Cliff Price Managing DirectorCPA Solutions Ltd

Tel: 01928 734177 www.cpasolutions.co.uk

“Carter and compliance”

Carter Metrics

• Sets Targets for Effectiveness and Efficiency Measures

• Compares against Model Hospital (median)

• EFM measures are clustered into 5 Domains

• Costs : Quality - Volume - location

• Effectiveness : Space type %- Cost - Fit for Purpose

• Safety : risks - Incidents

• Quality : Patient Environs - Infrastructure

• Governance : Capital spend

Risk based System :-

Assessment – Buildings ,Plant, Infrastructure

Operational processes – how the risk is managed

COMPLIANCE ?

Conforming

Rule

Specification

Policy

Standard

Law

Ref: Wikipedia

Skills

Competency

Knowledge

ExperienceWorkplace

Competency Loop

Competence stages for the individual

Individual presented with a new task

Not yet competent but aware of limitations

Competent, through training, development and experience

Key:Natural deteriorationEffective competence management Ref: HSE

Unaware of limitations arising from a changing environment

or from the development of bad habits

Not yet competent and unaware of limitations

Performs competently as a matter of practice and habit

COMPLIANCE SYSTEMSTraffic safety example

Engineering• Primary Safety: Road Surfaces, Street Lights• Secondary Safety : Seat Belts, ABS, Air Bags

Enforcement• Formal : Laws, Highway Code, Speed Cameras• Informal : Peer Pressure, Other Drivers

Education• Awareness / Attitude Change / Persuasion Campaigns

Compliance Improvement Loop

ACCOUNTABILITY

PROCESS[What has to be done]

OUTCOMES

MONITOR& REVIEW

AuditInspection

Capability

TrainingResources

Management StructureAccountability

Policy and Procedures

RegisterIncidents

Performance Logs

Risk AssessmentControl Measures

Not much mention of Compliance Pre 1990’s……….....….Vested In Experienced and Trained up staff with the right skills [COMPETENT]Now need to demonstrate……

Controls

Review

Risks

Records

Actions

Features of the CAAS Application: 1

Monitor Progress

CAAS helps you to build an overview of your Organisation’s areas of strength and weakness against areas of compliance and allows you to track progress over time.

Features of the CAAS Application: 2

Rate ComplianceRate your organisation against statements from the CAAS compliance statement bank. Responses can be given at both the organisational level, or per physical site

Features of the CAAS Application: 3

Manage ActionsThe CAAS application allows you to create, allocate, track and manage actionableTasks, moving your organisation forward towards its compliance targets

Compliance Areas Average Score by Topic

Topic

Accountability

 

Process

 

Capacity

 

Outcomes

 

Monitoring

                      

Average

73.46 74.67 81.85 65.11 76.42Water Hygiene and safety 87.00Facilities Infection Control 80.00 75.00 66.25 72.66 61.88 71.16Safe and Accessible Buildings 82.00 71.73 61.02 74.77 60.73 70.05Piped Medical Gas systems 77.17 72.08 66.92 71.28 60.90 69.67Electrical systems 64.19 77.16 68.92 76.02 59.36 69.13Asbestos Management 73.52 73.60 62.47 74.59 58.13 68.46Contractor Management 72.94 72.17 64.81 66.63 60.33 67.38Health & Safety Management 73.73 67.11 68.22 63.47 58.31 66.17Fire safety 70.00 65.17 64.43 66.88 64.17 66.13Emergency and Contingency Planning 64.56 59.83 67.00 64.00 65.00 64.08Mechanical Systems 67.70 67.10 62.39 60.50 59.70 63.48Asset Management and Maintenance 62.50 62.68 55.00 69.25 55.00 60.89Lifts 52.70 69.41 58.84 67.70 44.52 58.64Mechanical Ventilation 48.00 56.97 54.35 58.51 50.10 53.59Sustainability 55.83 51.77 47.46 56.67 50.83 52.51Waste Management 47.94 58.62 47.14 57.92 50.71 52.47Decontamination 51.85 46.84 48.63 42.75 44.52 46.92Security Management 50.63 38.47 38.75 46.67 36.25 42.15Medical Devices 49.52 41.61 46.00 32.50 35.71 41.07             

Average 64.83 63.20 59.12 63.40 54.80 61.07

Compliance Areas Comparision

GENERATIVE [High Reliability Orgs]HSE is how we do business round

here

PATHOLOGICALWho cares as long as we’re not

caught

PROACTIVESafety leadership and values drive

continuous improvement

CALCULATIVEWe have systems in place to manage all

hazards

REACTIVESafety is important, we do a lot every time we have an accident

Increas

ingly Infor

med

Increa

sing T

rust a

nd Acco

untab

ility

The Hearts and Minds Foundation

Messages…………………………..

Pressure to show compliance will not abate

System tools required to survive

Influence of organisations culture, better understood

Structure around competency

Sometimes-be careful how you answer……….

!!!!!!!!!!!!!!