Item IG15/32 To improve health and provide excellent care

Transcription

1 Committee Paper Integrated Governance Committee July Item IG15/32 To improve health and provide excellent care Title: Performance Management Strategy 2015 Author: Responsible Director: Summary of Key Issues: Action Required By Board: Morag Olsen, Chief Operating Officer Jill Newman, Director of Performance Morag Olsen, Chief Operating Officer This paper outlines the strategy by which the organization will assure itself and key stakeholders of its performance and internally manage the performance. The paper identifies the governance framework for performance assurance and performance management. This aligns to the organizational operational structure being put in place and so facilitates board to frontline connectivity, with both aggregation and disaggregation of performance information to enable decision making based on relevant and timely information at the lowest appropriate level. An earlier version of this paper was reviewed by the Finance and Performance Committee. Their comments have been reflected in this paper, which has been reviewed by the Performance Management and Accountability Framework Group and discussed at the Operational Delivery Group in June. To: Note Endorse Ratify X Approve Key Impacts: Corporate Objective Finance Quality Impact Assessment Health and Care Standards Equalities, Diversity & Human Rights Risk & Assurance Provides the Board with a strategy and operational framework for the performance assurance and management arrangements for the LHB. This forms part of the governance and accountability arrangements for the LHB. This is an integrated approach to performance management, included within this is the triangulation of quality, performance and financial and workforce information. Integrated performance management ensures that Quality impact is to the fore in decision making, balancing quality, performance, finance and workforce The integrated framework includes mapping to indicators within the Health Care Standards By supporting consistency and improved data quality and accessibility at all levels of the organization the performance strategy and operational framework aims to support equality, teasing out variation in service delivery. The performance strategy and operational framework should support early identification of risk, enabling mitigating actions to be taken. Key challenges to implementation arise from present informatics Page 1 of 19

2 systems capability linked to the national programme for development,combined with managing the risks associated with organizational change at the present time. Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board Page 2 of 19

3 Betsi Cadwaladr University Health Board PERFORMANCE MANAGEMENT STRATEGY INTRODUCTION This document describes the strategic context within which the Performance Management Strategy and Performance Management Framework which supports it have been developed. The lines of accountability within the Framework, the performance management processes and the key outcomes expected from delivery of the Performance Management Strategy are explained In developing this strategy, the Health Board has taken account of the changed political and economic climate and reiterated its commitment to the values, principles and pledges enshrined within the NHS. 2 Betsi Cadwaladr University Health Boards vision The vision of Betsi Cadwaladr University Health Board is set out in Health in North Wales 2020: Healthy Communities, Sustainable Services.Our vision as a University Health Board is to create a healthier and fairer North Wales, that maximises opportunities for everyone to realise their full potential. To improve the health of the population we serve, To provide excellent care, improving patient experience and outcomes To deliver effective and efficient care in line with Prudent Healthcare principles Improving the health of the population we serve means that, over time, everyone will see outcomes in improved quality and length of life, and that these outcomes will be more fairly distributed across the whole population 2.2 Providing excellent care means that, our focus for the next 3 years will be on developing a network of high quality services which are person centred, safe and effective Delivering effective and efficient care means that, our focus will be in ensuring that care provided is in line with an evidence base and optimises the use of resources available to the health board to ensure public resource and clinical skills are allocated appropriately. It is important that the Performance Management Framework helps to deliver this vision and strategic objectives. 3 WHAT IS PERFORMANCE MANAGEMENT? Performance Management is the leadership, values and systems which an organisation puts in place to help it manage and continuously improve its performance, as outlined below: Page 3 of 19

4 Diagram 1 The specific aims of Betsi Cadwaladr University Health Board Performance Management Framework are: To provide performance assurance to key stakeholders To enable performance management at the levels of the organization that can affect delivery, connecting Board Assurance to frontline delivery. To monitor and report performance against identified key national and local performance indicators. To achieve internal indicators that the organisation believes also contribute to the delivery of quality accessible services. To ensure corrective action or service redesign takes place where low performance is identified as an issue. To ensure that performance is benchmarked at peer, national or international level, to help enable the organisation to measure its progress towards achieving its vision. To ensure that responsibility for performance management is delegated as closely as possible to the clinical and corporate areas and in line with their proven ability to deliver the agenda. To ensure that the support and performance intelligence necessary to enable the achievement of objectives and standards is available. To ensure that performance is consistent and that variation is minimised. To ensure that the organisations data and information is of a high quality in order to support its operational management, decision-making, planning and performance management. In summary, Betsi Cadwaladr University Health Board Performance Management Framework will consist of four main elements: Indicators what is measured. Structure who is involved. Process when and how performance is monitored and managed. System redesign how do we modernize to deliver the Vision? Page 4 of 19

5 3.1.1 Indicators Indicators adopted within the performance management framework will arise from both national performance and quality frameworks such as the annual delivery framework and also from local priorities. Indicators will change over time. Indicators will be reported at aggregated level for Board reporting and assurance however will be reported at disaggregated level for performance management and to reduce the risk arising from aggregation of variable levels of performance. For instance ED performance on 4 hour access times is reported at aggregate health board level on a monthly basis, at a site level on a monthly basis for secondary care reviews and at site level on a daily basis for operational management Structure The structure for performance assurance and performance management is closely aligned to the structure of the Health Board governance framework and operational structure Performance Assurance Structure To provide Board assurance the framework will align to the National framework for Performance Management in NHS Wales. This is based on 7 domains: Staying Health, Safe Care, Individual Care, Dignified Care, Timely Care, Effective Care and Using Staff and Resources. Domain Staying Healthy Safe Care Effective Care Dignified Care Individual Care Timely Care Use of Staff and Resources Indicators, national and local aligned to these 7 domains will be reported via the Board sub committees via the Integrated Governance Committee to the Health Board. The sub committees will be allocated domains aligned to their function and the Board will receive an integrated report which reflects all 7 domains. Indicators within the 7 domains arise from the National Delivery, Outcome and Quality Frameworks plus key indicators for the Health Board determined as Local indicators by the Executive Director leading each domain. Diagram 2 depicts the performance assurance structure for the Health Board. Page 5 of 19

6 BCU Board Integrated Quality and Performance Reports Integrated Governance Committee Triangulation of Performance Information Thematic Reports Audit Committee WAO Internal Audit HIW reports Action tracking Finance and Performance Committee 4 of the 7 national performance and quality domains Quality Safety and Experience Committee 3 of the 7 national quality and performance domains Strategy Planning and Partnership Committee Diagram Performance Management In order to support performance management and connect performance assurance indicators to performance delivery a structure is provided that supports information flows up and down the organization and allows triangulation of information to inform decision making. The performance management structure reflects the organizational operational structure so as to align to the line management relationships within the organization. The management structure is set out in Diagram 3 with expanded examples showing for one Area and for Secondary Care. These expanded sections are replicated across the 3 areas and within MHLD and Estate and Facilities professional areas. To support the development of performance indicators and steer an annual programme that improves the performance management and accountability framework, a performance management and accountability group exists. Membership of this group is made up of corporate, area and secondary care leads with a role in performance information..(terms of reference is available from the Director of Performance).This group reports to the operational delivery group( ODG), chaired by the COO. The operational delivery group performs a vital role of connecting the performance assurance and performance management functions of the organization. The chair of the operational delivery group is required to report the work of this group to Board Page 6 of 19

7 and to the Corporate directors group. The CEO is invited to attend the ODG as ex officio member.(terms of reference is available from the COO). Diagram 3 Performance Management Structure Operational Delivery Group Chaired by COO Integration of performance Performance Management and Accountability Framework Group West Area Monthly accountability meetings and Quarterly Performance Central Area Monthly accountability meetings and Quarterly Performance East Area Monthly accountability meetings and Quarterly Performance Secondary Care Monthly accountability meetings and Quarterly Mental Health and Learning Disabilities Monthly accountability meetings and Estates and Facilities Monthly accountability meetings and Quarterly Locality/ Cluster Reviews Division reviews Wrexham Site Monthly Accountability meeting YGC Site Monthly Accountability Review YG Site Monthly Accountability Review Site level F+P, QSE and WOD meetings Reviews Site level F+P, QSE and WOD meetings Reviews Site level F+P, QSE and WOD meetings Reviews Page 7 of 19

8 4 ACCOUNTABILITIES WITHIN THE PERFORMANCE FRAMEWORK To deliver the Performance Framework a stepped approach to performance management (Diagram 4) is required which clearly specifies roles and accountabilities. ACCOUNTABILITY Board Subcommittee Diagram 4 Note the integrated quality performance reporting arrangements ensure that responsibilities for monitoring delivery of specific KPIs and reporting exceptions to the Board is clear to the sub committees of the Integrated Governance Committee of the Board. The alignment of these KPIs is in accordance with the Welsh Government delivery and outcome domains and directly related to the business of the sub committees.the Quality,Safety and Experience Sub committee receives an integrated report relating to indicators within 3 of the 7 national performance domains, the Finance and Performance Committee receives reports relating to the other 4 domains. 5. RESPONSIBILITY 5.1 The Health Board The Health Board has corporate responsibility for the organisations performance and in discharging this responsibility must ensure that it receives relevant and timely intelligent information. The Board is responsible for: Approving the Performance Management Strategy and ensuring it is introduced and maintained in accordance with the terms set out. Signing off approved Key Performance Indicators. Setting Strategic Direction and approving the Integrated Medium Term Plan. Corporate performance including ensuring the delivery of the annual operational plan, national and local targets as defined. Agreeing Strategic Objectives to be achieved each year. Reviewing progress on delivery of objectives during the year and, where appropriate, agreeing plans to address off plan performance. Page 8 of 19

9 Review risks to delivery through the Board Assurance Framework. Agree the annual revenue and capital budgets. Review and monitor organisations financial performance against target performance. The Board will receive a monthly corporate integrated quality performance report detailing, quality finance and business, operational delivery and workforce metrics these metrics will be reported under the 7 national domain headings. Risks to achievement of key performance indicators will be identified and actions to mitigate the risks discussed in exception reports. 5.2 Chief Executive The Chief Executive, on behalf of the Board, is accountable for ensuring the requirements of the Performance Management Strategy are appropriate and meet the needs of the organisation and its strategic objectives. 5.3 Executive Directors Each Executive Director is responsible for ensuring that annual objective setting, periodic individual performance review processes and personal development planning are timely and effective within their sphere of responsibility. Responsibilities include ensuring: that the Performance Management Strategy is implemented within their own areas of corporate responsibility; that managers and staff co-operate in applying the strategy throughout their Directorate, with the involvement of the Finance and workforce colleagues that steps are taken to secure resources for the implementation of associated controls following risk assessment; that targets for key performance indicators are agreed, communicated and delivered; that governance arrangements to underpin the Performance Management Strategy are approved and in place. 5.4 Finance and Performance Sub Committee The Finance and Performance sub-committee has responsibility for providing a strategic, operational and tactical view of financial performance and operational delivery performance and workforce agendas. It monitors formally achievement of key KPIs, ensuring that plans are put in place to take any necessary corrective action. Detail of the sub Committees remit and responsibilities are contained within its terms of reference. As an outline this sub-committee will receive and be responsible for KPIs under the domains of: Timely Care, Use of Staff and Resources, Individual Care and Dignified Care Quality Safety and Experience Sub Committee The sub-committee is responsible for overseeing the improvements and outcomes in safety, quality, effectiveness and experience and ensuring delivery of the Quality Improvement Strategy. This sub-committee will be responsible for KPIs under the domain of: Staying Healthy. Safe Care and Page 9 of 19

10 Effective Care. Details of the sub-committees remit and responsibilities are contained within its terms of reference. 5.6 Strategy Planning and Partnership -Committee The Committee is responsible for providing information and making recommendations to the Trust Board on infrastructure and investment issues and for providing assurance that these are being managed safely. This includes reviewing post implementation plans to ensure that the expected outcomes have been achieved. 5.7 Integrated Governance Committee The Integrated Governance Committee is responsible for assuring the Board on the management of all governance and assurance issues that fall within its remit. This includes risk management arrangements, Governance Strategy, HIW/WAO and other regulatory body compliance, information governance, safeguarding and medical revalidation. This committee will act to triangulate performance information from across all domains within the performance framework and will receive thematic reports. 5.8 Operational delivery structure The operational delivery structures will be accountable to the Chief Operating Officer of the Health Board. All operational delivery structures will be led by the Area or Secondary Care Directors supported by a senior clinician and senior nurse, forming a triumvirate that will be duplicated down the operational structure Each Operational Team and Corporate Department has a responsibility to act upon the data quality reports produced by the Information and Performance Departments. Each Operational Team / Corporate Department will have its own senior team meeting with an integrated performance report, which reflects the content of the Board Integrated Performance Report and contains additional metrics that are relevant to their areas of responsibilities The individuals within the Operational Teams / Corporate Departments are accountable to the Executive for performance at specialty, ward and departmental level. The performance management of the individual clinical specialities and sub department is provided through their own specialty/ departmental meetings reporting into the Operational Teams or Corporate Departmental Senior Team meeting Examples of the operational delivery structure is shown in diagram Performance Indicator Information The generation, interpretation and presentation of performance indicators and activity information are fundamental to the delivery of the Performance Management Framework. It is acknowledged that whilst corporate teams will Page 10 of 19

11 support the Operational Teams in the development of this information, within each Corporate Department there are also a number of KPI s that they too will need to deliver against. To this end the following corporate teams will provide the relevant information for both Operational Teams and Corporate Departments: The Information Team, including the Coding Department, will provide the majority of the Organisation s activity and performance data and has specific responsibility for compiling the statutory performance returns and performance assessments required by an internal or external body. Responsibilities for data quality are built into the job descriptions of relevant members of the team. National Performance returns will be scrutinized and signed off within the Performance Team under the Executive leadership of the Chief Operating Officer prior to submission. The Finance Team will ensure that management accounts, service line reports and contract income reports are provided to the organisation. Responsibility for data quality, compiling and submission of national returns in accordance with professional standards lies with the Director of Finance. The Human Resources Team will ensure that the appropriate workforce information is available. Responsibility for data quality, compiling and submission of national returns lies with the Director of Workforce and Organizational Development. The Performance Team will ensure that the organisation understand the current challenges and performance required against key national standards. The Quality, Governance and Assurance teams will ensure that appropriate risk information is provided, and work with operational and planning teams on Business Continuity, their Assurance Framework and key quality standards The governance team will also support provision of information to the public in relation to the organizations performance, business continuity and risk management. The Quality Improvement Strategy objectives will provide a prioritized list of safety indicators. The Director of Quality Assurance will work with clinical leads for these quality indicators to ensure quality of data collection, analysis, performance management and reporting, integrating this reporting with the performance management reporting at all levels of the organization. The above teams will work to ensure the appropriate level of information provision to the Board and the organisation. As previously stated, a close working relationship will be fostered with the Operational Team and Corporate Departments by a named contact from within the central team acting as the link worker. Members of the above teams are all represented on the Operational Delivery Group to further support integrated working between these corporate functions. The Operational Team / Corporate Departments will also be provided with the following systems and information to help them benchmark and analyse their own data: Page 11 of 19

12 Public Health Data PAS, Nurse Metrics, and QOF data CHKS Efficiency Metrics Specialty performance reports Financial and Budgetary Performance Information Workforce Dashboard and mandatory training information PMO tracker Delivery Plans progress monitoring Relevant Benchmark information from NHS national benchmark club Regulatory reports received relevant to sphere of influence 6. PERFORMANCE MANAGEMENT PROCESSES Performance within the organisation is managed through a number of processes: 6.1 The Board The Board will receive the Integrated Quality and Performance Report and updates on the Board Assurance Framework every month. Given the role of the sub- committee detailed above, an Executive Director, normally the Chief Operating Officer, will highlight only exceptions to the Board. Quarterly the board will receive an expanded integrated quality and performance report that provides greater coverage for the organizational business, allowing for narrative, qualitative as well as quantitative information. 6.2 Sub - Committees The sub-committees will oversee the detailed monitoring and action planning for performance in accordance with the framework set out above. This will ensure that the KPIs and national domains are appropriately aligned to the work of each sub-committee and that triangulation between the domains is provided through the Integrated Governance Committee of the Board Operational Teams / Corporate Department - Performance Reviews The COO,DOF and Director of WOD will hold accountability meetings with the operational teams on a monthly basis, using an expanded version of the Board level integrated quality and performance reported information. This meeting will focus on quality, performance, finance and workforce indicators from within the 7 domains. The Executive Directors will meet with each of the Operational Teams / Corporate Departments on a quarterly basis for a formal review against an agreed set of performance criteria for that quarter. The Operational Team / Corporate Department will then be given an operating level against a Freedom to Act scale. The process and operational framework of the quarterly performance reviews is illustrated at Appendix 1 The criteria for the performance reviews will be reviewed on an annual basis to ensure they reflect the Health Board s strategic objectives. Page 12 of 19

13 6.4 Service Groups The Area and Secondary Care Directors will meet monthly with sites/service groups for a formal review against an agreed set of performance criteria for the service area. The Directors will establish a risk rating for the service based on these reviews and confirm actions levels required for continuous improvement in line with the escalation framework Contracted Services and Contractor Performance The corporate contracting team will review the performance of contracted services using an appropriate performance framework. The contracting team will report progress through the corporate department reviews outlined under 6.3. The contracted service activity and performance will be aligned to the work of the Finance and Performance sub-committee. Primary Care Contractor performance will be reviewed by the PCSU. The PCSU will report progress through the corporate department reviews outlined under The Primary Care national KPIs are reported through the Quality, Safety and Experience sub-committee Appraisal and Personal Development Review (PDR) Effective people performance management is a fundamental process for achieving organisational vision, values and strategic objectives. It also provides the vehicle for staff to be more engaged with the organisation itself, the core principle being focused on two way communications between manager and employee and not the top down approach that typifies most appraisal processes. The PDR system will include a role specific approach to performance management. This will enable the organisation to focus their efforts on improving the quality of individual staff performance reviews that are necessary to enhance individual and team performance and organisation effectiveness. Furthermore the PDR system will enable the LHB to undertake more timely and improved monitoring, and reporting on performance. The value and quality of PDRs from a staff perspective is monitored through the Staff Survey and organizational pulse surveys. 7. KEY OUTCOMES EXPECTED FROM THE DELIVERY OF THE PERFORMANCE STRATEGY The Board and its sub-committees will play a key role in monitoring and managing performance. The operational teams and corporate departments will have a key role in ensuring alignment of strategic and national priorities with delivery of high performance outcomes in all service areas. Service area will have clarity on performance expectations and timescales for delivery aligned to their resources. All staff employed by the organisation will have a clear understanding of the Performance Management Framework and will believe that achieving continuous improvement in performance is important. Page 13 of 19

14 All employees will have a demonstrable appreciation as to how their work contributes towards the delivery of all priorities. Integrated performance management frameworks will be in place at corporate and operational service level. There will be integrated and timely reporting with high quality commentary for performance reviews. Data quality will be taken seriously with good arrangements in place at all levels, acceptable external audit reports provide assurance on activities undertaken Assurance processes which can be relied upon (no surprises) 8. REVIEW AND UPDATING OF THE STRATEGY The Performance Management Strategy will be reviewed on an annual basis by the Chief Operating Officer and any changes will be submitted to the Integrated Governance Committee for endorsement, prior to ratification by the Health Board. Page 14 of 19

15 Appendix 1 OPERATIONAL TEAMS / CORPORATE DEPARTMENTS QUARTERLY PERFORMANCE REVIEW PROCESS Monthly Accountability Meetings The COO, Director of Finance, and Director of Workforce and Organizational Development supported by the Director of Performance will meet monthly with the Directors of the operational structure teams accompanied by their Medical and Clinical/Nurse leads to hold to account the operational team for delivery of expected quality, performance, financial and workforce metrics. The 7 domain framework used at Board will be disaggregated to the level of the area/secondary care or MHLD division and circulated to the senior management team approximately 1 week prior to their review meeting. The outcome from the review meeting will be documented and actions identified for completion of the next review. These outcomes will feed into the quarterly internal review process. Quarterly Internal Review Process The Executive Directors will meet with each of the Operational Teams / Corporate Departments on a quarterly basis to review performance against an agreed set of criteria for that quarter. The criteria will be reviewed on an annual basis to ensure they reflect the Health Boards strategic objectives. The process to be used to hold to account the relevant Directors and there teams will be the quarterly performance reviews. The reviews will be led by the COO. The reviews will be held over 2 days each quarter (July, October, January, and April). 1 week prior to the reviews corporately held performance information will be shared with the Director and the review panel. All Corporate Directors will be invited to form part of the review panel, with a minimum of 4 corporate directors being required for each review. The reviews will be held in Carlton Court meeting room. The 3 Area, Secondary Care and Mental Health will be allocated 2 hours for each of their reviews. The review process will include a: Retrospective look at the previous quarter s performance against pre-defined key performance indicators. The retrospective review of performance for the previous quarter will be pre scored using a pre-determined system. Three qualitative elements linked to the Health Boards Strategic Objectives. These will be identified at the end of the each review in agreement with the Executives and the Operational Teams / Corporate Departments, as being an area of concern and requiring greater focus over the next three months or an area of focus for the organisation. And a topic/ thematic area of focus for the Operational Team or Corporate Department. The Directors are expected to prepare 4 presentations for the reviews, with each being no longer than 15mins. 3 of the 4 presentations will be on topics provided to the Directors by the Executive Directors and would normally expect to cover the domains of: Quality and Safety, Finance and Performance, and Workforce and Page 15 of 19

16 Appendix 1 Organizational Development. The fourth area will be an area of significance to the Director and his team and may be an area of concern or area to showcase across the wider organization. Following completion of each review the performance will be scored and areas of concern and areas for celebration and spread will be recorded. At the end of the 5 reviews a combined feedback session will be provided to the 5 area teams as a single session with all teams and corporate directors present. The feedback session will be led by the COO. Each Director will receive a summary of the outcome of the review, aligned to their level of escalation and key actions required. The topics for presentation at the next quarterly review will be confirmed based on outcomes from the reviews and these will be included in the summary letter. The escalation framework will apply to any areas of significant concern that need to be addressed prior to plan quarterly reviews. Outcomes from the performance review process will be reported to the Finance and Performance Committee of the Board. 2. ATTENDANCE All Executive Directors will commit to attending all quarterly assessments. On the rare occasion when this is not possible another Executive Director will be pre briefed on areas of focus or concern prior to the meeting. The Executive Directors will be supported by the corporate performance director. As a minimum the following will attend on behalf of the Operational Teams: Area Director or Secondary Care Director Area Medical Director or Secondary care Medical Director Area Nurse Director or Secondary Care Nurse Director Area Finance Officer or secondary Care Finance Director HR Manager The Operational Teams may choose to bring other representatives as a development opportunity or to contribute to the assessment process. For Corporate Departments, Corporate Director Departments Management Accountant Departments HR Manager Corporate Departments may also choose to bring other representatives as a development opportunity or where the quality of discussion would be enhanced by individuals with greater knowledge of specific subject areas. 3. PERFORMANCE REVIEW PROCESS Operational Teams / Corporate Departments' performance should be considered a live process whereby Operational Teams / Corporate Departments will be monitoring, reviewing and planning on an ongoing basis and through the monthly accountability meetings. The ongoing process will contribute to the preparation for the assessment. Page 16 of 19

17 Appendix 1 On the day of the assessment it is up to the Operational Team / Corporate Department to decide what evidence they bring along and how this is presented to the Executives. The assessment will last for two hours and will adhere to the following format: 1. A review of the Operational Team / Corporate Departments performance against the key KPI s will be undertaken, where key successes and challenges will be identified, progress against trajectories and recovery plans where indicated, maximum 30 minutes for the presentation and subsequent questions. 2. A 15 minute presentation of the pre-defined three qualitative areas of focus that are linked to the Strategic Objectives of the LHB. The Operational Team / Corporate Department will be asked to demonstrate how the objectives relate within their sphere of responsibility, their direction of travel and expectations for delivery over the course of the year and current progress to date. The panel will be looking for areas where good practice has been established and how this can be shared across the organisation together with areas of learning and future action. 3. A further 15 minute presentation of the Operational Team / Corporate Departments chosen topic area. Feedback will be given to all Operational Team and Corporate Departments at the end of the day, together with the panel s assessment regarding the level that has been agreed with regard to their Freedom to Act. The levels of escalation shown below align to the Welsh Government escalation framework for LHBs. High Performing Operational Team /Corporate Department Level 0 Freedom to Act within Specified Areas Level 1 Limited Freedom to Act Level 2 Targeted Support Level 3 IntensiveSupport Level 4 The outcome of both the performance matrix and the presentation will determine the level of the Operational Team or Corporate Departments Freedom to Act. The escalation levels identified at the end of the review are aligned to the national escalation framework for NHS Wales and the actions arising from these levels relate to these. DF Escalation Tiers.pdf Page 17 of 19

18 Appendix 1 Level Multiple KPI Trigger Description Actions High Performing Level 0 All indicators achieved On plan for quality, finance, workforce and operational delivery Business as usual monitoring through monthly meetings focused on delivery sustainability with COO and CFO or relevant Executive Director Freedom to Act within Specified Areas Level 1 More than one Indicator off target for one period, but within normal variation. Evidence of minor continued movement from profile Concerns raised regarding delivery of recovery plans Continued monitoring as above through monthly meetings Focused support to stress test the deliverability of recovery plans Limited Freedom to Act Level 2 More than one indicator off target for two periods Failure to deliver one of more key target areas Material variances across several areas Continued monitoring as above through monthly meetings. Identified improvement support given dependant on the areas of concern Targeted Support Level 3 More than one indicator off target for three periods Lack of confidence in recovery plans Material variances across a large number of areas, with significant impact on patients Weekly interaction with dedicated senior support Commission independent review Undertake a risk summit including the whole Executive Team Intensive Support Level 4 More than one indicator off target for four periods Performance continuing to deteriorate Material issues as above with failure to achieve improvements within agreed timescale Review of the leadership of the Operational Team / Corporate Department led by the Chief Operating Officer or relevant Executive Director Page 18 of 19

19 Appendix 1 4. OPERATIONAL TEAM AND CORPORATE DEPARTMENT SUPPORT Following the quarterly performance review assessment Operational Team/ Corporate Departments will receive a letter outlining the summary feedback, any specific areas of concern and the level of support the Operational Team / Corporate Department requires. Support will be offered to Operational Team / Corporate Department with the higher intensity rating such as Level 2 and Level 3. However, an Operational Team / Corporate Departments may be offered support for a particular area of concern regardless of the intensity that they achieve. For example, an Operational Team / Corporate Departments may be at Level 1, but within that be in intensive support for operational delivery or finance concerns. Should that be the case, the lead Executive will specify any support required. The support offered to an Operational team / Corporate Department will be customised based on their specific requirements. Operational Team / Corporate Departments who achieve a Level 0 rating will be managed differently, if this is sustained. Following three consecutive Level 0 ratings an Operational Team / Corporate Department will receive a license to operate. From that point on the Operational Team / Corporate Department will only need to attend two quarterly performance reviews a year in quarter two and quarter four. The license to operate provides Operational Team / Corporate Departments with a level of Freedom to Act, whilst providing assurance to the Executive that the Operational Team / Corporate Department will stay within its plans, budgets, and the limits of this license. It also ensures the relevant Operational Teams Board / Corporate departmental board will address all issues swiftly and effectively and will inform the Chief Executive or other appropriate Executive of any potential failing before it occurs. 5. GOVERNANCE ARRANGEMENTS Each Operational Team / Corporate Department will receive the results of their quarterly performance review on the day of the assessment and the full letter regarding their performance will be received within 10 working days following the last quarterly performance review. The overall results for each of the Operational Team / Corporate Department will be presented to the first available Integrated Governance Committee after all quarterly reviews have been completed. As a minimum, this will include details by Operational Team / Corporate Department of: Overall progress against Freedom to Act across the organisation Progress compared to previous quarters Areas of concern Support provided to Operational Team / Corporate Departments. This information will be reported by exception to the Corporate Directors and Operational Delivery Group. Page 19 of 19