged. The Executive Team led by the COO will hold the Chief of Divisions, Divisional Directors and Head of Nursing/Midwifery to account for performance at this meeting and will request remedial action if performance is below standard. At the Performance, Finance & Resources Committee, Workforce Development Committee and Integrated Governance Committee the corporate scorecard is presented in full with detailed exception reports for all relevant areas which are red rated. At Operational Management Group the balance scorecard and all exception reports will be provided for information. The Chief of Divisions will present their Divisions scorecard and single exception report noting areas of concern, action and areas where cross Divisions help is required. At Trust Board and the Board of Directors the corporate scorecard will be presented for information only. Below is an example of how the performance monitoring and management framework will work, based upon a balanced scorecard approach with performance areas and a range of metrics yet to be fully agreed. Status Framew ork status Triggers Actions / Interventions Earned Autonomy Operational performance Financial performance Executive concern HR standards Local Quality standards minimum - Fully achieved minimum - Fully achieved minimum - Fully achieved min 2 out the remaining 2 framew orks to be fully achieved Monthly 121 w ith COO / MD / DoN Usual performance management arrangements Monitor Compliance Financial Plan Executive concern HR standards Local Quality standards minimum - Partially achieved minimum - Partially achieved minimum - Partially achieved min 1 out the remaining 2 framew orks to be partially achieved Monthly performance review Progress against plans w ith measurable objectives and milestones, w ith executive challenge and review of progress against plans Enhanced monitoring Monitor Compliance Financial Plan Executive concern HR standards Local Quality standards Any one area under achieved As above + Recovery Plan Bi w eekly monitoring by COO Intensive support + mentorship Assessment of leadership Special measures Monitor Compliance Financial Plan Executive concern HR standards Local Quality standards Any tw o areas under achieved Recovery Plan w eekly monitoring by COO Intensive support - internal / external and mentorship consider change of leadership, expected to attend escalation meeting w ith CEO 12 P a g e

15 7.1 The Trusts Strategic Objectives 1. To provide high quality care to individuals, communities and the populations we serve Quality Reducing the number of cases of Trust attributed C-Difficile % compliance with hand hygiene Total antibiotic consumption per 1,000 admissions Avoidable grade 2 & 3 pressure tissue damage % compliance with SSKIN bundle Falls with moderate/severe harm % compliance with the falls care bundle Compliance with the sepsis CQUIN Number of cardiac arrests outside of A&E/Cath lab Number of medication incidents with harm Proportion of patients with omitted doses of critical medication 90% of stroke patients seen on a designated stroke ward for 90% of the time Maintain HSMR & SHMI mortality within expected range Improve dementia screening to 95% Achieve a net promoter score of 80 Complaints response performance Reducing the number of GP concerns related to discharge letters 1. To be a clinically and financial sustainable organisation Financial Variance from recurrent financial position Delivery of CIP 2. To maintain a fulfilling and developmental working environment for our staff OD Sickness Absence rate Agency Turnover Appraisals Statutory and Mandatory Training 3.To be a strong and effective partner in the wider health and social care community Operational Monitor governance standards, including all cancer waiting times targets, A&E transit time performance, and Infection control Clostridium difficile target delivery, RTT will be excluded from the performance framework in 2018/2019, while the work to improve the data supporting this target is addressed. Executive/Divisional concern This covers any area that the Executive/ Divisional teams may have concern around Quality and delivery of services, including areas not routinely measured and monitored by the Trust. 13 P a g e

16 Compliance with Ward Accreditation metrics will fall under this heading as it is implemented. Based upon an agreed set of metrics a score for each of the areas will be compiled to provide an overall performance status for each Division, rated as below Minimum Standard Balanced Score Card determining operational status - April 2018 (Example) Performance Performance Management Framework (minimum standards) Status / Performance Score Local Quality standards (Month 1) Workforce (Month 1) Executive or Divisional concern (Month 1) Finance (Month 1) Operational Performance (Quarter 1) Medicine Division Usual performance management arrangements Partially achieved Under achieved Staffing levels Partially achieved Partially achieved (Transit times & RTT) Surgery Division Usual performance management arrangements Partially achieved Partially achieved Staffing levels Partially achieved Fully achieved (RTT) Family Health Division Usual performance management arrangements Partially achieved Fully achieved CQC Actions Partially achieved Fully achieved (RTT) 8. Responding to Adverse Performance Where performance reporting identifies: A failure to meet a current target The risk of not meeting a current or future target 14 P a g e

17 The risk of failing to put in place effective arrangements for the purpose of monitoring and improving the quality of healthcare provided An area of failing performance masked by an overall compliant position The Board will be informed through the sub-committee highlight reports. Adverse performance month 1 direct action by Divisions. Continued adverse performance month 2 where the action plan is not sufficiently robust or performance does not improve the following month the Trust will take the following measures: Provide targeted Divisions support Intervention from a specific Director to remove significant obstacles Benchmarking service against successful comparator to identify improvement opportunities Use the capability policy to address individual performance issues Weekly special measures meetings Continued adverse performance month 3 the Chief of Divisions, Divisional Directors, Deputy Divisional directors and Divisional Head of Nursing/Midwifery will be required to attend an escalation meeting with the CEO, COO and DOF. Central control, removal of autonomy. 9 Promoting Excellent Performance One of the key elements of this framework is the implicit requirement for development and support to divisions. Directorates in oversight categories 3 and 4 are expected to review their own development needs and work with the Chief Operating Officer to ensure that the offer to staff is relevant and meets the needs of the divisions. 9.1 Understanding Development Needs Directorate reviews existing capacity and capability to deliver plans Directorate works to ensure a development plan is in place Plans reviewed at accountability review 9.2 Meeting Development Needs Support is provided through day-to-day interactions with colleagues, learning and development. Additional support may be required for example:- Improving leadership Quality improvement Coaching, mentoring Benchmarking External capacity/capability Where directorates have a potential support need, based on the triggers, the Performance and Accountability Review will consider the circumstances to determine the level of support required. Practically, it will consider: 15 P a g e

18 The extent to which the directorate is triggering concerns Measure under one, or more, of the three themes Any associated circumstances the directorate is facing The degree to which the directorate understands what is driving the issue The directorates capability and the credibility of plans it has developed to address the issue The extent to which the directorate is delivering against a recovery trajectory. Presentation of the Divisions 6 monthly performance & achievements The Divisions will be expected to formally present their performance and achievements to the Executive Management Group team twice yearly at a meeting chaired by the CEO or Chairman. 10. Corporate functions Corporate specialties present their performance and achievements directly to the sub-committees of the Board. The Directors are held to account for their individual portfolios and objectives by the CEO. Good performance motivates people. It requires strong and inspirational leadership to create the right environment to allow innovation, team and individual excellence, where success is celebrated and challenges tackled proactively and positively. The Performance Framework puts front line delivery at the pinnacle of a strong underpinning system of support and clinical leadership. Every member of staff needs to be able to see how their contribution is reflected in what the Board and public see for organisational performance. Kettering General Hospital s approach is to ensure a robust personal development and appraisal system. Regular performance reviews are undertaken with individuals and individual objective setting is in line with the Trust s objectives and values. Rebecca Brown Chief Operating Officer May P a g e