ANEURIN BEVAN HEALTH BOARD PERSONAL APPRAISAL DEVELOPMENT REVIEW (PADR) POSITION PAPER

Transcription

1 ANEURIN BEVAN HEALTH BOARD PERSONAL APPRAISAL DEVELOPMENT REVIEW (PADR) POSITION PAPER 1. INTRODUCTION The purpose of this paper is to provide a short briefing for the Board on the current position in relation to organisational compliance levels for the Knowledge and Skills Framework (KSF) Personal Appraisal Development Review (PADR) process within Aneurin Bevan Health Board. Current organisational compliance is 34.22%. This means that 65.78% of the workforce do not have a completed PADR and can therefore not demonstrate that they are aligned to the organisational objectives. All Divisions are currently working with their teams to address this issue. The Health Board received limited assurance in a recent PADR internal audit and this paper outlines the actions put in place to address the recommendations within the audit to improve compliance. The Board are asked to: Note the contents of this paper and continue to promote the positive message that where PADR is undertaken against clear objectives aligned to the organisational outcomes, effectiveness and efficiency improves. Endorse the reduction of the overall target for compliance as recommended in the internal audit report to 85%. Financial Assessment and link to Financial Recovery Plan Risk Assessment The activity outlined in this paper requires no additional resourcing. There is clear evidence to show that where individuals and teams are undertaking effective PADRs where appraisal is undertaken against clear objectives aligned to the organisational objectives, effectiveness and efficiency improves. 1

2 Annual Operating Framework Standards for Health Services Wales Equality Impact Assessment Child Impact Assessment Links to AOF target 8 Efficiency and Productivity The KSF PADR processes link to the following Standards for Health Services: STANDARD 6: Participating in Quality Improvement Activities, STANDARD 7: Safe and Clinically Effective Care, STANDARD 25: Workforce Recruitment and Employment Practices, STANDARD 26: Workforce Training and Organisational Development. The contents of this paper have undergone equality impact assessment screening with no differential negative impacts identified. Not applicable to this report 2. BACKGROUND The purpose of this paper is to provide a short briefing for the Board on the current position in relation to the compliance levels for the Knowledge and Skills Framework (KSF) Personal Appraisal Development Review (PADR) process within Aneurin Bevan Health Board for staff covered by NHS terms and conditions. It is recognised that Medical and Dental staff who are not covered by NHS terms and conditions, have their own process in place for recording annual appraisal. This electronic recording process has been reviewed on an All Wales basis and is being implemented alongside revalidation. There is clear evidence that undertaking effective PADRs and having clear objectives aligned to the organisational outcomes results in improved effectiveness, efficiency and positive patient outcomes. An internal audit undertaken by Deloittes in July 2012 explored the entire PADR process within the Health Board and the report provided the Health Board with limited assurance. Several specific recommendations were made to improve the quality and compliance with PADR. 2

3 There has been some progress in relation to PADR compliance, since the migration from the e-ksf to the revised PADR system. Organisational compliance has increased from 11.9% in October 2011 to 34.22% in November In October 2011, the Health Board set compliance targets for completed PADRs of 50% by the end of January, 75% by the end of February and 100% by the end of March These are not currently being achieved within the Health Board s Divisions. Following the recent audit report these targets are currently under review to reflect an intelligent target approach. This has also been the focus of recent 6 month reviews with all the Divisions: for some this demonstrated an understanding of the importance of this specific target; for others it showed a need for further support as well as a focus on compliance. Recommendation 3 of the audit report suggests that the Health Board should consider reducing the overall target to an achievable target of between 80%-90%. This would take into account sickness, turnover and maternity leave. An overall target of 85% has been agreed. A range of interventions have been initiated to support and take forward the PADR process within the Health Board. 3. INTERNAL PADR AUDIT The internal audit assessed the adequacy and effectiveness of the Health Board s internal controls in operation regarding the HR Management: Performance and Appraisals Review. This audit work was carried out by discussion with appropriate staff, reading of documents and testing, as necessary, to confirm the effectiveness of the controls in place. The final audit report that provided the organisation with limited assurance has been presented to Audit Committee and made a number of recommendations. The following actions have been taken to address the recommendations: Shared accountability for PADR policy compliance has been agreed between Executive Directors. 3

4 PADR compliance data has been included on the Board s performance dashboard to demonstrate the importance of this specific measure. Training is already provided for appraisers, however a new induction programme for managers that includes assessment of competence has training included to address underperformance as one of the core requirements. A revision of the overall 100% target has been undertaken and agreed at 85%. Intelligent targets for each division based on turnover, sickness and maternity leave are under development. The message that both the PADR and KSF Policy require staff to have a completed and centrally recorded PADR prior to any form of study being approved has been reinforced through the divisional structures. This message has been reflected in a revision of the Study Leave Policy and the study leave approval forms within this policy have been simplified. The KSF task and finish group has been redesigned to ensure improved divisional representation and to take forward the recommendations within the audit with particular emphasis on quality and compliance analysis. PADR support is being offered through the Operational HR Helpdesk, this is supported by frequently asked questions. A divisional PADR/KSF Champions role is being introduced to support divisional actions to improve compliance and the quality of reviews. This role will lead cross divisional audits to review progress and quality and will support the work to simplify KSF Post Outlines. This has been elevated within the Divisional performance review process with Executive Team. It has been agreed that the following actions require further discussion and agreement within the organisation: Divisional management teams should review the current spans of control to ensure that the best practice guidelines of a manager/reviewer having no more that 10 staff to review. The recommendation to align the PADR process to April each year requires further discussion and debate to consider the risk this would pose to both compliance and NHS terms and conditions incremental dates that could impact on pay Gateways. 4

5 A need to review the process of PADR to ensure that we make it as easy as possible for staff and line managers to properly comply. A paper outlining the risk/benefit analysis for these recommendations will be presented to the Workforce and Organisational Development Committee. In addition to these actions, the Audit Committee have stated that the Division with the lowest level of compliance will attend to present their plan for improvement. This would reflect the move to intelligent targets and enable the appropriate level of challenge and support. 4. KSF DEVELOPMENT GROUP The KSF Development Group chaired by the Assistant Director of Therapies and Health Science have developed and agreed revised documentation and continue to monitor compliance and drive local awareness. The revised documentation includes a mandatory objective for all managers relating to the management of sickness absence and explicit reference to the requirements of the Health Board s vision and values, dignity and respect and Statutory and Mandatory training requirements. Completed and centrally recorded PADRs provide the baseline data required to inform plans to increase compliance across all Health Board areas. The Education and Development team have been working with divisions to support the implementation of the revised documentation and the required increase in compliance. Those areas with the highest sickness absence rates and low PADR compliance are receiving prioritised support and intervention. This Group is supported by Divisional PADR/KSF Champions as core members and they will be leading a review of KSF Post Outlines with a view to simplifying them and therefore making them more user friendly. Part of this review will include a revised system of storage on the Health Board intranet and a means of ensuring that staff who do not readily have access to the intranet will not be disadvantaged. 5

6 5. STAFF ENGAGEMENT AND COMMUNICATION The KSF Development Group have a clear communication and engagement plan to ensure all relevant staff groups are aware of the changes taking place and know what is required. The KSF intranet page has been further developed and contains information and resources for staff in relation to the KSF PADR process including: PADR documentation PADR ESR recording document The Aneurin Bevan Health Board KSF policy Reviewer and reviewee guidance Frequently Asked Questions (FAQs) related to PADR Codes of conduct information Organisational objectives information KSF post outline library PADR statistics PADR monthly bulletin Role of PADR/KSF Champions Links with Operational HR ensure that staff also have access to PADR information via the HR helpdesk. 5.1 Training The eksf tool was taken out of commission on an all Wales basis and a revised PADR process was introduced in September 2011 within Aneurin Bevan Health Board. Training sessions on the revised system have seen a total of 461 members of staff trained. PADR/KSF awareness training sessions for reviewers and reviewees are delivered to individuals, teams and in classroom based sessions. 6

7 The strategic KSF Lead for the Health Board is readily accessible to advise and support staff via face-to-face contact, telephone and e mail. The intranet pages have be revised to provide a comprehensive resource. 6. CONTROLS Monitoring and control processes are in place to ensure the required improvements can be tracked and reported and appropriate action can be taken to support improved compliance. The following monitoring, reporting and recording processes are in place. 6.1 Monitoring and Reporting Current organisational compliance for completed and centrally recorded PADRs is very poor at 34.22%. PADR compliance data has been added to the ABHB monthly Performance data reported to the Board. The current Divisional breakdown is shown in Appendix 1. Completed PADR s as a percentage against staff in post is reported to the Strategic KSF Lead on a weekly basis, and to the Executive Team and Divisions on a monthly basis. This monthly report includes Key Messages in relation to PADR. Corporate monthly non-compliance reports are sent to Executive Directors for distribution and to highlight areas that require support to improve compliance. In addition to monthly compliance figures, each Divisional General Manager receives a non-compliance report for staff at 8a and above. The purpose of this report is to highlight blocks within the system and areas that require support to improve compliance. All centrally agreed funding for study requires evidence of a completed and recorded PADR in accordance with the Aneurin Bevan Health Board policy. 7

8 6.2 Recording Completed PADRs are recorded on the Electronic Staff Record (ESR). All completed PADRs are recorded by the reviewer on an electronic recording form and sent to a central e mail address for entry onto ESR. This recording is undertaken centrally by the Education and Development function. The organisations ESR Manager Self Serve roll out plan will enable managers to record this themselves using the ESR Oracle Learning Management (OLM) system. 7. CONCLUSION The PADR measure and supporting process has been highlighted by the Board as a key success measure for the organisation and for the Executive Team. There is clear evidence to show that where individuals and teams are undertaking effective PADRs, where appraisal is undertaken against clear objectives aligned to the organisational outcomes, effectiveness and efficiency improves. The limited assurance reports shows that there is more that can and should be done. It is therefore essential that the Health Board improve its PADR compliance. The evidence seen in this paper demonstrates that: Progress has been made in implementing the recommendations from the internal audit completed in July There is a slow steady increase in % of completed and centrally recorded PADRs, however compliance remains poor % of the workforce do not have a completed PADR and can therefore not demonstrate that they are aligned to the organisational objectives. ABHB will not be viewed as an improvement organisation without improved compliance. Managers cannot demonstrate that they are managing their staff and effectively using the resources available to them. 8

9 Despite this, the organisation is continuing to show good performance on a wide range of operational and strategic objectives, which shows there is a developing performance improvement culture in place. However, this needs to be evidenced with process and compliance in support of staff and the management structures. 8. RECOMMENDATIONS The Board are asked to: Consider the content of the paper and continue to promote the positive message that where PADR is undertaken against clear objectives, effectiveness and efficiency improves. Endorse the reduction of the overall target for compliance as recommended in the internal audit report to 85%. Oversee the progress with actions set out in this report. Sponsored by: Anne Phillimore, Workforce & Organisational Development Director Prepared by: Sue Ball, Head of Development & Well-being Date: 19 th November

10 Appendix 1 CORPORATE DIVISIONS 03/06 10/06 17/06 24/06 01/07 08/07 15/07 22/07 29/07 05/08 12/08 19/08 26/08 02/09 09/09 16/09 23/09 30/09 07/10 14/10 21/10 28/10 04/11 11/11 BOARD SECRETARY CHIEF EXECUTIVE/NON EXECUTIVE DIRECTOR OF PUBLIC HEALTH FINANCE DIRECTOR MEDICAL DIRECTOR NURSE DIRECTOR OTHER PERFORMANCE DIRECTOR PLANNING DIRECTOR THERAPIES & HEALTH SCIENCES DIRECTOR WORKFORCE & OD % Heads PADR Weekly - Cor por ate / 06 10/ 06 17/ 06 24/ 06 01/ 07 08/ 07 15/ 07 22/ 07 29/ 07 05/ 08 12/ 08 19/ 08 26/ 08 02/ 09 09/ 09 16/ 09 23/ 09 30/ 09 07/ 10 14/ 10 21/ 10 28/ 10 04/ 11 11/ 11 BOARD SECRETARY CHIEF EXECUTIVE/ NON EXECUTIVE DIRECTOR OF PUBLIC HEALTH FINANCE DIRECTOR MEDICAL DIRECTOR NURSE DIRECTOR OT HER PERFORMANCE DIRECTOR PLANNING DIRECTOR THERAPIES & HEALTH SCIENCES DIRECTOR WORKFORCE & OD Page 10 of 11

11 DIVISION 03/06 10/06 17/06 24/06 01/07 08/07 15/07 22/07 29/07 05/08 12/08 19/08 26/08 02/09 09/09 16/09 23/09 30/09 07/10 14/10 21/10 28/10 04/11 11/11 FACILITIES DIVISION FAMILY & THERAPIES DIVISION LOCALITIES LOCALITY COMMUNITY CARE LOCALITY PRIMARY CARE MENTAL HEALTH & LD SCHEDULED CARE UNSCHEDULED CARE % Heads PADR Weekly - Division / 06 10/ 06 17/ 06 24/ 06 01/ 07 08/ 07 15/ 07 22/ 07 29/ 07 05/ 08 12/ 08 19/ 08 26/ 08 02/ 09 09/ 09 16/ 09 23/ 09 30/ 09 07/ 10 14/ 10 21/ 10 28/ 10 04/ 11 11/ 11 FACI LI T I ES DI VI SI ON FAMI LY & T HERAPI ES DI VI SI ON LOCALI T I ES MENT AL HEALTH & LD SCHEDULED CARE UNSCHEDULED CARE LOCALITY COMMUNITY CARE LOCALI T Y PRI MARY CARE Page 11 of 11