NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST Documentation Control Reference HR/PT&C/020 Approving Body Trust Board (Director of Human Resources) Date Approved 9 April 2015 Implementation Date 14 Summary of Changes from Previous Version Previous 5.1 removed, acknowledging rostering no longer in project stage. Added during 2015 will have supervisory status. Previous 6.2.3 and 6.2.4 removed. Acknowledging that shift duration changeable according to service need. 6.3.4 Under normal circumstances added to allow managers/staff flexibility e.g. specialist areas, hard to recruit to areas or staff return after retirement. 6.4.1 Increase range of hours for staff with 1 request. Acknowledges that majority of rostered staff work long shifts. Previous 6.4.4 Removed as already covered within policy 6.8.1 Addition of wording to support smaller teams and annual leave allocation. Supersedes Version 4 (May 2014) Consultation Undertaken Date of Completion of Equality Impact Assessment 6.9.2 added in birthday month 6.9.6 Addition of wording to reflect need to record medical device training Staff Side, HR Policy Sub Group Trust Managers Directors Group February 2010/reviewed 2015 Date of Completion of We February 2010/reviewed 2015 1
Are Here for You Assessment Date of Environmental Impact Assessment (if applicable) Legal and/or Accreditation Implications N/A Target Audience Review Date February 2018 Lead Executive HR.WLB.002 Work Life Balance Procedure HR.R&C.004 Temporary Staffing Policy HR.PTC 022 Annual leave Policy All Employees Director of Human Resources Author/Lead Manager Further Guidance/Information Rachel Finn Safe Staffing Lead ext. 57413 Peter Wiklo HR Projects Manager ext. 62768 erostering intranet web site http://nuhnet/human_resources/erostering/pages /default.aspx HR Policies & Procedures intranet site 2
CONTENTS Paragraph Title Page 1. Introduction 4 2. Executive Summary 4 3. Policy Statement 5 4. Definitions (including Glossary as needed) 5 5. Roles and Responsibilities 5 6. Policy and/or Procedural Requirements 6 7. Training, Implementation and Resources 13 8. Impact Assessments 13 9. Monitoring Matrix 14 10. Relevant Legislation, National Guidance 15 and Associated NUH Documents Appendix (1) Equality Impact Assessment 16 Appendix (2) Environmental Impact Assessment 25 Appendix (3) Here For You Assessment 27 Appendix (4) Certification Of Employee Awareness 29 3
1.0 Introduction 1.1 The purpose and aim of this Policy is to ensure that duty rosters are produced to an agreed standard which is consistent with the Trust wide erostering system, ensuring effective utilisation of the Trusts workforce through efficient rostering. 2.0 Executive Summary 2.1 Through the implementation of a, the Trust will achieve more effective and efficient management of the workforce by ensuring safe and appropriate staffing levels for all. In conjunction with the European Working Time Directive and Work- Life Balance Procedures, the effective utilisation of the workforce in Trust wards/departments will support a fair and consistent roster and will provide a safe workforce level which meets with service needs. NUH has implemented a system of electronic rostering which aims to: Ensure safe/appropriate staffing for all wards/departments using fair and consistent rotas. Minimise clinical risk associated with the level and skill mix of staffing levels. Improve monitoring of sickness and absence by department/ward and/or individual, generating comparisons, whilst identifying trends and priorities for action. Improve planning of annual leave, sickness and study leave Provide effective management of all wards/departments The Staff Rostering policy supports a robust Trust wide electronic erostering system for all staff. 4
3.0 Policy Statement 3.1 The Trust will achieve more effective management of the workforce by ensuring safe and appropriate staffing levels. The Staff Rostering Policy supports a robust Trust wide electronic erostering system of all staff. 4.0 Definitions 4.1 4.2 erostering is the electronic system used by staff to record staff attendance, work times and non work time. It also calculates the number of hours for pay enhancements and regulates through the form of a rule based monitor the maximum and minimum numbers for given criteria based on employment legislation and health and safety at work. MAPS is the supplier s acronym for the software. 5.0 Roles And Responsibilities 5.1 Individual Officers Director of Workforce and OD The Director of Workforce and OD is accountable to the Trust Board for ensuring Trust wide compliance with the policy General/Assistant General Managers. Responsible for ensuring compliance with the policy in Directorates. Matrons/Heads of Departments Responsible for ensuring policy implementation and compliance within each Directorate/Department. Ward / Department Managers. Responsible to either Matrons/Heads of Departments/General/AG Managers for implementing the policy at local level and for ensuring compliance. While the General Manager holds ultimate accountability for expenditure, the ward/department manager is responsible for ensuring that their expenditure does not exceed the allocated budget in all wards/departments unless otherwise agreed. 5
Responsibility for updating of establishments and the safe staffing of each ward/department lies with individual managers. Staff All staff working within ttingham University Hospitals NHS Trust are responsible for complying with the policy. 6.0 Policy and/or Procedural Requirements 6.1 Staffing Levels/Skill Mix 6.1.1 Each area will have a minimum number of staff per shift, as agreed between ward/department manager and matron/head of department. Agreed numbers and skill mix must be achievable within budget. It is acknowledged that occasionally numbers may drop below this number when specific workload/dependency issues should be considered 6.1.2 Each ward/department will have a level of staff with specific competencies on each shift, as agreed between ward/department manager and matron/head of department. 6.1.3 A risk assessment by the ward/department manager should be completed if the minimum number is not achieved. Actions should be taken to utilise staff from across the Trust or proceed within the guidelines of the Temporary Staffing Policy 6.1.4 Band 7 managers should not be routinely rostered for weekend, night or bank holiday shifts unless as a requirement in specialist specific areas (e.g. ED, Theatres, Critical care areas, Maternity, Radiology or bleep holding), to work with specific staff or to occasionally review service demand out of hours. 6.1.5 Band 7 managers must be visible, accessible and have maximum presence in their area. It is expected that full time ward managers will work at least 4 days per week, between the core hours of 0700 and 1930 and during 2015 will have supervisory status. 6
6.1.6 Deputies with managerial responsibility should be rostered equally over the 24 hour period ensuring consistent leadership/management of wards/departments. It is expected that Band 6 s shall have 7.5 hours non clinical time per month. (Pro rata if part time) 6.2 Shift Duration 6.2.1 To ensure the health and wellbeing of staff, and to comply with working time regulations, every shift exceeding 6 hours must include an uninterrupted rest period of at least 20 minutes. The rest period is unpaid. Staff working a long shift will be entitled to two unpaid breaks of at least 20 minutes. Given that the work in most clinical areas is heavy and intense the total recommended break time for a long shift is 60 minutes unpaid. 6.2.2 Where possible and at the discretion of the shift coordinator/team leader a ten minute drink break may be given during paid working hours.. All managers should be aware of and adhere to the Trusts Take a Break campaign. 6.2.3 Handover periods must be realistic and allow adequate and safe handover of clinical and managerial ward/department functions. 6.3 Shift Allocation 6.3.1 All staff must be expected to cover a locally agreed number of weekend/night/on call during a set period unless flexible working entitlement has been granted for which these shifts are exempt or for health reasons supported by Occupational Health. 6.3.2 NUH fully supports the Health and Safety Executive Guidelines that states 2 full nights sleep should be allowed when switching from day to night shifts and vice versa. Staff choosing to not adhere to such guidelines must discuss personal preferences with their ward/department manager. The decision remains at the discretion of the ward/department manager 7
6.3.3 Ward / department managers will have an agreed procedure with their staff in the event of changes needing to be made to a roster when available to view 6.3.4 All staff should have an annual formal review of existing shift patterns with their ward/department manager. In some occupations, particularly registered healthcare professionals, it will be necessary for staff to work a minimum number of hours in order for the member of staff to retain core knowledge and skills and to fulfil all mandatory and role specific training requirements. Under normal circumstances, from April 1 st 2014, newly appointed registered and unregistered nursing and midwifery or such staff changing roles at NUH, the minimum contracted hours shall be not less than 64 hours per 4/52 rostered period (69 hours contracted per month). 6.3.5 Staff are able to change a shift from a completed roster with another appropriately skilled/competent member of staff - only with authorisation from the ward / department manager/shift leader/ coordinator. This avoids unforeseen problems with changes in skill mix and continuity of cover. 6.3.6 The shift leader/coordinator takes responsibility that any shortages in staffing are adequately covered or reported to appropriate line managers. 6.3.7 Over contracted/unused hours all hours either worked in excess or unused shall be either worked or paid back in time within 2 working rosters. more than the equivalent of 1 shift over/under worked shall be carried forward. All over contracted/unused shall be either worked or paid back in time within 2 working rosters 6.4 Requests 6.4.1 All requests to be made via the e erostering Employee Online 8
system. A maximum of four requests per person per four week off duty are allowed. This is pro rata for part time staff. 0 11.5 hours = 1 request 12 19 hours = 2 requests 19.5 28 hours = 3 requests 28.5 hours and over = 4 requests The granting of requests will remain at the discretion of the ward/department manager. 6.4.2 Three months worth of rosters will be visible at any one time for staff to make requests to allow for fair accessibility for all staff. The erostering team shall centrally manage the opening of rosters. Ward managers will close rosters to requests 8 weeks prior to the start date of the roster. 6.4.3 Any issues relating to individual specific requests remain confidential to the individuals concerned and will be dealt with using the Trusts Work- Life Balance Procedures. 6.5 Roster Responsibility/Production of Roster 6.5.1 The ward/department manager is accountable for either completing the roster or appointing a responsible individual to create the ward / department roster within the constraints of the. Responsibility for off duty lies with the ward/department manager. Any issues relating to over/under rostering need to be raised with Matron/Head of Department before final authorisation. 6.5.2 Publication of rosters will take place as scheduled across all wards/departments in the Trust using e Rostering. All rosters will commence on a Monday. 6.5.3 Rosters will be completed at least 6 weeks in advance of the start date using e rostering in adherence to the roster timelines as communicated on the erostering web site. 9
6.5.4 All rosters should be composed to adequately cover 24 hours (or agreed set hours) utilising permanent staff proportionally across all shifts. Nights, weekends, bank holidays and specific shifts given a high priority must be filled first. 6.5.5 Ward/Department Administration/Clerical staff should be entered as appropriate. 6.5.6 The ward / department manager has a responsibility to give staff accessibility to view the authorised roster. 6.6 6.7 Self Rostering 6.6.1 It is expected that e rostering will replace localised self rostering systems. Validation/Approval 6.7.1 Ward /Department Manager must check roster analysis and if it meets defined parameters approves roster. 6.8 6.7.2 The Matron/ Head of Department will hold responsibility for approving the roster and become the designated second approver. Directorates will develop a process of ensuring finalisation of roster managers own rosters. 6.7.3 Ward / Department managers should be involved in annual auditing of the rosters (see audit tool, Appendix 1), to monitor the effectiveness of the roster to meet service need and maintain fairness and equality to all staff. Leave Management 6.8.1 Annual leave should be allocated according to Annual Leave Policy. The weekly annual leave granted should be between 11-17% of the WTE in the ward/department. Ward Manager/Department managers have a responsibility to ensure that this is allocated 10
according to skill mix within the team. It is recognised that in smaller teams allocation of leave needs to take account of service provision. 6.8.2 Fair and equal allocation of annual leave requests should be available to all staff in highly sought after periods, such as school holidays, Christmas, New Year, Easter and the observation of other religious holidays. 6.8.3 Quarterly reviews of outstanding annual leave for each member of staff should be made by the ward manager/department manager to avoid accumulation of untaken leave. 6.8.4 Annual leave of more than 2 weeks is at the discretion of the ward/department manager. The ward manager / head of department and matron/manager must approve annual leave of more than 2 weeks and formally record approval. Requests for annual leave must be made well in advance and within ward/department existing limits for annual leave. Unless minimal ward/department annual leave has been booked, leave of more than 2 weeks shall not be taken during July, August, September or Christmas period. 6.8.5 Staff have a responsibility to ensure that they take their entitlement to leave within the annual leave year. 6.9 Special Leave/Study Leave 6.9.1 Special leave should be allocated in conjunction with the Work-Life Balance Procedures after agreement with matrons/department managers. 6.9.2 Ward/department must ensure all staff are allocated annual mandatory study days in their birthday month. The responsibility for identifying such need lies with individual staff. 6.9.3 Other study leave should be allocated equally and in accordance with the available workforce headroom in each individual area. 11
6.9.4 Fair and equal allocation of study leave should be available to all staff and requested following Trust procedure. 6.9.5 Study Leave should be for a maximum duration of 7.5 hours per day. It is acknowledged that some study days are shorter or longer than 7.5 hours. These will be adjusted by the ward/department manager. 6.9.6 Link Nursing Roles/Medical Devices The Trust recognises a number of core link roles. Each link nurse is allocated 6 hours of protected time per 4/52 roster to carry out such roles. It is the roster manager s responsibility to ensure link roles and medical device training is recorded accurately. 6.10 Flexible Working 6.10.1 The Trust recognises that there may be occasions when staff are unable to work the normal shift pattern used in their workplace. 6.10.2 The Work Life Balance Procedures should be used as a process by any staff unable to work normal working hours/ shift patterns to apply to their ward/department manager for a suitable variation to these that will continue to provide cover to meet the service need. 6.10.3 Flexible working entitlement must be reviewed yearly for each individual to ensure fairness and equality in rostering is maintained. 6.11 Temporary Staffing 6.11.1 The use of bank/agency staff should be booked according to the Temporary Staffing Policy. 6.11.2 Temporary staff will not be used to cover for planned annual leave. 6.11.3 All staff must be made aware they may at times be required to move 12
temporarily within the Trust to cover unfilled shifts or sickness absence within any ward/department/directorate or campus as stated in employee contract 7.0 Training and Implementation 7.1 Training The support for training of erostering processes will form part of the HR Workforce strategy and resources from HR will control training for staff. Full details of available training on the erostering system can be found on the erostering intranet web site. 7.2 Implementation This procedure will be included in the Trust s Policy and Procedures Library for reference by staff and managers as appropriate. 7.3 Resources A fully resourced erostering team will be the responsibility of the Director of workforce and OD and will form part of HR Workforce Resource and Planning 8.0 Trust Impact Assessments 8.1 Equality Impact Assessment An equality impact assessment has been undertaken on this version and has not indicated that any additional considerations are necessary. Please refer to appendix 1. 8.2 Environmental Impact Assessment An environment impact has been undertaken on this version and has not indicated that any additional considerations are necessary. Please refer to appendix 2. 8.3 Here For You Assessment A Here For You assessment has been undertaken on this document and has not indicated that any additional considerations are necessary. Please refer to appendix3. 13
9.0 Policy / Procedure Monitoring Matrix Minimum requirement to be monitored Responsible individual/ group/ committee Process for monitoring e.g. audit Frequency of monitoring Responsible individual/ group/ committee for review of results Responsible individual/ group/ committee for development of action plan Responsible individual/ group/ committee for monitoring of action plan n adherence to the policy will be reported to the relevant Matron and/or the erostering team. All staff groups. Report As and when cases occur Programme Manager, Nursing Development & HR Projects Manager Assistant Director of Workforce and OD Director of Workforce and OD 14
10.0 Relevant Legislation, National Guidance and Associated NUH Documents 10.1 Legislative o European Working Time Directive NUH documentation guidance o HR.WLB.003 - Work-life Balance Procedures o HR R & C 008 - Temporary Staffing Policy o HR H & A 002 Health & Attendance Policy o HR PTC 022 - Annual Leave policy 15
Equality Impact Assessment (EQIA) Form (Please complete all sections) APPENDIX 1 Q1. Date of Assessment: 11 th February 2010/reviewed March 2015 Q2. For the policy and its implementation answer the questions a c below against each characteristic (if relevant consider breaking the policy or implementation down into areas) Protected Characteristic a) Using data and supporting information, what issues, needs or barriers could the protected characteristic group s experience? I.e. are there any known health inequality or access issues to consider? The area of policy or its implementation being assessed: b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics, screening c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality Race and Impact Identified Impact Identified Impact Identified Ethnicity Gender Impact Identified Impact Identified Impact Identified Age Impact Identified Impact Identified Impact Identified Religion Impact Identified Impact Identified Impact Identified Disability Impact Identified Impact Identified Impact Identified Sexuality Impact Identified Impact Identified Impact Identified
Pregnancy and Impact Identified Impact Identified Impact Identified Maternity Gender Impact Identified Impact Identified Impact Identified Reassignment Marriage and Impact Identified Impact Identified Impact Identified Civil Partnership Socio-Economic Factors (i.e. living in a poorer neighbour hood / social deprivation) Impact Identified Impact Identified Impact Identified Area of service/strategy/function Q3. What consultation with protected characteristic groups inc. patient groups have you carried out? ne Q4. What data or information did you use in support of this EQIA? Full Equality Impact Assessment February 2010 Q.5 As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments? Q.6 What future actions needed to be undertaken to meet the needs and overcome barriers of the groups identified or to create confidence that the policy and its implementation is not discriminating against any groups ne Q7. Review date When policy reviewed 2018 17
2 Equality Impact Assessment Report Outline 1. Name of Policy or Service 2. Responsible Manager Rachel Finn and Peter Wiklo 3. Name of Person Completing Assessment Antonia Kingaby 4. Date EIA Completed 11 February 2010 5. Description and Aims of Policy/Service The purpose and aim of this Policy is to ensure that duty rotas are produced to an agreed standard which is consistent with Trust wide erostering system and to ensure the effective utilisation of the Trusts workforce through efficient rostering 6. Brief Summary of Research and Relevant Data Trust Rostering Project 7. Methods and Outcome of Consultation Directors Group Staff Side, HR Trust Managers
8. Results of Initial Screening or Full Equality Impact Assessment: Equality Group Age Gender Race Sexual Orientation Religion or belief Disability Dignity and Human Rights Working Patterns Social Deprivation Assessment of Impact Impact Identified Impact Identified Impact Identified Impact Identified Potential Impact Identified Impact Identified Impact Identified Potential Impact Identified Impact Identified 9. Decisions and/or Recommendations (including supporting rationale) Following the initial impact assessment two strands of equality have been identified as having a potential impact. At present the policy states in: Section 11.2 no allowance for the observation of other religious holidays Section 12.5 a maximum of 7.5 hours per day is permitted for study, this should also state pro rata for part time staff. 10. Equality Action Plan Please refer to action plan 11. Monitoring and Review Arrangements Once the changes have been made as suggested in the action plan, it is recommended that the policy and associated documents are implemented and reviewed in line with NUH guidelines. 19
Screening Grid Equality Area Key Equalities Legislation / Policy Is this policy or service RELEVANT to this equality area? YES / NO Assessment of Potential Impact: HIGH MEDIUM LOW NOT KNOWN positive negative Reasons Age Age Regulations 2006 Gender Sex Discrimination Act 1975 Equal Pay Act 1970 Equalities Act 2006 Gender Recognition Act 2004 20
Equality Area Key Equalities Legislation / Policy Is this policy or service RELEVANT to this equality area? YES / NO Assessment of Potential Impact: HIGH MEDIUM LOW NOT KNOWN positive negative Reasons Race Race Relations Act 1976 Race Relations (Amendment) Act 2000 Sexual orientation Equalities Act 2006 Relevant employment legislation Religion and beliefs Equalities Act 2006 Relevant employment legislation Yes Low High Section 11.2 of the policy does not allow for the observation of other sought after religious holidays 21
Equality Area Key Equalities Legislation / Policy Is this policy or service RELEVANT to this equality area? YES / NO Assessment of Potential Impact: HIGH MEDIUM LOW NOT KNOWN positive negative Reasons Disability Disability Discrimination Act 1995 and 2005 Dignity and Human Rights Human Rights Act 1998 (relevant articles) Working Patterns The Part-time Workers (Prevention of Less Favourable Treatment) Regulations 2000 Yes Low High Section 12.5 states that a maximum of 7.5 hours per day is permitted for study, this should also state pro rata for part time staff. Social Deprivation Neighbourhood Renewal Strategy Tackling Health Inequalities Local Area Agreement 22
Full Impact Assessment Grid te: Only the equality areas marked as relevant in the screening need to be fully impact assessed Relevant Equality Area (from Screening) Key points Breach equalities legislation? Does the policy / service or its implementation: Prevent discrimination or inequality? Promote equality / good relations? Key issues Religion and Beliefs Working Patterns Section 11.2 of the policy does not allow for the observation of other sought after religious holidays Section 12.5 states that a maximum of 7.5 hours per day is permitted for study, this should also state pro rata for part time staff. 23
Action Plan Name of Policy or Service: Equality groups or communities affected Issue identified Action to be taken By When Responsible Person Expected Outcome Monitoring Arrangements Religion and Beliefs Section 11.2 of the policy does not allow for the observation of other sought after religious holidays Add sentence to include the observation of other religious holidays TBC Rachel Finn/ Peter Wiklo Section will be more inclusive of other religious holidays Working Patterns Section 12.5 states that a maximum of 7.5 hours per day is permitted for study, this should also state pro rata for part time staff. Add sentence that clearly states study leave granted for part time workers will be on a pro rata basis TBC Rachel Finn/ Peter Wiklo Policy will make clear that study leave is on a pro rata basis for part time staff 24
Appendix 2 Environmental Impact Assessment The purpose of an environmental impact assessment is to identify the environmental impact of policies, assess the significance of the consequences and, if required, reduce and mitigate the effect by either, a) amend the policy b) implement mitigating actions. Area of impact Environmental Risk/Impacts to consider Action Taken (where necessary) Waste and materials Soil/Land Water Is the policy encouraging using more materials/supplies? Is the policy likely to increase the waste produced? Does the policy fail to utilise opportunities for introduction/replacement of materials that can be recycled? Is the policy likely to promote the use of substances dangerous to the land if released (e.g. lubricants, liquid chemicals) Does the policy fail to consider the need to provide adequate containment for these substances? (E.g. bunded containers, etc.) Is the policy likely to result in an increase of water usage? (estimate quantities) Is the policy likely to result in water being polluted? (e.g. dangerous chemicals being introduced in the water) Does the policy fail to include a mitigating procedure? (e.g. modify procedure to prevent water from being polluted; polluted water containment for adequate disposal) 25
Energy Nuisances Is the policy likely to result in the introduction of procedures and equipment with resulting emissions to air? (E.g. use of a furnaces; combustion of fuels, emission or particles to the atmosphere, etc.) Does the policy fail to include a procedure to mitigate the effects? Does the policy fail to require compliance with the limits of emission imposed by the relevant regulations? Does the policy result in an increase in energy consumption levels in the Trust? (estimate quantities) Would the policy result in the creation of nuisances such as noise or odour (for staff, patients, visitors, neighbours and other relevant stakeholders)? 26
Appendix 3 We Are Here For You Policy and Trust-wide Procedure Compliance Toolkit The We Are Here For You service standards have been developed together with more than 1,000 staff and patients. They can help us to be more consistent in what we do and say to help people to feel cared for, safe and confident in their treatment. The standards apply to how we behave not only with patients and visitors, but with all of our colleagues too. They apply to all of us, every day, in everything that we do. Therefore, their inclusion in Policies and Trust-wide Procedures is essential to embed them in our organization. Please rate each value from 1 3 (1 being not at all, 2 being affected and 3 being very affected) Value Score (1-3) 1. Polite and Respectful 3 Whatever our role we are polite, welcoming and positive in the face of adversity, and are always respectful of people s individuality, privacy and dignity. 2. Communicate and Listen 3 We take the time to listen, asking open questions, to hear what people say; and keep people informed of what s happening; providing smooth handovers. 3. Helpful and Kind 2 All of us keep our eyes open for (and don t avoid ) people who need help; we take ownership of delivering the help and can be relied on. 4. Vigilant (patients are safe) 2 Every one of us is vigilant across all aspects of safety, practices hand hygiene & demonstrates attention to detail for a clean and tidy environment everywhere. 27
5. On Stage (patients feel safe) 2 We imagine anywhere that patients could see or hear us as a stage. Whenever we are on stage we look and behave professionally, acting as an ambassador for the Trust, so patients, families and carers feel safe, and are never unduly worried. 6. Speak Up (patients stay safe) 1 We are confident to speak up if colleagues don t meet these standards, we are appreciative when they do, and are open to positive challenge by colleagues 7. Informative 1 We involve people as partners in their own care, helping them to be clear about their condition, choices, care plan and how they might feel. We answer their questions without jargon. We do the same when delivering services to colleagues. 8. Timely 1 We appreciate that other people s time is valuable, and offer a responsive service, to keep waiting to a minimum, with convenient appointments, helping patients get better quicker and spend only appropriate time in hospital. 9. Compassionate 1 We understand the important role that patients and family s feelings play in helping them feel better. We are considerate of patients pain, and compassionate, gentle and reassuring with patients and colleagues. 10. Accountable 2 Take responsibility for our own actions and results 11. Best Use of Time and Resources 3 Simplify processes and eliminate waste, while improving quality 12. Improve 3 Our best gets better. Working in teams to innovate and to solve patient frustrations TOTAL 24 28
APPENDIX 4 CERTIFICATION OF EMPLOYEE AWARENESS Document Title Version (number) 5 Version (date) 14 I hereby certify that I have: Identified (by reference to the document control sheet of the above policy/ procedure) the staff groups within my area of responsibility to whom this policy / procedure applies. Made arrangements to ensure that such members of staff have the opportunity to be aware of the existence of this document and have the means to access, read and understand it. Signature Print name Date Directorate/ Department The manager completing this certification should retain it for audit and/or other purposes for a period of six years (even if subsequent versions of the document are implemented). The suggested level of certification is; Clinical directorates - general manager n clinical directorates - deputy director or equivalent. The manager may, at their discretion, also require that subordinate levels of their directorate / department utilize this form in a similar way, but this would always be an additional (not replacement) action. 29