Transcript Corporate Plan 2007/8 - Welcome

Corporate Plan 2007/8
Progress Report to Trust Board
September 2007
Deborah Shaw
Director of Strategy
CO1:To continue to improve patient safety and the patient
experience
Corporate
Objective
CO1:To
continue to
improve patient
safety and the
patient
experience
Strategic
priority
To continue to
Improve the
quality of our
services
Operational
Objective
ED
Assessment
RAG
Meet the Healthcare
Commission’s standards
for 2007/8 set through the
Annual Health Check
DSD
System established and progress monitored through
assurance compliance unit. Reported to Board
through integrated performance report. The Trust is
currently not on track to achieve the MRSA target
A
Continue to reduce MRSA
and hospital acquired
infection rates
CE/DS
The HCAI Action Plan was signed off by Trust
Board 31/5/07. New STICC arrangements in place
from 31/7/07. DH review 26/9/07. The Trust has
particularly focused attention recently on:
revising and embedding antibiotic policies,
screening policies, central and peripheral line
policies
establishing cohort infection wards on both sites
re emphasising “clean your hands campaign”
R
Continue work on nursing
standards
DSD
The Trust has made some progress with the
implementation of Essence of Care Standards,
specifically focusing on privacy and dignity. Further
work is planned when the Head of Nursing Practice
joins the Trust. ‘Programme of Care for the Older
Patient’ project has been launched within the Trust
and 16 champions have been identified across the
hospital. Agreement with Staffordshire University to
jointly appoint a Professor of Nursing who will lead
on privacy and dignity practice and development
issues. The Trust has developed its own set of
Nursing Performance Indicators and developed the
software to support the monitoring on a monthly
basis.
G
Deliver CNST level 3 for
maternity
DSD
Achieved.
G
CO1:To continue to improve patient safety and the patient
experience
CO1:To
continue to
improve patient
safety and the
patient
experience
To continue to
improve the
quality of our
services
Continue to improve the
patient environment
DSD
Patient Environment Action Team is established led
by the Director of Service Delivery and includes
Estates and Facilities representation, infection
control nurses, ,nurse managers and PPI
representatives. Regular programme of planned
assessments and unannounced visits in place. The
Trust has consistently scored well in external
assessments and both sites recently received a
score of 5 (excellent) for cleanliness and food. The
Trust has recently been chosen from all Trusts in
the West Midlands to become a Learning Partner for
the implementation of the ‘Productive Ward’ in
partnership with the National Institute of Innovation
and Improvement.
G
Continue to improve patient
satisfaction
DSD/
DCA
Ward managers identified as champions.
Presentation given July 2005. To develop local
action plans and exit surveys and monitor through
Community Engagement Forum
A
CO2: To achieve Foundation Trust Status by July 2008
CO2:To achieve
Foundation
Trust status by
July 2008
To deliver a
long term
service
development
strategy for the
Trust
Perform a fact-based
assessment of all clinical
specialties and produce a 5
year market-driven Service
Development Strategy
DS
26 workshops completed June-July 2007. Draft
outputs reviewed by Divisions, Executive and Trust
Board by 30th August. Shortlist of priorities based
on urgency and impact analysis has been
produced that will now inform the draft integrated
business plan (IBP). Next stage is to align priorities
with the SHA “Investing for Health Strategy“ and
commissioner intentions.
G
Prepare an Integrated
Business Plan (IBP) that
includes detailed market
assessment, long term
service and financial
strategies and workforce
plans
DS
Board SWOT and PESTLE completed. FT work
streams on track to deliver individual elements of
the IBP for end of September 2007. Good progress
on market analysis: health profiles demographic
data presented to Trust Board; Dr Fosters data on
referral patterns from GPs now available. Market
assessment priorities have been identified.
G
Working with key
commissioners and other
stakeholders to develop a
Shropshire WHE Strategy
CE/DS
Commissioning Strategy promised from both PCTs
by 30th September 2007. Workshops scheduled for
September with PCT and PBC leads to share draft
outputs from service reviews.
G
To develop and implement a
number of integrated care
pathways with our health and
social care partners that
support the priorities
identified through the LDP
and ISIP process
DS
Four agreed priorities for 06/07: Sexual Health,
advanced primary care services (APCS),
diagnostics and admission avoidance. Regular
reports to ISIP Board. ISIP maturity matrix
performed by SaTH, SCPCT and T&W PCT leads
as part of a health economy-wide review of
integrated planning processes. Draft action plan
produced and identifies a need to strengthen the
prioritisation process and the programme
management approach to ensure that committed
plans are properly resourced.
A
CO2: To achieve Foundation Trust Status by July 2008
CO2:To achieve
Foundation
Trust Status by
July 2008
To develop the
Trusts
governance
arrangements
that are fit for
purpose for a
Foundation
Trust
Implement fit for purpose
business systems into the
Trust from “Board to floor”
DS/FD
Revised approach to corporate planning process in
place. Divisional business plans developed focusing
on approach to delivery of corporate objectives.
Revised business case proforma implemented for
consultant posts and major service developments.
Performance report revised to focus on exception
reporting and mitigating action. Implemented webbase analytics for activity data.
A
Review corporate
governance arrangements
and further develop the
concept of the compliance
unit
DCA/
FD
Integrated governance review to July Board.
Compliance unit in place with terms of reference to
be reviewed in the Autumn in line with Monitor
Compliance Framework.
G
Implement the “Intelligent
Board” concepts in decision
making
CE
Review of committee structure completed and
implemented. Consistent reporting approach at
Board and sub committees against corporate
objectives
G
Review the Board and
organisational capability
and capacity and
implementation of a Board
development programme
CH/
DCA
Board development programme implemented.
Board gap analysis planned for October 2007.
Board to Board Challenge planned with auditors
December 2007 and March 2008
G
Further development of
performance management
and risk management
systems and processes
FD/
DCA
Risk management systems well embedded. Internal
audit assessment “substantial assurance”. External
Audit assessed internal control as “GOOD” in
Auditors Local Evaluation. Integrated performance
report developed. Balanced scorecard/dashboard
approach under review.
G
CO3:To achieve all key national targets and priorities on an annual
basis
CO3:To achieve
all key national
targets and
priorities on an
annual basis
To continue
the Trust’s
financial
recovery
To continue to
improve
access to our
services
Deliver in-year financial
surplus.
CE
Surplus £387k at Month 4
G
Deliver a CIP of at least
£7.8m.
FD/
DSD
Divisional Finance Review Meetings have been
reestablished on a monthly basis to review the
operational budget position and performance
against CIP. £5.3m CIP identified against a target of
£7.5m. The Finance Director and the Director of
Service Delivery continue to work with the Divisions
to identify a further £2.2m.
A
Make progress with
addressing the historic
deficit.
CE
Resolved by working capital loan and new NHS
Financial Strategy
G
Improve on Health check
“Use of Resources”
assessment
FD/
DCA
Trust scored 3 for Internal Control. Other elements
improved scores since last year.
G
Make progress towards the
18 week referral to
treatment target and
achieve national milestones
DSD
The Director of Service Delivery has Executive
responsibility and the newly appointed Access
Manager has project management responsibility. A
project group and an IT sub group have been
established to develop data collection and reporting
systems. The medical secretaries are piloting the
role of “patient trackers”. The group is currently
developing an escalation policy for reporting
information to the relevant managers/clinicians
regarding patients’ progress through their pathway.
Further work on reviewing pathways of care will
require strong clinical engagement.
A
CO3:To achieve all key national targets and priorities on an annual basis
CO3:To achieve
all key national
targets and
priorities on an
annual basis
To continue to
Improve
access to our
services
Reduce waiting times for
diagnostics.
DSD
There has been great improvement in reducing
diagnostic waiting times. The Trust is confident that
it will achieve a maximum wait of 6 weeks by
December 07 in advance of national target of
December 2008. Pathology waiting times are under
scrutiny as a result of some breaches of 11 week
target.
A
Continue to achieve national
access targets in A&E
DSD
The A&E target has proved particularly challenging
this financial year. The challenges are threefold:
an increasing number of delayed discharges in
acute hospital beds due to social service funding;
an increasing number of delayed discharges due to
inability to transfer patients to Community Hospitals;
disestablishment of 40 unfunded escalation beds
(which accommodated delayed discharges) to allow
renal unit development at PRH and the infection
ward development at RSH.
Division 1 action plan is in place with signs of
impact. First week achievement of 98% in early
August since May 2007.
Continue to achieve national
access targets in Cancer
DSD
The Trust has an excellent track record of
consistently achieving the cancer targets.
G
Achieve target for GUM
100% offered an
appointment within 48hrs by
March 2008
DSD/
DS
The Trust has not achieved its internal profile since
April 2007 although a month on month improvement
is evidenced. The Trust approved the management
transfer of GUM services to PCT at the July Board.
This should support the achievement of the targets
in managing patients in the appropriate setting.
A
Plan for maternity services
DSD
Shropshire model of care follows national guidance
with consultant-led and midwifery-led units. The
Trust has performed an assessment against
Maternity Matters standard and has minimal gaps
but is developing action plan to address. Model of
care perceived as exemplar nationally.
G
R
CO3:To achieve all key national targets and priorities on an annual basis
CO3:To achieve
all key national
targets and
priorities on an
annual basis
To continue to
improve our
productivity
LOS reductions emergency
and elective:
to reach England upper
quartile LOS over the next
18 months
to reduce pre-operative
LOS by 10% by March 08
DS/
DSD
Not achieving monthly profile for elective and non
elective LOS. Statistical process control charts
show inconsistencies between sites that need to be
explored. Action plan is being developed by the
Head of Service Improvement focusing on patient
flows and standardized patterns of working. Some
progress with social care delays.
A
Increase day surgery rates
to 78% by March 2008.
DS/
DSD
The day case rate for surgical procedures was
reported at 77.8% in July 2007 and is above profile
and on track to achieve 78% by March 2008.
G
Maximise theatre utilisation
DS/
DSD
Target to increase theatre utilisation to 85%
Monitoring to be included within Integrated
Performance report in September. Live theatre
utilization system being developed through SEMA.
A
Maximise use of outpatient
capacity
DS/
DSD
Outpatient review completed with action plan.
Nominated project lead and service manager
identified. Project group established . Plan approved
and being progressed.
A
Clinical support services
review
DS/
DSD
Clinical service review has identified lack of
integrated systems and processes across sites.
Review of Imaging and Pathology flagged within
service improvement priorities. New Head of
Pharmacy starts in post September 2007 with a
remit to review site specific issues .
A
Application of lean principles
particularly to corporate
functions
CE/DS
Implemented in A/E and theatres. Review of
structures to be undertaken in corporate
departments by September 2007
G
Review of all non clinical
support functions
FD
Estates maintenance & operations workshop (phase
3 corporate services review) undertaken
G
Implementation of
Productivity Improvement
action plan
DS/FD
Clinical element of productivity improvement action
plan has been incorporated into service
improvement plans. Non clinical elements
incorporated into CIP targets.
A
CO4:To recognise and enhance through organisational development, the
contribution of the workforce to the success of the organisation
CO4:To
recognise and
enhance
through
organisational
development,
the contribution
of the workforce
to the success
of the
organisation
To improve
staff
satisfaction
and staff
engagement
in effective
decision
making
Implement and maximise the
value from the new
management structure
through staff development
and KSFs.
DSD
The Trust has now successfully appointed 3
Divisional Directors and three Divisional General
Managers for each of the new Divisions. All
managers in the supporting infrastructure have also
been appointed. A Management Development
Programme is being developed for Autumn 2007.
G
Implementation of the clinical
skill mix review findings
DSD
Implementation of the recommendations of the
Nursing Skill Mix review is almost complete. A
priority for the newly appointed Head of Nursing
Practice is to develop a Ward Managers
Development Programme to support ‘Modernising
Nursing Careers’.
G
To respond to changes in the
medical workforce to include
EU WTD, Modernising
Medical careers and new
consultant contract
FD
Contingencies in place for MTAS
Increasing Staff Grade and Trust Grade
appointments for service
Job planning tool available September 2007
A
Embed the concept of “the
business unit” and the culture
of “earned autonomy” within
the business systems and
processes of the organisation
DSD
The Divisional Boards are now established, with the
Divisional Director and the Divisional General
Manager receiving dedicated Finance, Human
Resource and Professional Advisory Support.
Divisional Review meetings are planned on a
quarterly basis first of which is August 2007. Focus
on achievement of national, organizational and
divisional key performance indicators; will determine
the level of earned autonomy.
A
Develop a management and
leadership programme for
clinicians
MD
Options paper presented to Organisational
development Group. Considering corporate signup to BAMM “Fit to Lead”
G
Develop an OD strategy to
support change management
programme
Ch/
DCA
Work in progress with gap analysis. Interviews with
key stakeholders taken place. Strategy development
by October 2007
G
Develop more formal
processes to capture idea
generation from staff
DS
Internal communications improved through regular
staff bulletins and CE briefings
G
CO5:To achieve Teaching Hospital Status
CO5:To achieve
Teaching
Hospital Status
To achieve
Teaching
Hospital Status
Provision of suitable
additional residential
accommodation for
undergraduates through a
partnership approach with
the private sector
MD
Shrewsbury and Atcham Borough Council deferred
a decision on the application for planning
permission from 15th August 2007 to 11th September
2007. It has now been approved with conditions.
Further discussions to take place with the Secretary
of State to agree use of land adjacent to
Racecourse Lane for recreational purposes.
A
Provision of enhanced and
improved professional
education facilities through
the development of an
Integrated Education Centre
based at RSH School of
Health
MD
Plan on schedule
Awaiting formal PCT approval
A
Foster and facilitate research
and development for all
professional groups
MD
Trust now represented on the new West Midlands
North Comprehensive Local Research Network.
Currrent focus is a review of research governance
arrangements. DH R&D funding reducing year on
year as is management resource to support
G
Development of the clinical
teaching infrastructure
required to support the
curriculum requirements for
96 undergraduate students
by 2008
MD
Joint teaching appointments with University on
schedule. One of the aims of the R&D group is to
provide an environment for the new undergraduates
to “experience” research both in the form of clinical
trials and as applied research.
To develop an Institute of
Applied Research within the
Trust that supports the
application of research and
evidence-based practice
through improving and
enhancing the experience
and outcomes for patients
and employees.
CH
A group has been established to focus on best use
of intellectual property and information related to the
evaluation of new techniques or treatments. A key
aim is the introduction of a knowledge management
system that allows access for all staff to outputs
from research and best practice. A conference is
being organized in the Spring 2008 to celebrate
applied research projects and evidence based best
practice.
G
G
CO6:To improve partnership working in developing and delivering a
coherent vision for the future of health and social care
CO6:To improve
partnership
working in
developing and
delivering a
coherent vision
for the future of
health and
social care
To improve
partnership
working
Develop and deliver an
external and internal
communications action plan
for the Trust
DS
Stakeholder mapping exercise completed and
communications plan presented to Trust Board.
Focused on improving stakeholder relations,
developing staff as ambassadors for the
organisation, strengthening media relations, and
developing effective internal and external
communication systems CE face to face staff
briefings completed, Frequent Staff Updates and
monthly Team Brief now all in place.
G
Develops a hospital
marketing strategy
DS
Draft market assessment plan completed. Thinking
around organizational values and future corporate
brand management begun linked to Foundation
Trust work.
A
Improve integrated planning
processes with both
commissioners and partners
in health and social care
CE/
DS
Progress via Chairs/CEs meeting and STEG.
Improved relationship with SCC and T&W OSCs
and Powys LHB
G
Focus on reputation
management to ensure that
the Trust has a high external
profile “for the right reasons”
CE/
DS
Head of Communications and Business
Development now in post, with a focus on reputation
management with the media. Opportunities for
Ministerial visits currently being scoped linked to
major hospital developments.
G
Glossary of Terms
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A&E
CE
CIP
CNST
DH
EUWTD
GUM
IBP
ISIP
IT
KSF
LDP
LHB
LOS
MRSA
MTAS
OD
OSC
PBC
PCT
PESTLE
Accident and Emergency
Chief Executive
Cost Improvement Programme
Clinical Negligence Scheme for Trusts
Department of Health
European Union Working Time Directive
Genito-Urinary Medicine
Integrated Business Plan
Integrated Service Improvement Plan
Information Technology
Knowledge Skills Framework
Local Delivery Plan
Local Health Board
Length of Stay
Methicillin-Resistant Staphylococcus aureus
Medical Training Application Service
Organisational Development
Overview and Scrutiny Committee
Practice Based Commissioning
Primary Care Trust
Political, Economic, Social, Technological, Legal, Environmental
Glossary of Terms
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PPI
PRH
RSH
R&D
SaTH
SCPCT
SDS
SHA
STEG
STICC
T&WPCT
Patient Public Involvement
Princess Royal Hospital
Royal Shrewsbury Hospital
Research and Development
Shrewsbury and Telford Hospital
Shropshire County Primary Care Trust
Service Developed Strategy
Strategic Health Authority
Shropshire and Telford Executive Group
Shropshire and Telford Infection Control Committee
Telford and Wrekin Primary Care Trust
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CH
CE
DCA
DS
DSD
FD
MD
Chairman
Chief Executive
Director of Corporate Affairs
Director of Strategy
Director of Service Delivery
Financial Director
Medical Director