CO1 Maintain our status as a performing Trust in alignment ... · Board Assurance Report Quarter...

Board Assurance Report Quarter 12012/13 Northern Devon Healthcare NHS Trust Trust Board 25 September 2012 Incorporating community Services in Exeter, East and Mid Devon

SO1 Strategic Objective: High quality We will be recognised for delivering care of the highest quality, measure in terms of clinical effectiveness, patient safety and the patient experience.

Linked corporate objectives:

CO1 Maintain our status as a performing Trust in alignment with national and local targets. Lead Executive Carolyn Mills Existing supportive evidence: Board Governance Memorandum and self-assessment against Monitors Quality Governance Framework – Independently

verified. Quality and Assurance Committee reporting to the Board Annual Quality Account Internal and external audit programme Monthly Internal performance report External benchmark comparators reviewed External assessment undertaken as part of FT Process Performance monitoring by Commissioners and Strategic Health Authority Annual assessment report from regulators

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Integrated Performance Board report to be developed

Introduction of Quality Impact Assessments for all CIP schemes

Implement a system for providing clinician level data to assess and compare quality and safety of performance.

Integrated performance report is in development QIAs introduced and monitored by CIP Steering Board and

QAC

In Progress Complete Complete

Q2 Introduce new performance management arrangements required to support the new divisional structure.

Developing an effective escalation system to ensure a prompt response/actions of corporate risk owners.

Q3 Embed process for annual Quality Governance self assessment into the organisation

Develop an information assurance framework. Enhance the Integrated Performance Report to include data

quality assessment for all metrics. Update Trust’s Data Quality Policy to include all data strands

and services of the organisation.

Q4

Programme Management Office Page 1 of 25


CO2 Demonstrate ability to embrace, identify and adopt innovation and best practice in order to position the Trust as eligible for CQUIN payments and to secure membership of Academic Health Science Network.

Lead Executive Carolyn Mills

Existing supportive evidence: Monthly performance reporting

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Q2 Additional CQUIN action plans for delivery to be developed.

Introduce mechanism for ongoing performance monitoring of actions plans against trajectory.

Action plans are still being developed. Performance monitoring in place via CIP Steering Group.

In Progress Complete

Q3 Q4 Secure membership to Academic Health Science Network Involved in the project groups, stakeholder event held 17.09.12

CO3 Develop and implement a Quality Strategy to incorporate and triangulate a set of performance

measures that provide assurance on quality of care provided as a Trust with reference to: a) Patient experience; b) Patient safety; and c) Clinical effectiveness


Existing supportive evidence: Patient Experience Strategy and work plan Patient Safety Strategy and work plan Clinical Effectiveness; R & D strategy and work plan and clinical effectiveness strategy and workplan All above are specialist advisory groups to Quality and Assurance Committee

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Write overarching Quality Strategy. Quality Strategy approved by Trust Board Jun 2012 Complete Q2 Q3 Q4



CO4 Ensure compliance with any improvement actions required as a result of inspection visits by the CQC. Lead Executive Carolyn Mills Existing supportive evidence: Actions plans monitored through Quality Assurance Committee.

Process for actioned response approved Period Planned Initiatives/Objectives/Actions Progress Report Status

Q1 Q2 Mechanism for rapid identification of actions required once

improvement actions identified. Demonstrate compliance within three months of issue of

improvement actions.

No improvement actions outstanding @ 4/9/2012 Complete

Q3 Demonstrate compliance within three months of issue of improvement actions.

Q4 Demonstrate compliance within three months of issue of improvement actions.

CO5 Risk assess the requirements for the attainment of Level 2 CNST and NHSLA Lead Executive Andy Robinson

Existing supportive evidence: Trust assessed Oct 2011 for CNST level 1 for Maternity – (due for reassessment Oct 2013) NHSLA assess at Level 1 Mar 2012 – bi-annual assessment

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Q2 Proposal paper to go to Execs for Level 2 CNST for

Maternity Proposal paper to go to Execs for Level 2 NHSLA

Decision made to progress to Level 2 CNST for maternity

Decision made to progress to level 2 NHSLA NDHT (excl Maternity)

Complete Complete

Q3 Business Case completed 12/2012 Q4

CO6 Establish a system for ensuring the meeting of new standards required by contracts or regulation. Lead Executive Andy Ibbs

Existing supportive evidence: Audit Committee meets bi-monthly Performance monitoring against existing contracts reported to Board.

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 None Q2 None Q3 Map current arrangement for the identification of new

standards/requirements and identify any gaps/risks.

Q4



CO7 Establish and implement the new Integrated Performance Report to include Health and Social Care key performance indicators.

Lead Executive Andy Robinson

Existing supportive evidence: Recent Executive Team and Trust Board performance reports.

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Initial revision of Executive/Board level reporting to include

greater use of dashboard format and less detailed data. Incorporate shadow tracking of progress against the Monitor

Compliance Framework. Commence implementation of the Covalent Performance

Management system.

Initial phase completed. Incorporated and reported monthly

Implementation in progress

Completed Completed On Track

Q2 Continue Covalent implementation Establish Health & Social Care Key Indicators Realign internal performance systems to accommodate new

Directorate structure.

Progressing Meeting planned 20/09 with DCC to identify Board level key

indicators. In progress

On Track On Track On Track

Q3 Commence roll-out of Covalent system to Execs/DGMs and other key performance leads.

Establish data flows for agreed Health & Social Care KPIs

Initial phase will include Workforce Management indicators and CQUINs

Not yet started

On Track

Q4 Covalent system to become main tool for accessing corporate KPIs.

Integrated Performance reports primarily produced using Covalent functionality.



CO8 Evidence and demonstrate compliance with NICE Standards and Guidance. Lead Executive Alison Diamond Existing supportive evidence: Quarterly reporting to QAC for NICE Guidance

Period Planned Initiatives/Objectives/Actions Progress Report Status

Q1 Q2 Ensure systems are in place to demonstrate distribution,

implementation and evidence of implementation of NICE guidance to give Board assurance via QAC

Regular reporting to QAC in place Complete

Q3 Baseline assessment of NICE Standards to be presented to QAC (Nov 12)

Baseline assessment with Clinical leads for populating In Progress

Q4 Develop action plan from GAP analysis and to be presented to Jan QAC

Develop robust quality assurance and delivery of NICE standards that identify those we can meet and those that need Commissioner resource.

CO9 Implement patient experience strategy Lead Executive Carolyn Mills

Existing supportive evidence: Patient Experience Strategy and work plan monitored by LPEG and QAC

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 N/A Q2 Introduction of patient stories at Trust Board First story presented at Trust Board in July 2012 Complete Q3 Q4

CO10 Roll-out human factors training. Lead Executive Alison Diamond

Existing supportive evidence: Principle risk 10 about peoples behaviour Period Planned Initiatives/Objectives/Actions Progress Report Status

Q1 Q2 Q3 Q4 Develop and implement a human factors training programme




CO11 Deliver commitment within Quality account Lead Executive Carolyn Mills Existing supportive evidence: Annual Quality Account

Annual audit of Quality Account by Audit Commission Annual Quality Account performance measures monitored by Safer Care Delivery Group and QAC

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Q2 Q3 Enhance the Integrated Performance Report to include data

quality assessment for all metrics. Update Trust’s Data Quality Policy to include all data strands

and services of the organisation.

Q4 CO12 Demonstrably increase the visibility of Non-Executive directors within the organisation Lead Executive Jac Kelly

Existing supportive evidence: NEDS have an open invitation to attend Patient Safety walkarounds All NEDs either chair sub committees to the Board or act as representatives on non Board sub-committee meetings.

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 NEDs to engage in GP liaison visits NEDs engaged in GP visits, and have provided feedback Complete Q2 Establish a register which demonstrates presence of Board

members at different meetings/events.

Q3 Review current meeting structure between Chairman and NEDS to develop relationships and broaden their collective view of the role.

All NEDs to participate in patient safety walkarounds

Q4 Schedule a programme of unannounced visits for NEDs to service areas to broaden the scope of understanding and experience of the Trusts services and increase their visibility throughout the organisation.


SO2 Sustainable services delivered locally We will ensure access to a sustainable range of services that are delivered locally through established partnerships and clinical networks with other organisation where necessary.

Linked corporate objectives: CO13 To achieve Foundation Trust status. Lead Executive Andy Ibbs

Existing supportive evidence: Tripartite Formal Agreement in place. Foundation Trust Steering Group chaired reports to Trust Board. Foundation Trust Programme Director in post

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Board Governance Memorandum completed, externally

assessed and associated action plan developed

Q2 Quality Governance Memorandum completed, externally assessed with a score of 3 Better than the maximum score of 4 allowed to progress for authorisation), and associated action plan developed

Legal clearance given on constitution 3,000 membership target met Financial Risk Rating remains at 3 Governance Indicator = 0.0 Significant progress on commissioner convergence Significant progress on developing a balanced LTFM. Latest version of IBP and LTFM submitted on 21 September Tripartite meeting with DH and SHA will be on 15 October

Complete

Q3 Submit FT Application to DoH 1/10/2012 Q4 Move into Stage 3 Monitor phase



CO14 As a part of the Southern Cluster Acute EPR Programme complete the procurement phase for the replacement of our existing PAS system with enhanced functionality to support order communications, clinical decision making and electronic prescribing

Lead Executive Alison Diamond

Existing supportive evidence: Member of consortium with Gloucestershire and Yeovil NHS Foundation Trust’s Electronic Patient Record Steering Group

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Q2 Develop local business case in support of consortium’s

Outline Business Case and present to Board Develop Output based specification (OBS)

OBC to go to September Board

OBS to go to Steering Group

In Progress In Progress

Q3 Evaluation process to be developed in support of tendering process.

Q4 Full Business Case developed and approved by the Trust Board.

This is dependent on tender time scales but will be monitored and reviewed.

CO15 Develop a service strategy that risk assures the sustainability of all services going forward. Lead Executive Kate Lyons

Existing supportive evidence: Evolving Chapter 5 of IBP

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Q2 Commence scoping work for community hospital provision

going forward Review of Outpatient services

Discussions with commissioners and stakeholders commenced Outpatient review completed

In progress Completed

Q3 Identify project management resource for community hospitals project (to incorporate CHC)

Develop detailed project plan for community hospitals project

Develop detailed project plan for emergency hub Develop project plan for implementation of outpatient review Develop detailed project plan for acute hospital initiatives - Theatre provision - Bed reconfiguration

Timescales for community hospitals work identified Ongoing discussions with commissioners Project to reduce by one theatre commenced

Q4 Complete Theatre closure Implement recomendations of outpatient review Discussion on future of community hospitals with

stakeholders



CO16 Develop and agree a Memorandum of Understanding with each of the other acute providers with whom

we operate in networks. Lead Executive Kate Lyons

Existing supportive evidence: Limited SLAs in place.

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Identification of all current network arrangements

Identification of any existing SLAs / MOUs for services Collated picture developed identifying all existing networks,

current activity levels and current costs Complete

Q2 Review continuing requirement for each network – discussion with local clinicians

Yet to commence

Q3 Review continuing requirement for each network – discussion with local clinicians

Develop MOU template for discussion with partners

Q4 Agree MOUs with partner providers CO17 Deliver the capital investment programme.

Lead Executive Andy Robinson

Existing supportive evidence:

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Delivery of the Capital Programme is on track. Complete Q2 Q3 Q4



CO18 Develop a new Estates strategy and deliver year one of the programme. Lead Executive Iain Roy Existing supportive evidence:


Q1 Undertake Estates survey within DH guidelines Identify current costs of services in Eastern properties and

identify alternative incomes via leases etc

Complete Complete

Q2 Complete DH national ERIC “Estates Return Information Collection” returns

Identify TCS Estates shortlist for transfer from PCT to NDHT Confirm with SHA the process for identifying due diligence

for estates transfers

Complete

Complete Complete

Q3 Complete due diligence process for estates transfers

Using DH data, benchmark the estates performance and identify areas of concern

Finalise estates transfer list Identify final service development plan

A process underway with PCT and SHA Awaiting DH information

Transfer list to be finalised by 31st October 2012 Awaiting final plan

Q4 Produce professional estates plan to best meet service development plan and opportunities to improve the estates performance

Together with key stakeholders, develop a pragmatic estates strategy that takes into account phasing, funding availability and political doability

Ratify estates strategy at Board

CO19 Strengthen the arrangement for quality governance within service level agreements and contracts.



Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Develop a revised template for reviewing all Trust SLAs to

include specific quality measures. Revised template developed Complete

Q2 Revised template to be shared with relevant managers Complete Q3 Q4




CO20 Exploit the operational, and explore the marketing, opportunities following the implementation of ComPAS.

Lead Executive Kate Lyons

Existing supportive evidence: ComPAS in active use across community services

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Implement ComPAS

Secure ComPas project lead and support team ComPas board in place ComPas operational group in place

ComPAS has been implemented for approximately 90% of community services. The outstanding services are those which require some additional functionality added to ComPAS until it is operationally viable for them.

Ongoing

Q2 ComPas reporting to be specified and delivered to support operational use

Introduce ComPAS team to Innovations South West

ComPas reporting in place. Further refinements and specification work undertaken

Complete Complete

Q3 Produce options appraisal on future commercial development of ComPAS 9/2012

ComPas activity reporting to be shared with commissioners to demonstrate community services activity against plan

ComPas road map to include functionality to support patient safety and quality requirements

ComPas road map to include functionality to support CQUIN reporting

The development of the application is still ongoing. As such the options appraisal will not be carried out until completion of project and as part of the post project review.

Not started

Q4 Produce business case for the commercial development of ComPAS

Review impact of ComPAS on productivity / efficiency

There is a dependency between the business case and the above options appraisal being carried out.

Project still ongoing so no post project review has been undertaken to measure the impact on productivity / efficiency.

Not started


SO3 Integrated care We will maximise the benefits derived from an integrated model of health and social care that provided the right care at the right time in the right place at the right level for the individual.

Linked corporate objectives: CO21 Successfully implement a number of ‘tests of change’, agreed with our commissioners, in order to

demonstrate our capacity to deliver the transformational agenda ahead of any potential retendering of services currently provided by the Trust under the TCS agreement.


Existing supportive evidence: S256 Investment and consortia level investments to improve community capacity and resilience to support admission avoidance and ensure timely discharge from hospital settings. Financial commitments agreed with local commissioners and NHS Devon

Eastern reablement board established Northern Devon Optimising community services steering group in operation to oversee S256 investment with NHS Devon Full implementation of Rapid Intervention Centre in Eastern Devon – 7 day per week model from July 2012 Redesign of onward care services within RDE to support elderly frail pathways in Eastern Devon, ongoing 2012/13 Eastern S256 Evaluation report v1(August 2012) Hospital at Home Evaluation report (September 2012) Northern Devon S256 Evaluation report summary v1 (August 2012)

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Implementation of schemes across Eastern and Northern

Devon Schemes (North / East) operational in line with plan Complete

Q2 Early evaluation of impact Initial evaluation completed for Eastern and Northern Services Complete Q3 Continued delivery and service redesign to inform

commissioning plans for 2013/14. Dashboard development to be finalised and reporting

commenced on agreed basis

Q4 Formal evaluation of investments and recommendations for future service delivery


Board Assurance Report Quarter 12012/13 Northern Devon Healthcare NHS Trust Trust Board 25 September 2012 ng community Services in Exeter, East and Mid Devon


Incorporati

CO22 Continue to work towards development of Single Accountable Provider by: a) Developing a system of joint governance with Devon County Council for social care. b) Triangulate performance reporting across Health and Social Care to support future resource

mapping.


Existing supportive evidence: Partnership Agreement in place Quarterly Review meetings

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Memorandum of agreement and annual statement drafted to

outline anticipated outcomes of partnership Complete

Q2 Quarterly Partnership meetings established and in place MOA and annual statement finalised

Complete

Q3 Identify KPIs to include in integrated Board report Identification of capacity challenges to enable integrated board reporting

Q4 Commence Board reporting


SO4 Flexible workforce We will recruit and develop a flexible and multi-skilled workforce fully engaged in turning our vision into a reality

Linked corporate objectives: CO23 Identify targeted areas for improvement from the staff survey 2011/12 results.

Lead Executive Maureen Bignell

Existing supportive evidence: Sharing of results with staff Agreement of key areas of improvement with staff side Engagement events with wider workforce on issues that matter to them Implementation of new appraisal system Development of divisional improvement plans Agreement of supervision meetings supporting appraisal discussions

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Improvement of quality of appraisals Guidance issued to managers Complete Q2 Communication of initiatives to improve staff satisfaction Issued on BoB and via Partnership Forum Complete Q3 Mini-surveys to be targeted where staff satisfaction is low

Increase awareness of how V&A incidents are dealt with.

Instigate an audit of the process of appraisal (content and outcome) to be undertaken in all divisions to provide assurance around the quality of appraisal and subsequent development plans. (Sept 2012)

Due in October 2012 From staff engagement events feedback this does not appear

to be an major concern but will be included as an action for October 2012.

Q4 Engagement events planned for March



CO24 Complete development of strategic workforce plan that embeds workforce planning across the organisation, through the development of granular workforce plans, at divisional, departmental and professional levels.


Existing supportive evidence: Strategic Workforce Plan Terms of reference for workforce plans signed off Some divisional/workforce plans in place Plans triangulated with service 0perational workforce planning meetings taken place CIP workforce reductions identified Flexible recruitment processes commenced Workforce information provided to managers Workforce planner in place through existing resources

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Ensuring strategic workforce plans links with service and

financial plans Complex work continuing

Q2 Operational plans linked to LTFM and CIP requirements Q3 All divisions to have completed workforce plans Q4

CO25 Running the Development Centre to promote innovation and energise managers through delivery of

selected CIP projects. Lead Executive Maureen Bignell

Existing supportive evidence: Staff identified for development centre programme Four development centres taken place Leadership Framework completed for majority of participants Development plans for individuals Projects underway and working towards completion Commencement of talent database from feedback on development centre

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Progress presentations to executives for projects – to be

timetabled in Report from coding project to executives

Q2 New projects for programmes to be identified Q3 Q4



CO26 Implement plans to build a peripatetic pool and make the workforce more flexible. Lead Executive Maureen Bignell Existing supportive evidence: CIP project underway to introduce more flexible workforce

Project team in place Recruitment processes revised to enable more flexible workforce Generic recruitment processes completed

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Generic job descriptions to recruit to a set of skills rather

than a post In progress

Q2 People on Move implementation Amended contracts issued to new staff

Insufficient staff identified to enable flexible workforce

Q3 Q4

CO27 Implement CRAB to provide board assurance on competency of clinical workforce Lead Executive Alison Diamond

Existing supportive evidence: Software purchased


Q1 Q2 First individual Consultant Surgeons reports to be circulated

in Sept 12. First aggregated report to Medical Director Sept 12

First reports being circulated. In progress In progress

Q3 Governance developed and meetings to be set up. Q4 Introduction of reports to physicians.




CO28 Review and update the Organisational Development strategy. Lead Executive Maureen Bignell Existing supportive evidence: Draft engagement strategy developed with staff

Revised formal staff partnership arrangements Succession planning framework agreed

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Q2 Engagement strategy published Final draft for October Partnership Forum Q3 Implementation of recognition awards

E&D annual report and action plan to be agreed Equality and diversity objectives to be agreed

Agreed in principle with staff side Drafted Staff equality objectives agreed, lack of engagement is a

barrier to agreeing service user objectives

Q4 Talent pool identified to support succession planning A number of individuals identified CO29 Improve recruitment and applicant numbers through;

a) Revamped recruitment literature. b) A better programme of orientation for staff recruited from out of area. c) Increased rates of apprentice appointments.


Existing supportive evidence: Revision of recruitment templates Attendance at recruitment fares Generic recruitment events Reduction in processes to enable speedier appointments Review of internal processes through development group

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Q2 Implementation of NHS Jobs 2 In progress due to implement first stage December 2012 Q3 Development of new ways of recruitment

Option appraisal produced Current processes reviewed and options being considered

Q4 Final option agreed


SO5 Efficient and effective We will efficiently and effectively run our services; generating surpluses to reinvest in services to benefit our local community and underpinning all we do with systems and processes which deliver safe, high quality services.

Linked corporate objectives: CO30 Deliver the cost improvement programme within financial year to release the planned cash releasing

efficiency savings. Lead Executive Andy Robinson

Existing supportive evidence: Monthly reports to the Finance Committee and Board. KPMG support to CIP assurance Weekly Cost Improvement Steering Board

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 CIP performance reported routinely through Finance

Committee

Q2 Corrective action required to assure delivery of current year and future years to support the FT assessment supported by KPMG.

CIP tracker supported by detailed PIDs that include financial analysis evidencing CIP achievement.

Q3 Q4

CO31 Deliver the control total. Lead Executive Andy Robinson

Existing supportive evidence: Finance reports to the Finance Committee and Board

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Q2 Current forecasts indicate achievement of the control total. Q3 Q4



CO32 Establish a programme management office to ensure delivery of the cost improvement programme and other trust-wide projects.

Lead Executive Andy Ibbs

Existing supportive evidence: Cost Improvement Programme Steering Group set up.

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Q2 Establish 5 year CIP in alignment with the Trust’s IBP and

LTFM Produce CIP Governance process and procedure

Intensive work with SROs, project leads and KPMG has developed a balanced LTFM and identified a £60 million CIP programme.

CIP Governance process has been agreed by the CIP Steering Group and will now go to Finance Committee for approval

Complete

Q3 Produce PMO strategy 10/2012 Q4 PMO strategy implemented 03/2013

CO33 Improve the knowledge of the FT finance regime amongst the Board and other senior managers. Lead Executive Andy Robinson

Existing supportive evidence: Board Briefings. Finance reports to Finance Committee and Board are presented in a FT format. HFMA e-learning includes FT finance module – Board and Senior Managers have been allocated this (and other) modules. Staff briefings on IBP and LTFM Briefings to current and future commissioners.

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Deliver presentations internally and externally of the LTFM

and its implications. Board Briefings. Finance reports to Finance Committee and Board are

presented in a FT format. HFMA e-learning includes FT finance module – Board and

Senior Managers have been allocated this (and other) modules.

Staff briefings on IBP and LTFM Briefings to current and future commissioners.

Q2 Deliver presentations internally and externally of the LTFM and its implications.





CO34 Develop the LTFM to a standard where it satisfies Monitor. Lead Executive Andy Robinson

Existing supportive evidence: Board briefings Previous IBP submissions

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 LTFM to support June submission of the IBP. IBP version 5 and supporting LTFM was submitted to the SHA

in June 2012.

Q2 LTFM to support June submission of the IBP. IBP version 6 and supporting LTFM is being finalised for submission to the SHA on 21 September 2012.

The Trust has an indicative date of 1 October for a review of the LTFM with the SHA and DH. This will inform a further iteration of the LTFM prior to submission to the DH.

Q3 LTFM Review meeting with SHA and DH during October 2012

Q4 CO35 Implement and utilise Service Line Reporting and Service Line Management. Lead Executive Andy Robinson


Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Procure SLR system SLR system has been procured and the reporting structures

and data feeds are being created. The Trust is being supported by the software supplier providing

the project management support to development and implementation.

Q2 Develop structure and data feeds for SLR system. Q3 Produce initial SLR report from 2011/12 finance and activity

report. Test 2011/12 output. Produce initial SLR report from 2012/13 finance and activity

report. Roll out SLR information to new Clinical Management

Groups.

Q4



CO36 Ensure the Trust achieves a level of EBITDA that secures a minimum financial risk rating of three. Lead Executive Andy Robinson Existing supportive evidence: Finance reports presented to the Finance Committee and Board.

LTFM submissions as part of the FT process.

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Provide monthly Finance reports to the Finance Committee

and Board that clearly identifies performance against Monitor’s Financial Risk Rating.

Reports to Finance Committee and Board reflect that the FRR for EBITDA margin in 2012/13 was planned for and will remain at 2 due to the current treatment of TCS assets that are not owned by the Trust.

This issue will be resolved under guidance on the transfer of assets and the LTFM demonstrates achievement of the EBITDA margin required to achieve a 3.

The overall FRR for the Trust taking into account all financial metrics is a 3 for 2012/13.

Q2 Q3 Q4

CO37 Develop a corporate objective monitoring and assurance report. Lead Executive Andy Ibbs

Existing supportive evidence: Strategic objectives set and agreed by the Trust Board

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Corporate Objectives to be approved by Trust Board Corporate Objectives approved at Trust Board 22/5/12 Complete Q2 Corporate Objective Assurance Report to Trust Board

9/2012

Q3 Q4




CO38 Achieve Trust performance targets for completing appraisals and delivery of mandatory training. Lead Executive Maureen Bignell Existing supportive evidence: Review of appraisal documentation

Introduction of e-learning opportunities Increased training at local sites Specialist trainer action plans to improve attendance Monthly monitoring of appraisal and training figures

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Increased support for managers conducting appraisals Q2 HR intervention for non-compliance of attendance at training Letters issued where appropriate Q3 Continue to increase training at local sites Evidence submitted Q4


SO6 Provider of choice We will be the local provider of choice; working in partnership with the public and commissioners to promote independence and well being and meet the needs of our community.

Linked corporate objectives: CO39 Position the organisation to have the commercial capacity and capability to selectively bid, under any

qualified provider, with successful outcomes by: a) Recruiting a Commercial Director.

b) Establishing a Business Development Unit.

c) Establishing a means by which the Trust can make informed decisions about whether or not to bid for services.

Lead Executive Andy Ibbs


Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Q2 Commercial Director Recruited Complete Q3 Agree plan for improving commercial capability of

organisation Business Development unit established Write and implement an investment strategy

Q4 Develop commercial capability of the Executive and senior staff



CO40 Establish means by which feedback, from patients and commissioners, is collated and used. Lead Executive Carolyn Mills Existing supportive evidence: Patient Experience Strategy and work plan

Monthly CQRM meeting with Commissioners One to One between Director of Nursing and NHS Devon Quality Lead for North and East Devon

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Patient experience strategy reviewed for inclusion of

feedback loops Complete

Q2 Q3 Q4

CO41 Revise and implement the communication strategy to promote the Trust as provider of choice. Lead Executive Andy Ibbs


Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Q2 Q3 Commence re-drafting of strategy Q4 Revised strategy agreed by Board

CO42 Development and implementation of Governors and Members strategy to demonstrate increased levels

of accountability. Lead Executive Andy Ibbs

Existing supportive evidence: Governance Rationale has been produced

Period Planned Initiatives/Objectives/Actions Progress Report Status Q1 Q2 Agreement to hold FT Briefing session with existing SWAST

Governor to understand their role and potential impact Complete

Q3 Develop draft Governors and Members strategy for consideration

Q4 Finalise Governors and Members strategy




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CO1 Maintain our status as a performing Trust in alignment ... · Board Assurance Report Quarter...

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