RESPONSE TO
RISK & GOVERNANCE REVIEW
MARCH 2005 ~ JANUARY 2006
July 2006
2
SECTION PAGE NUMBERS
Introduction
3
The Review
4
Objectives and Terms of Reference of the Services
Review
4
Chronology of the Service Review
4
Validation of the Trust’s initial Risk Assessment on
Anaesthetic and Critical Care Services
5
Surgery and Accident and Emergency Services
Review
5~6
Inpatient Medical Services Review
6~7
Obstetrics and Gynaecology Services Review
7
Radiology Services Review
7
Acute and Community Children’s Services Review
7~9
Risk and Governance Review of Sperrin Lakeland
Trust ~ Final Report
9~11
Corporate Developments in Sperrin Lakeland Trust
11~12
Chronology of key milestones within the Trust
(October 2005 ~ July 2006)
12~13
Action Plan in response to key recommendations
13~14
Performance, Accountability and Monitoring
Arrangements
14~18
Conclusion
18~19
CONTENTS
3
The Trust has over this past 15 months been subject to considerable detailed review from
a number of external and professional bodies. The review brought to the Trust’s attention
significant deficits in service provision and as a result a set of actions were put in place to
address the deficits. This report details the sequence of events from March 2005, the
specific issues that were brought to the attention of the Trust and the Trust’s response to
these issues.
It is important to realise that this has been an all consuming exercise for Trust staff, its
greatest asset and, without their continued commitment and dedication, the significant
changes that have taken place within the organisation would not have been possible. The
Trust would like to sincerely thank the staff and acknowledge the support and guidance
which has been given by the Clinical Governance Support Team (CGST), the Department
of Health, Social Services and Public Safety (DHSSPS) and the Western Health and
Social Services Board (WHSSB).
During 2004, the Trust undertook an internal risk assessment which identified clinical
governance issues in maintaining anaesthetic and critical care services at Tyrone County
and Erne Hospitals
In early 2005 the Trust commissioned the NHS Clinical Governance Support Team (NHS
CGST) to validate the Trust’s internal risk assessment and perform a comprehensive risk
and governance review of all the acute hospital services within the Trust. The Trust
subsequently requested that community children’s services were included as part of the
review.
The validation exercise, and the report which followed, highlighted deficits in service
provision with associated risk to patient safety. A number of changes took place at senior
management and Trust Board level following the validation of the Trust’s Risk Assessment
by the Clinical Governance Support Team (CGST), along with a set of actions to
implement the recommendations of the review. These changes supported the
development of the core elements of clinical and social care governance with the objective
of placing at the centre of the Trust’s business, patient/client safety high-quality safe care
and the provision of a competent workforce.
A substantial action plan was developed by the Trust to implement the recommendations
of the review and significant progress has been made with the primary aim of ensuring
safe and effective care for patients. To date 79 of just over 200 recommendations have
been fully implemented, with the remainder on the way to completion. The CGST now
recognises that the Trust is a changed and improved organisation with a corporate focus
and increasingly taking control over how it delivers its services.
The Trust has put robust performance management, accountability and monitoring
arrangements in place to ensure the smooth transition of the Trust into the new Western
Area Trust and the continued effective implementation of the action plan to take forward all
of the recommendations of the review. The Trust now considers itself to be in a much
stronger position than prior to the review and places the provision of modern safe services
at the core of its business.
INTRODUCTION
4
The CGST carried out a Risk and Governance Review in the Trust between March 2005
and January 2006. During the review the team met with 429 people both internal and
external to the Trust. These individuals included professionals, covering a diverse range
of disciplines, and service users.
The review made just over 200 recommendations which required a range of actions by the
Trust, WHSSB and the DHSSPS. The final overview report for all the reviews will be
presented to the Trust in July 2006.
The objectives and terms of reference for the review were as follows:
1) To assess the effectiveness of the Trust’s clinical and social care governance
arrangements including the extent to which the Trust’s clinical and social care
governance strategy has been operationalised across all acute care specialties.
2) To identify and assess service and practice-specific risks and the effectiveness of
current arrangements to manage these risks.
3) To make recommendations and develop a comprehensive action plan.
The Trust developed a comprehensive action plan to take forward the recommendations of
the review.
The review examined the clinical and social care governance arrangements across a wide
range of services provided by the Trust. These included:
Ø Validation of the Trust’s initial risk assessment on
anaesthetics and critical care service.
Published May 2005.
Ø Surgery and Accident and Emergency Services Published August 2005
Ø Medical Services Published November 2005
Ø Obstetrics and Gynaecology Services Published July 2006
Ø Radiology Services Published July 2006
Ø Acute and Community Children’s Services Published July 2006
Ø Risk and Governance Review of Acute Services and
Community Children’s Services for Sperrin Lakeland
Health and Social Care Trust: Final Report ~ to be
presented to Trust Board
Published July 2006
OBJECTIVES AND TERMS OF REFERENCE OF THE SERVICE REVIEW
CHRONOLOGY OF THE SERVICE REVIEW
THE REVIEW
5
Key Findings:
The report on this area identified issues and made recommendations in relation to the
capacity and capability of the Trust to provide the staff with the skills required for intensive
support of patients. Issues pertaining to the standards and suitability of facilities were also
raised. Based on the recommendations of the report the Trust redesigned its delivery of
critical care services.
Trust Response:
· Level 3 critical care services consolidated on the Erne site ~ March 2005
· Support for the provision of critical care formalised with Craigavon Area Hospital via
telemetry ~ June 2006.
· ALERT training and Early Warning System introduced ~ June 2006.
· Approval of the investment of an additional £700,000 to enhance the workforce,
address the required structural changes, improve information and communication,
and to help meet the training and development needs of the critical care team.
· Closer co-operation developed with Altnagelvin Hospital and with the critical care
services network.
Key Findings:
The report on this area drew attention to the need to realign services and to effect
improvements in the surgical and A&E Services. In August 2005 the Royal College of
Surgeons reaffirmed the concerns identified in the CGST review.
In conjunction with the consultation on surgical and A&E services, the Minister also asked
the Trust to establish the maximum level of safe and sustainable emergency and casualty
services and inpatient medical services that can be provided at TCH
On 19 December 2005 the Health Minister, Mr Shaun Woodward, confirmed the Trust’s
proposal to consolidate:
1) Emergency and major elective surgical services within the Trust on the Erne site as
soon as is practicable, leaving routine elective day surgery at TCH.
2) Full A&E services on the Erne site with the minimum of delay, to ensure that they are
safe and sustainable taking full account of the issues identified in the three reports.
The Trust, has implemented the changes to both surgery and A&E services, effective from
31 March 2006.
Trust Response:
- Appointment of two A&E consultants
- Major capital work at Erne Hospital A&E department, commenced in April 2006 with a
completion date of December 2006
- Appointment of eight nurse practitioners across the Urgent Care and Treatment
Centre and A&E departments.
REVIEW AREA: SURGERY AND ACCIDENT AND EMERGENCY (A&E)
REVIEW AREA: VALIDATION OF THE TRUST’S INITIAL RISK
ASSESSMENT ON ANAESTHETIC AND CRITICAL CARE SERVICES
6
- Appointment of eight middle grade doctors to the Urgent Care and Treatment Centre
and A&E departments
On the 31 March 2006 an Urgent Care and Treatment Centre opened at TCH and
arrangements to continue inpatient medicine were also put in place. In June 2006 a
Clinical Decision Unit with patients managed by the A&E consultant at TCH was opened to
support the model.
Key Findings:
The review team identified a number of areas for improvement in the provision of some
medical specialty services. The team acknowledged that the changes in surgical and A&E
services would have an impact on the existing service model. The Trust also invited the
Royal College of Physicians to offer advice on a model for delivering modern medical
services to the Trust area.
The Royal College stated that the model of inpatient medicine proposed by the Trust did
not fully conform to College recommendations and emphasised the need for ongoing
monitoring. In developing the model the Trust took account of this advice and will continue
to monitor the service to ensure its ongoing safety for patients.
In December the Minister, in referring to future services at TCH, stated:
“The centre will offer resuscitation and stabilisation for patients in an emergency situation
and the administration of vital drugs following heart attacks. These services will be needed
at Tyrone County until more robust and sustainable, community based life-saving services
can be introduced.
The hospital will continue to meet most of the inpatient medical care needs of the local
population including coronary care. Only very seriously ill medical cases, in particular
those likely to require intensive care services, would not come to Omagh”
Trust Response:
v Secured the agreement of the DHSSPS and WHSSB to proceed with the
implementation of an Urgent Care and Treatment Centre and Clinical Decision Unit
at TCH and to maintain inpatient medicine. These developments are subject to
ongoing monitoring to ensure patient safety and sustainability.
v The Trust has continued to develop protocols to ensure that very seriously ill medical
patients are not brought to TCH.
v Secured support from the Northern Ireland Medical and Dental Training Agency for
the continued placement and employment of junior medical staff.
v Reviewed referral and admission protocols.
v Reviewed and improved out of hours pharmacy.
v Reviewed and improved decontamination arrangements.
v Carried out a specific audit on the small number of patients requiring HDU services at
TCH (3%).
v The Clinical Director is developing/implementing a workforce plan for medicine to
take account of separation from renal medicine and the age profile of the existing
workforce.
v Maintained coronary care services.
REVIEW AREA: INPATIENT MEDICAL SERVICES
7
v Appointed an architect to enable further re-shape of the physical environment to
commence at TCH.
Key Findings:
The review team found that this service is responsive to the needs of patients. The team
expressed concerns around the modernisation of the service and the sustainability and
maintenance of skills for the workforce.
Trust Response:
The recommendations are currently being addressed by the directorate through the Trust’s
action plan. It is however worth noting that births from 2006/7 are projected to be between
1200 and1300 annually. Planning for a fifth consultant is currently underway for this
service.
Key Findings:
The review team found this service to be modern, responsive, of high quality and did not
identify any significant concerns in relation to clinical and social care governance and the
care provided by the radiology service. The review team made some recommendations to
strengthen governance arrangements which are being addressed through the Trust’s
action plan.
Trust Response:
It is worth noting that a new CT scanner facility, at a cost of over £1million, is now open in
TCH and two substantive consultants were appointed to the department in May 2006
giving it a full consultant establishment.
Key Findings:
To complement this review the CGST liaised with the Social Services Inspectorate (SSI) in
relation to child protection issues and as such the findings of their review are taken into
account in the action plan that has been developed in response to the SSI inspection
which to place in January/February 2006.
The review team, although recognising that there were examples of good practice,
identified some issues which they recommended required urgent action. These included:
Ø The need for improved paediatric leadership and advocacy.
Ø The need for consolidation nursing leadership on the children’s ward.
Ø Effective fluid management protocols and procedures.
Ø Effective arrangements for out of hours care for children at TCH and consultant
supervision for the ambulatory day unit.
REVIEW AREA: OBSTETRICS AND GYNAECOLOGY SERVICES
REVIEW AREA: RADIOLOGY SERVCIES
REVIEW AREA: ACUTE AND COMMUNITY CHILDREN’S SERVICES
8
Trust Response:
· The appointment of a Clinical Director in paediatrics (January 2006).
· A nominated consultant for child protection (April 2006).
· The appointment of a ward manager for the children’s ward with formal mentoring
arrangements negotiated with the Royal Belfast Hospital for Sick Children (June
2006.
· Addressed improvements in relationships/communication difficulties among staff
(January /February 2006)
· The issue around fluid management has been fully addressed and all newly
appointed staff will receive appropriate training by the Trust.
· Significant multi-disciplinary training and awareness sessions in the management of
fluids has taken place. New departmental guidance issued in April 2006 has been
fully implemented. Solution 18 has been withdrawn from all areas where children are
cared for (October 2005).
· The out of hours care for children at the Urgent Care and Treatment Centre has been
improved with the appointment of additional consultants in accident and emergency
medicine bringing senior expertise to TCH.
· Three consultant paediatricians are trained in Advanced Paediatric Life Support
(APLS). Forty-five nursing staff are trained in European Paediatric Life Support
(EPLS) with plans in place to have all staff trained to this standard.
· Destination protocols have been developed to prevent children presenting at TCH.
Those, who present in need of emergency treatment, have protocols for transfer.
· ENT Services will be provided on a day case basis and no child will be treated
overnight at TCH. This will result in children receive ENT treatment on a day case
basis with designated children lists and appropriately skilled and trained
professionals.
· In the exceptional circumstances of a child requiring an overnight stay, arrangements
will be put in place to transfer them to an appropriate paediatric unit. The new
arrangements will be introduced by August 2006.
· The paediatric directorate is supporting the reshaping of ENT services for children
and the Ambulatory Care Unit at TCH.
· The Ambulatory Care services will be developed to ensure that there is rapid access
to consultant opinions and an effective child centred service is provided for the local
community.
· Major refurbishment of the inpatient paediatric unit at the Erne Hospital completed
June 2006.
Since the appointment of the Director of Social Work progress has been made in
implementing the recommendations of this service review and the 185 recommendations
of the SSI inspection of child protection arrangements. Although a separate action plan is
required by DHSSPS for the SSI report it is agreed that this will be incorporated into the
Clinical and Social Care Governance action plan. This is currently being actioned. With
respect to the CGST review, the following specific actions have been taken:
v New Executive Director of Social Work (March 2006)
v Children’s Services Programme established (May 2006)
v Brindley House closed (June 2006)
v Relocation of all children in that facility (June 2006)
v Appointment of Principal Social Worker (May 2006)
SOCIAL SERVICES
9
v Appointment of Programme Manager (June 2006)
v Development Programme for staff involving
Chief Executive and Chairperson (May 2006)
v Full reporting at Trust Board of all family and child care matters
The implementation of the SSI report ie being taken forward on a western area basis with
formal project planning arrangements now in situ. In relation to the CGST review
initiatives which are inter-related are currently progressing.
The Better Lives for Children project is currently being taken forward, This includes the
promotion and development of integrated working and new management structures for
children’s services, improved communication mechanisms, implementing performance
targets for children’s services and addressing resource requirements for staff, training and
estates. A project, chaired by the Director of Social Work, specifically to promote, across
all directorates, the safeguarding of children is being implemented.
The review team acknowledged how the Trust had, over the past 15, and in particular the
last 9 months, lived through an unprecedented experience of continued scrutiny. The team
recognised that the Trust is now a changed and improved organisation with a corporate
focus and which is increasingly taking control over how it delivers its services.
The Trust now has a stronger involvement of clinicians in decision making, has in place
improved governance arrangements and has made meaningful investment in its staff, its
greatest asset.
While recognising the considerable achievements which the Trust has made, the review
team expressed some concerns in relation to the general medical, emergency and critical
care services at TCH. The review team stated that the service model implemented by the
Trust, and agreed by WHSSB and DHSSPS is not fully consistent with the
recommendations of the CGST and the Royal Colleges of Surgeons and Physicians.
The review team has advised that this model of service delivery should be formally
monitored on an ongoing basis and contingency plans put in place to urgently address any
issues of patient safety identified. The Trust fully accepts this requirement.
The three areas of specific concern highlighted by the review were:
1) Sustainability of the critical care services at TCH in the future.
2) The appropriate care and treatment of patients with life threatening or potentially life
threatening conditions.
3) The out of hours care for children at TCH which included ENT in-patient care.
RISK AND GOVERNANCE REVIEW OF SPERRIN LAKELAND TRUST ~
FINAL REPORT
10
Trust Response:
Sustainability of the critical care services at TCH in the future.
Ø An Early Warning System introduced in TCH ~ March 2006
Ø ALERT Training is continually ongoing.
Ø Approval of the investment of an additional £700,000 to enhance the workforce,
address the required structural changes, improve information and communication
and to help meet the training and development needs of the critical care team.
Ø Closer co-operation developed with Altnagelvin Hospital and with the critical care
services network.
Ø Carried out a specific audit on the small number of patients requiring HDU services at
TCH (3% of admissions) and will continually monitor the utilisation of the HDU to
assess service sustainability and ensure patient safety.
Ø Telemedicine links in TCH and the Erne hospitals.
Ø Support for the provision of critical care within TCH has been formalised with
Craigavon Area Hospital via telemetry.
Ø Review of anaesthetic/critical care workforce is being carried out with a focus on
cross-site working to ensure skills maintenance.
The appropriate care and treatment of patients with life threatening or potentially life
threatening conditions.
· The Trust has reviewed referral and admission protocols (March 2006).
· The Trust has introduced destination and bypass protocols to ensure surgical
patients are transferred to the appropriate clinical environment (March 2006).
· Protocols developed to ensure the small number of patients who are expected to
require intensive care are not admitted to TCH
· Secured support from the Northern Ireland Medical and Dental Training Agency for
the continued placement and employment of Junior medical staff.
· Clinical Director carrying out a workforce plan for medicine to take account of
separation from renal medicine and the age profile of the existing workforce.
· There is an ongoing audit of coronary care patients.
· There is Trust participation in the Regional Review of Rural Medicine which will
produce standards for inpatient medical units in rural areas. The standards will be
implemented across N. Ireland and will be adopted by the Trust
The out of hours care for children at TCH which included ENT inpatient care.
v Out of hours care for children at the Urgent Care and Treatment Centre has been
improved with the appointment of two additional consultants in Accident and
Emergency medicine who are skilled in handling emergencies
v Three consultant paediatricians are trained in Advanced Paediatric Life Support
(APLS). Forty-five nursing staff are trained in European Paediatric Life Support
(EPLS) with plans in place to have all staff trained to this standard.
v ENT Services will be provided on a day case basis and no child will be treated
overnight at TCH.
v In the exceptional circumstances of a child requiring an overnight stay, arrangements
will be put in place to transfer them to an appropriate paediatric unit. The new
arrangements will be in place August 2006.
v The directorate is supporting the reshaping of ENT services for children and the
Ambulatory Care Unit at TCH.
11
v The Ambulatory Care services will be developed to ensure that there is rapid access
to consultant opinions and an effective child centred service is provided for the local
community. This will result in children receive ENT treatment on a day case basis
with designated children lists and appropriately skilled and trained professionals.
v A review of Anaesthetic workforce to ensure there are designated anaesthetists for
paediatric lists.
v Preoperative assessment of all children requiring elective surgery.
The final report made a further 11 recommendations to the Trust which have been
incorporated into the overall Trust action plan and will be monitored through the robust
performance and accountability arrangements which have been put in place between the
Trust, WHSSB and DHSSPS.
These have taken place to respond to the overarching management, governance and
organisational matters raised by the CGST.
Controls Assurance
- Controls assurance standards for ‘Risk Management’ and ‘Governance’ for 04/05
have been revisited and rescored
- Actions plans have been developed to address shortcomings identified and evidence
portfolios established for each Controls Assurance standard
- Quarterly progress reports on those actions are completed by the appropriate
functional manager and signed off by the lead director
Risk Management
- The Risk Register for each directorate as well as the corporate Risk Register has
been ’cleaned’ and we have established a departmental directorate and a corporate
risk register
Incident Reporting
- The back-log of incidents reported in May 2005 was cleared by July 2005 and there
has been no recurrence
- A target of 24 hours was set to record all reported incidents since July 2005 and this
has been achieved since that time
- Additional support staff have been deployed to support incident recording
- An on-line version of DATIX has been purchased and a roll out plan is well underway
- Accountable staff can now record on-line actions taken as a result of reported
incident, lessons learned and close the incident
- A monthly incident report is produced and widely circulated. It provides information at
directorate and corporate level
- Incident reporting and response is one of the performance indicators set out in the
balanced score card report, presented monthly to Trust Board
CORPORATE DEVELOPMENTS IN SPERRIN LAKELAND TRUST
12
Complaints Management
- New internal targets have been set for complaint investigation – 10 working days
- A target of 75% response within 20 working days has been agreed
- Directorate performance is reported monthly on the balanced scorecard
October 2005
- Chief Executive and Chairperson appointed.
- Senior Nurse Development programme for senior nurse managers.
December 2005
- Appointment of Director of Nursing
January 2006
- Appointment of Non-Executive Directors
February/March 2006
- Business Case for Acute Hospital approved at Trust Board
- Appointment of Director of Human Resources.
- BAMM training for senior professional leaders.
- LEO Leadership programme for ward manager and team leaders.
- Reconfiguration of surgical and A&E services
- Successful international recruitment for A&E/UCTC middle grade doctors.
- Regained financial control £1.8 million to working break-even.
- Director of Nursing assumes executive responsibility for governance.
April 2006
- Appointment of Director of Social Services
- Trust Corporate Plan launched.
- ICT DBS OBC 1 Services in the Trust approved
May 2006
- Appointment of Head of Clinical and Social Care Governance.
- Trust Board approval of new Clinical and Social Care Governance Directorate and
structure.
- First meeting of the newly established Clinical and Social Care Governance
Committee.
- Appointment of Principal Social Worker (Quality Assurance).
- Introduction of new appraisal system for doctors.
- New performance management and accountability arrangements introduced.
- Establishment of Project Board to take forward the recommendations of the CGST
and SSI reviews.
CHRONOLOGY OF KEY MILESTONES WITHIN THE TRUST ~
OCTOBER 2005 – JULY 2006
13
- Review of incident reporting and investigation processes.
- Business Case for Local Hospital in Omagh approved at Trust Board.
- First tranche of new corporate nursing policies approved at Trust Board.
June 2006
- New renal physician takes up post.
- Appointment of two substantive consultant radiologists.
- A&E consultant rota introduced.
- Permanent appointment of lead nurses.
- Appointment of social services programme manager.
- Appointment of ward manager ~ Children’s Ward.
- Critical Care Business Case approved.
- Clinical Decision Unit at TCH opened.
- First quarter of financial year break-even position.
July 2006
- The placing of the European Journal advert for the acute hospital has enabled the
commencement of the procurement process.
- Commencement of a Trust Coaching Programme for senior professionals in the Trust
provided through the N. Ireland CSGT.
- Publication of the Risk and Governance Progress Report.
- Multi-disciplinary workshops regarding SSI report recommendations.
An Action Plan was developed by the Trust to implement the recommendations of the
review of anaesthetics and critical care services. Recommendations in subsequent CGST
reports have been incorporated into the action plan. The purpose of the action plan is to
manage, monitor and report on the implementation of all of the recommendations from the
review.
In this regard the plan articulates the:
a) Improvements already made to the effectiveness of governance arrangements within
the Trust both at specialty-specific and corporate levels
b) Process by which the Trust will address and manage key risks in the short and
medium term.
c) How the Trust will ensure the delivery of high quality and safe services to the
population of Fermanagh and Tyrone in the longer term.
The recommendations from all of the service reviews have been collated into the action
plan with the responsibility for implementation being assigned using a model which has
identified five key areas/main groups.
Key Areas/Main Groups:
1) Surgery
2) Medicine
ACTION PLAN IN RESPONSE TO KEY RECOMMENDATIONS
14
3) Children’s
4) Support Services
5) Senior Management Team
To date 79 recommendations have been fully implemented by the Trust with progress
being made on the remainder. Where progress has already been made against
recommendations, this has clearly been detailed in the plan. Where work still needs to be
progressed, the deliverables have been identified for each recommendation.
The Trust has, over the past number of months, committed to developing a new system to
ensure effective internal performance management and accountability arrangements. The
new system is used to ensure that regional targets and objectives for health and social
care delivery are transferred into meaningful local objectives for the Trust. This
methodology has proved extremely helpful in the implementation of the Trust’s action plan
for the recommendations of the CGST and the SSI reviews.
Throughout this period the Trust has reported to the Strategic Change Management
Group, a group comprising of Trust representatives, DHSSPS, WHSSB, CSGT, N. Ireland
Ambulance Services and Western Health and Social Services Council.
The Trust has put in place a formal monitoring process with active participation from
DHSSPS and WHSSB. This process will ensure that the recommendations of the review
will continue to be delivered during the period of transition to the Western Area Trust.
The Chief Executive has instigated a process of formal performance management and
accountability to ensure the effective delive ry of safe services for patients. This process
includes:
Ø Monthly performance and accountability meetings with each director and the
designated clinical lead ~ governance is a standing item on the agenda.
Ø The respective person with lead responsibility updates the Chief Executive on
progress on the action plan and each Directorate provides a summary of progress to
the Clinical and Social Care Governance Committee, which in turn is reported at
Trust Board.
Ø The Head of Clinical and Social Care Governance has overall responsibility in
conjunction with the respective clinical or Senior Management Team director for
ensuring timely progress is made against implementation timescales for the
recommendations of the action plan.
Ø The Trust has established a group chaired by the Head of Clinical and Social Care
Governance to oversee the implementation of the action plan.
Where there are issues that militate against progress, these are also highlighted at the
performance and accountability meetings, Clinical and Social Care Governance
Committee and Trust Board. Through this the Trust Board has assurance of robust
arrangements for effective performance management of which governance is integral, with
clear lines of accountability.
PERFORMANCE, ACCOUNTABILITY AND MONITORING
ARRANGEMENTS
15
These processes and systems will enable the Trust to provide assurances of progress
against the action plan to the Western Board as its commissioner and to the DHSSPS. In
addition:
v
The Trust will provide a copy of the update report developed for Trust Board, on a
monthly basis, to the DHSSPS and WHSSB.
v The Trust will communicate on a quarterly meeting with the DHSSPS and WHSSB,
both to facilitate the monitoring of progress made against the action plan and to
inform them of any services developments needed to ensure the continued focus on
patient safety.
v The Trust, through the continued monitoring arrangements, in conjunction with
relevant stakeholders will ensure that steps are taken to ensure patient safety at all
times.
The Trust will not shirk from its obligation to continue to make recommendations, decisions
and take action as appropriate to ensure patient safety is at the core of its business.
The monitoring processes will be particularly important under the Review of Public
Administration as the three Trusts in the Western Board area merge to form the new
Western Area Trust. The N. Ireland Clinical Governance Support Team has provided
support and guidance during the period of review across a number of fronts. This
arrangement will continue and the relationship will be developed in the future to assist with
the further implementation of the action plan and the development of staff leadership
capacity within the organisation.
The key elements of the Trust’s performance management and accountability
system are made up of the following
1. The setting of clear, Trust wide, realistic but challenging targets and objectives within
our Corporate Plan, covering the eight key areas of our work including services
delivered in hospital and community settings, sound governance arrangements,
financial management, improved performance, ensuring a skilled workforce, effective
leadership and management and the maintenance and development of facilities and
equipment (Figure 1).
The Trusts monitoring arrangements look at ’perspectives’ on organisational performance
outcomes and select a range of indicators that can be used to show progress from a:
¨ Financial Perspective
¨ Governance Perspective
¨ Service User Perspective
¨ Staff Perspective
¨ Activity and Targets Perspective
16
Figure 1
Performance Framework and examples of the types of indicators used to measure
progress
2. Translating those objectives and targets into operational plans for each of our four
service delivery Directorates or Divisions and the Senior Management Team which
are monitored on a monthly basis at the Chief Executive’s accountability reviews.
3. Allocated those activities and sub -tasks to Accountable Officers to be achieved within
given timescales.
4. Setting out the commitment of Support Services Directorates and special projects to
enabling agreements, again assigned to Accountable Officers that will aid the
achievement of service delivery objectives (Figure 2).
17
Trust Directorates and Relationships (Figure 2)
Finance
Directorate
Planning/Business
Support
Directorate
Human Resources
Directorate
Support
Services/Facilities
Management
Directorate
Developing Better
Services &
Special Projects
ISD, ICATS…
Acute Services
Directorate
Children’s
Directorate
Adult MH and
Disability
Directorate
Elderly and
Primary Care
Services
Directorate
Corporate Objectives and
Targets
CORPORATE PLAN
Enabling Agreements
Operational Plans
Governance
& Professional Accountability
18
5. The presentation of measurable progress on achievement using the Balanced
Scorecard tool to show how one area of work links with or impacts upon another
(Figure 3).
Corporate Plan 2006/07 – Key Themes (Figure 3)
6. Ensuring the progress and achievements of Accountable Officers, and the Trust
collectively, is subject to appraisal and review.
These processes and systems set out the basis for the Trust Performance and
Accountability Framework which is designed to ensure the effective and efficient delivery,
and sustainability, of services and provide an open and transparent performance reporting
system.
The Trust services have, over the past 15 months, been subject to considerable detailed
review from a number of external and professional bodies. The extent of the scrutiny has
been without precedent in Northern Ireland.
The review brought to the Trust’s attention significant deficits in its service provision. The
Trust has accepted these conclusions and has embarked on a programme of change to
address the matters raised.
It is important to acknowledge that this has been an all consuming exercise for staff and
the organisation alike. Nevertheless, there has been significant progress made in relation
CONCLUSION
19
to implementing the recommendations of the review, promoting and embedding new
arrangements for Clinical and Social Care Governance, ensuring safe and effective patient
centred care and maintaining public confidence. These improvements will help the Trust to
sustain the momentum for making its services safe and sustainable and support the
proactive management of the transition.
The organisation has taken ownership of the entire process and has demonstrated its
continual commitment to proactively managing the extensive health and social care
agenda along with the quality improvement agenda.
There has been a drive to ensure robust leadership throughout the organisation with the
re-establishment of a Trust Board and an effective Senior Management Team. The Trust
has also facilitated leadership development across all levels of the organisation and is
continuing to invest in further development opportunities for staff. This is paramount in
order to ensure that services, now and in the future, are safe, sustainable and of high
quality and places the Trust in a strong position as it becomes part of the new Western
Area organisation.
The Trust considers it is now in a stronger position than prior to the review and has the
ambition to embrace the continual change necessary to provide modern, safe services to
its population.
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