Board of Directors
Reference:
Date of Meeting:
Document Title:
Responsible Director:
Author:
Agenda Item no: 8a
Enclosure no: 9
28 April 2016
Q4 2015/16 Annual Plan Deliverables Update
Michelle Rogan, Corporate Governance Director
Michelle Rogan, Corporate Governance Director
Public/ Confidential
Public – Non Confidential
Purpose of
the Paper &
Key Points
The purpose of the paper is to provide assurance to the Trust Board in relation
to the delivery of the annual plan and therefore delivery of the Strategic
Objectives and Quality Priorities.
1. Significant progress has been made since the report presented to the
Board in Quarter 4 with all but one Strategic objective having attained an
overall rating of green.
2. The PRICE objective is amber rated; there are mitigation plans in place
where delivery has not been achieved against the plan and timescales
for delivery identified.
3. The Quality Priority in relation to Information Technology is rated red
overall due to a delay in implementation of Windows 7; this was forecast
at Quarter 3 and plans are in place to deliver in May 2016.
4. The report includes detail where delivery is not in line with that planned
outlining any impact, actions needed and expected timescale for
recovery.
5. All deliverables which are not at the planned stage in Quarter 4 are
scheduled to be delivered in Quarter 1 2016/17.
Action
required by
the Board
The Trust Board is asked to note progress and to seek further assurance of the
delivery of the Quarter 4 milestones to deliver the Strategic Objectives and
Quality Priorities for 2015/16.
Board Assurance Framework Risks
Risks to the achievement of the Annual Plan and therefore the strategic objectives are
documented within the Board Assurance Framework and reported separately to the Board.
Impact and Implications
Quality
Financial
Legal or Regulatory
Equality
Y/N
Y
Y
Y
Y
If yes, what impact or implication
Non-delivery of the strategic objectives and/or quality
priorities has the potential to impact all areas.
Page 1 of 9
Strategic Objectives this reports relates to: (please tick)
People
Purpose
Partnerships
Promotion




Quality Priorities this report relates to: (please tick)
Safe
Care
Patient
Information
Staffing
Planning
Experience
Technology




CEO
COO
MD
DNT
CFO
DBOD
PDR
PPMB
WAF
A4C
CQC
QGRC
SLM
SLR
QIA
MASH
EPR
CCG
SDIP
C&F
A&C
KPIs
IMTs
QIA
CSE
CCG
ECIs
Price

Patient Safety
Programme

Place

Measuring Clinical
Outcomes

Acronyms
Chief Executive Officer
Chief Operating Officer
Medical Director
Director of Nursing and Therapies
Chief Finance Officer
Director of Business and Organisational Development
Performance Development Review
Performance and Programme Management board
Workforce Approval Form
Agenda for Change
Care Quality Commission
Quality Governance and Risk Committee
Service Line Management
Service Line Reporting
Quality Impact Assessment
Multi-Agency Safeguarding Hub
Electronic Patient Record
Clinical Commissioning Group
Service Development Improvement Plan
Children and Families Division
Adults and Communities
Key Performance Indicators
Integrated Multidisciplinary Teams
Quality Impact Assessment
Child Sexual Exploitation
Clinical Commissioning Group
Essential Care Indicators
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Summary of Key Points / Executive Summary
Narrative:
This report has two sections:
1. Quarter 4 2015-16 Annual Plan Performance against delivery of actions to deliver the Strategic Objectives and Quality Priorities
2. Narrative Exception Report where planned milestones have not been achieved
On receipt of updates for the milestones detailed scrutiny of the update against the plan is undertaken before a RAG rating is approved.
In order to provide a measurable objective of the overall position, a RAG rating has been applied to the overall position of each objective.
This is defined as:
>75% deliverables green = green overall
60 - 74% deliverables green = amber overall
< 60% deliverables green = red overall
The above defined and measurable RAG rating provides a headline position in Quarter 4 as follows for each of the Organisational Strategic
Objectives and Quality Priority actions:
1. 2015-16 Quarter 4 Deliverables Report Summary
Strategic Objective
People
Purpose
Partnerships
Promotion
Price
Place
Number of
indicators
rated Green
22
11
13
6
9
3
Number of
indicators rated
Amber
1
2
0
0
2
0
Number of
indicators rated
Red
0
0
1
0
2
0
Total Indicators
this quarter
(Quarter 3)
23
13
14
6
13
3
Overall Q4
Position
96%
85%
93%
100%
69%
100%
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Quality Priority
Number of
indicators
rated Green
Safety Express
Safe Staffing
Care Planning
Measuring Clinical
Outcomes
Patient Experience
Information Technology
Number of
indicators rated
Amber
Number of
indicators rated
Red
Total Indicators
this quarter
(Quarter 3)
Overall Q4
Position
5
2
4
2
0
0
0
0
0
0
1
0
5
2
5
2
100%
100%
80%
100%
3
2
0
0
0
1
3
3
100%
67%
2. Comparison with previous quarters
Strategic Objective
People
Purpose
Partnerships
Promotion
Price
Place
Q1
Q2
Q3
Q4
Quality Priority
Safety Express
Safe Staffing
Care Planning
Measuring Clinical
Outcomes
Patient Experience
Information Technology
Q1
Q2
Q3
Q4
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3. 2015-16 Deliverables Exception Report
People Objective
Overall this objective is GREEN – with one amber deliverable as follows:
Deliverable
Review and evaluate patient safety visit/walkabout programme within Trust Board seminar
Quarter 4 Action
Quarter 4 Action Update
Evaluate changes and report
back to board
The changes agreed are in the process of being implemented, but
currently too early to evaluate the outcome. It is anticipated that the
new approach will be evaluated in Q1 2016/17.
Q1
RAG
DNT
Q2
RAG
Q3
RAG
Q4
Q1
RAG
CFO
Q2
RAG
Q3
RAG
Q4
RAG
Q1
RAG
Q2
RAG
Q3
RAG
Q4
RAG
Purpose Objective
Overall this objective is GREEN – with two amber rated deliverables
Deliverable
Developing concept of a personalised offer in the context of personalised budgets
Quarter 4 Action
Quarter 3 Action Update
Agree action plan with service
There is a planned briefing to the SLR group / FPAC in Q4. Briefing
and corporate departments to
for CMIDF / trust managers / Trust board will follow discussion at
pilot personalised budgets, and FPAC. Action to be completed by June 2016.
share progress with CMIDF /
trust managers / trust board
Deliverable
Implement new complaints process across all services and reduce complaint response times
Quarter 4 Action
Quarter 4 Action Update
Reduce complaint response
times by 4 weeks
The overall Trust complaint response time has reduced by 2 weeks
as opposed to the target of 4 weeks. Work continues to further
reduce this in 2016/17 with key performance indicators for each
Service. The Trust has not breached the national target for
complaint response time.
Page 5 of 9
Partnerships Objective
Overall this objective is GREEN - with one red rated deliverable
Deliverable
Increase use of the Centralised Relationship Management System
Quarter 4 Action
Quarter 4 Action Update
Complete evaluation
report
Commercial priorities have taken priority over the CRM re-launch. The
re-launch of CRM will be developed in Q4 and communicated in Q1
2016/2017. The impact of this delay on the Trust is minimal.
Q1 RAG
Q2
RAG
Q3
RAG
Q4
RAG
Q2
RAG
Q3
RAG
Q4
RAG
Q2
RAG
Q3
RAG
Q4
RAG
DBOD
Promotion Objective
All deliverables have been achieved for this Objective
Price Objective
Overall this objective is AMBER with two amber and two red rated deliverables
Deliverable
Undertake review of corporate/support services to ensure they are as efficient as possible
Quarter 4 Action
Quarter 4 Action Update
Deliver Q4 milestones as per
the case for change
programme plan and refresh
the plan for 16/17
The CRES programme of £2M identified for corporate areas has
been delivered. The remaining £470k gap is being addressed
through a further review of corporate structures to identify those
departments that can operate more effectively through a more
integrated management structure.
Deliverable
Define and implement new tariffs
Quarter 4 Action
Quarter 4 Action Update
Develop tariffs, and confirm
they meet initial criteria,
review ahead of 16/17
Tariff process embedded within SLR SDIP. Inpatient programme is
the priority. Other areas to follow in phase 2 and are expected to
be delivered in 16/17. The primary risk (bedded tariffs) has been
mitigated.
Q1 RAG
CEO
Q1 RAG
CFO
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Deliverable
Accelerate and refine SLR to better support performance management and decision making
Quarter 4 Action
Quarter 4 Action Update
Implement and review
refinements against timetable
SLR SDIP programme refreshed to reflect expected Q4 activity.
Data shared with commissioners and programme on track to
deliver rebasing and improved tariffs for bedded services.
Discussions continuing around in-patient tariffs for 2016/17
Q1 RAG
The in-patient tool has been developed and used as a basis for
tariff development. The community tool is in place but is yet to be
used to develop tariff
Q3
RAG
Q4
RAG
Q2
RAG
Q3
RAG
Q4
RAG
CFO
Deliverable
Develop and implement an acuity tool for community and in-patient services that is recognised by the system
Quarter 4 Action
Quarter 4 Action Update
Q1 RAG
Roll out agreed acuity tools
and review against prioritised
plan. Technical SLR group to
propose basis for acuity
costing / reporting approach
and rollout plan.
Q2
RAG
CFO/DNT
Place Objective
All deliverables have been met for this Objective
Quality Priorities
Safety Express
All deliverables have been met for this Objective
Safe Staffing
All deliverables have been met for this Objective
Page 7 of 9
Care Planning
Overall this Quality Priority is GREEN with one red rated deliverable
Deliverable
Increase to 85% the number of nurses who have completed the assessment and care planning skills update by March 2016.
Quarter 4 Action
Quarter 4 Action Update
Q1
Q2
Q3
RAG RAG
RAG
85% achieved
20% of nursing staff have undertaken the specific assessment and
DNT
care planning training. In addition there has been the support of a
senior nurse working with the clinical teams to support local
implementation. The ECIs, which monitor the standard of record
keeping, have been steadily improving over Q4. The impact of low
uptake of classroom based training is mitigated by the additional local
support that has been implemented within the Division. Regular notes
reviews identify areas for improvement. A focus on care planning will
continue through the Quality Priorities programme in 16/17 based on
two parallel approaches, firstly the development of a clinical
education and supervision which will be clinically based rather than
require attendance at training. Secondly there will be a review of the
assessment process and care plans as the new documentation has
now been in place for 6 months.
Q4
RAG
Measuring Clinical Outcomes
Overall this Quality Priority is GREEN with no red or amber ratings
Patient Experience
Overall this Quality Priority is GREEN with no red or amber ratings
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Information Technology
Overall this Quality Priority is AMBER with one red rated deliverable.
Deliverable
Implement plan for all Trust devices to be using Windows 7 March 2016 - quarterly update on process - monitored through Information
Board
Quarter 4 Action
Quarter 4 Action Update
Q1
Q2
Q3
Q4
RAG
RAG
RAG
RAG
Implement across the Trust
Minor slippage due to the need to re-plan to incorporate the West
DBOD
Midlands Rehabilitation Centre Windows 7 updates for RiO and
BEST software solutions. Minor technical delivery issues also
encountered with the Microsoft product. On track for delivery in May
2016.
Conclusion
Significant progress has been made to deliver the Strategic objectives between quarters 3 and 4 with only two area being amber rated
overall. PRICE is amber rated in the main related to tariff development which is progressing in 2016/17; the risks to non-delivery have been
mitigated. The Quality Priority in relation to Information Technology is rated red due to a delay in implementation of Windows 7; this was
forecast at Quarter 3 and plans are in place to deliver in May 2016.
Recommendation
The Board is asked to note the overall progress in delivery of the Quarter 4 deliverables and seek further assurance where deliverables
have not been met.
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