Mid Cheshire Hospitals NHS
Foundation Trust
Gap Analysis / Action Plan / After Action
Review
National OPD Survey
Document owner: Professional Lead, Diagnostic & Clinical Support Services- 5Th April 2012 – DRAFT 1
Page 1 of 5
1. Purpose of this document
The purpose of this document is to outline the monitoring and escalation process for any gap analysis / action plan / after action review undertaken
at Mid Cheshire Hospitals NHS Foundation Trust (MCHFT).
2. Process for monitoring and escalation of gap analysis / action plan / after action review (see flowchart on page 3)
The Trust standard template (see page 4) will be completed by the identified lead
Any gaps in assurance will be rated as follows:
Key:
Compliant
CLOSED
Partial Compliance
Non Compliant
The completed template will be submitted to the named committee responsible for that area. The actions and timescales will be monitored by the
named committee.
Timescale breaches for urgent actions with potentially serious implications require immediate escalation to the relevant Board subcommittee
If a timescale breaches by 2 months, the Chair of the named committee will escalate the breach to the reporting committee (e.g. Operational
Integrated Governance Committee) or, where appropriate, to the relevant Board sub-committee (e.g. QuEST)
If a timescale breaches by 4 months, the Board sub-committee will consider escalation to the Board of Directors.
The identified lead is responsible for ensuring that all actions are completed within the timescales agreed in conjunction with the person
responsible for the action.
Document owner: Professional Lead, Diagnostic & Clinical Support Services- 5Th April 2012 – DRAFT 1
Page 2 of 5
PROCESS FOR MONITORING AND ESCALATION OF ACTION
PLAN / GAP ANALYSIS / AFTER ACTION REVIEW
Trust standard template completed by identified lead
Template submitted to the named committee responsible for that area
Actions and timescales monitored by the named committee
Timescale breaches for any action potentially resulting in major or
catastrophic harm (as defined on the risk matrix) requires immediate
escalation to the Chair of the relevant Board sub-committee
If a timescale breaches by 2 months, named committee Chair to escalate to
reporting committee (e.g. Operational Integrated Governance Committee)
or where appropriate the relevant Board sub-committee (e.g. QuEST)
If a timescale breaches by 4 months, the Board sub-committee considers
escalation to the Board of Directors
The identified lead is responsible for ensuring that all actions are completed
within the timescales agreed in conjunction with the person responsible for
the action
Document owner: Professional Lead, Diagnostic & Clinical Support Services- 5Th April 2012 –
DRAFT 1
Page 3 of 5
Mid Cheshire Hospitals NHS Foundation Trust Template for Gap Analysis / Action Plan / After Action Review
RAG:
Compliant
CLOSED
Partial Compliance
Standard/Process/
Issue/Gap Identified
Patients not always
informed on how long
they would have to wait
after stated
appointment time.
Patients not always
informed how to take
their new medication,
the purpose of the new
medication and
possible side effects.
Non Compliant
Action Required

Patient appointment
letters to include
information regards
length of time the
appointment may take
 Patient Information
boards to be updated
with current delays
 Reception/ booking in
staff to be kept informed
of delays. Patients to be
informed upon arrival.
To launch a Medication
campaign and produce
posters to help raise
awareness of medication side
effects. A month will be
trialled to run the campaign
( Andy can you bullet point
your actions)
*RAG
Rating
Responsible
Lead
Timescales
(by end of):
Responsible
Committee
Del Owen
Task & Finish
group for OPD
National survey.
Andy Richings
Task & Finish
group for OPD
National survey.
Document owner: Professional Lead, Diagnostic & Clinical Support Services- 5Th April 2012 – DRAFT 1
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Progress /
Closure
Date & Evidence
(embed evidence into
document)
Standard/Process/
Issue/Gap Identified
Action Required
Patients not always
told before their
treatment, if there were
any risks and/or
benefits explained in
an understandable
way.

Patients appointments
changed to a later date
by the hospital.



To raise awareness of
the EIDO leaflets with
staff and request a
usage report from EIDO
to identify areas not
using EIDO information.
Each service to identify if
there are any gaps in the
availability of written
information both local
and national within
specialities.
To establish why clinic
appointments are
cancelled.
Identify if there are any
possible solutions to
reduce clinic
cancellations.
*RAG
Rating
Responsible
Lead
Timescales
(by end of):
Responsible
Committee
Sue Pickup
Task & Finish
group for OPD
National survey.
Julie and Sue
Hamman
Task & Finish
group for OPD
National survey
Document owner: Professional Lead, Diagnostic & Clinical Support Services- 5Th April 2012 – DRAFT 1
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Progress /
Closure
Date & Evidence
(embed evidence into
document)