shetland nhs board

Board Paper 2016/33

Shetland NHS Board Meeting: Shetland NHS Board

Paper Title: Corporate Action Plan (CAP) 2016/17

Date: 10th June 2016

Author: Ralph Roberts Job Title: Chief Executive

Decision / Action required by meeting:

The Board is asked to:

i) Note the link between the CAP, the Board’s Corporate Objectives, Strategic vision and the Scottish Government’s 2020 Vision.

ii) Provide Comments on the draft CAP, and subject to these comments iii) Agree the Board’s Corporate Action plan for 2016/17 iv) Note progress against this will be monitored through the Performance Board

High Level Summary:

The Corporate Action Plan sets out the Board’s proposed key actions for the next year. The delivery of these actions supports the delivery of key targets (HEAT & the Local Outcomes Improvement Plan anis d therefore linked to the delivery of the Local Delivery Plan (a description of how we will deliver against the HEAT targets) and the local Community Plan (with a suite of targets described within the LOIP). The Key actions are set out within our 5 Corporate Objectives, mapped against the Government’s “Route Map to the 2020 Health & Social Care Vision” and showing how we are delivering the 3 Quality Ambitions and 12 priority areas for improvement. The resources to deliver against these objectives are included within the Board’s and departmental budgets and the overall financial plan. Progress against the CAP will be reported to the Board on a 6 monthly basis and monitored through the Performance Board / EMT. Progress against the targets (outcomes) supported by the CAP will be reported to the Board as part of the Board’s Performance framework. The actions within the CAP have been prioritised as High / Medium / or Low priority to allow the Board to make a more appropriate judgement of progress during the year.

Key Issues for attention of meeting:

The Board is asked to consider:

i) if the draft CAP is appropriately ambitious and challenging ii) whether the relative priority of individual actions is correct iii) if the draft outcomes at the start of each section are appropriate and whether

there are other outcomes that might be considered iv) and if there are other outcomes / indicators that should be considered for

inclusion in the Board’s Performance framework

Impact of item / issues on:

Patient Safety:

This is a key priority within the CAP within a number of specific actions identified to improve the safety and quality of our services.

Staffing/Workforce: A number of actions have been identified to develop our staff governance arrangements. Other actions will require our workforce to be redesigned and respond to service change. Individual impacts will be assessed against specific projects

Finance/Resource:

The CAP supports the overall delivery of the Board’s financial targets. Actions identified within the CAP should be within the agreed financial plan.

Shetland Partnership / Joint Working

The CAP supports our Partnership working with a particular emphasis in the next year on work with SIC and NHS Grampian.

Equality & Diversity:

No specific issues identified

Legal Issues:

No specific issues identified

Previously considered by:

Committee/Group:

Developed by Executive Management Team

INTRODUCTION TO CORPORATE ACTION PLAN

1. BACKGROUND The Corporate Action Plan (CAP) is our annual plan to develop the organisation and address our key priorities. The plan sets out a range of actions to support delivery of our Corporate Objectives and provides a framework for the Board to monitor overall progress. The actions in the CAP should also be seen alongside our Local Delivery Plan (LDP) which specifically describes the actions and risks associated with delivery of the HEAT targets. The delivery of these actions is intended to support the overall delivery of our Clinical Strategy and local 2020 Vision. In turn these support the Scottish Government’s overall 2020 Vision for the Health service in Scotland. These are summarised in more detail below.

2. VISION NHS Scotland: Our vision is that by 2020 everyone is able to live longer healthier lives at

home, or in a homely setting. We will have a healthcare system where we have integrated health and social care, a focus on prevention, anticipation and supported self management. When hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm. Whatever the setting, care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions. There will be a focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of re-admission.

NHS Shetland 2020 Vision: to deliver sustainable high quality, local health and care

services, that are suited to the needs of the population; to make best use of our

community strength, community spirit and involvement; for people to make

healthy lifestyle choices, and use their knowledge and own capacity to look after

themselves and each other.

3. CORPORATE OBJECTIVES To deliver this vision NHS Shetland has identified the following Corporate Objectives:

to improve and protect the health of the people of Shetland

to provide quality, effective and safe services, delivered in the most appropriate setting for the patient

to redesign services where appropriate, in partnership, to ensure a modern sustainable local health service

to provide best value for resources and deliver financial balance.

to ensure sufficient organisational capacity & resilience

Against each of the Objectives the CAP sets out a number of high level Outcomes, against

which progress can be assessed over a number of years and a range of individual actions to be

progressed in the next year.

4. LINK TO 2020 ROUTE MAP

To support their 2020 Vision the Scottish Government has produced a Route Map to 2020

Health and Social Care Vision for Scotland with a TRIPLE AIM of:

Quality of Care / Health of the Population / Value & Sustainability.

This links to 12 Priority Areas for Improvement and the government objectives (phrased as key

deliverables) is shown in Figure 1

While NHS Shetland’s Corporate Action Plan is written to deliver against our Corporate

objectives, to demonstrate how these are compatible with the 12 national priority areas, we

have colour coded the CAP to show how our actions align with the Priority Areas for

Improvement.

N H S S h e t l a n d 2 0 2 0 V i s i o n

Clinical Strategy

Improve & protect Health of the

Population

Strengthen Organisational Capability, Capacity and Resilience

Deliver Quality, Effective & Safe

Services

Continuously Redesign to ensure Modern,

Sustainable Services

Best Value for Resources; Deliver Financial Balance

Co

rpo

rate A

ction

Pla

n

2016/17

Delivering

HEAT TargetsLocal Outcomes

Improvement Plan (LOIP)

Health & Wellbeing Outcomes

Perfo

rma

nce

Fram

ewo

rk

Co

rpo

rate

Ob

ject

ives

Stra

teg

yV

isio

n

Ou

tco

mes

Figure 1: Relationship between Vision, Strategy, Corporate Action plan and Outcomes

ROUTE MAP TO THE 2020 VISION FOR HEALTH & SOCIAL CARE

Triple Aim

Quality Ambitions

12 Priority Areas for

Improvement 25 Key Deliverables

Quality of Care

Person-centred

Person-centred Care

1 Person-centred Health and Care Collaborative implemented

2 Information and support to enable people at home and during times of transition

Safe Safe Care

3 Further increase in safety in Scottish hospitals

4 New broader measure of safety developed (SPSI)

5

Maternity, mental health and primary care components of the Scottish Patient Safety Programme implemented with measurable improvements

Effective

Primary Care

6 Implementation of new GP contract

7 2020 Vision for expanded primary care

8 New models of ‘place-based’ primary care

Unscheduled and Emergency Care

9 Out of hospital care action plan

10 Sustainable performance on 4-hour A&E Waits

11 Increase flow through the system

Integrated Care

12 New Bill

13

Preparatory work with NHS Boards, local authorities, third and independent sector and the building of effective integrated Health and Social Care Partnerships

Care for Multiple and Chronic

Illnesses

14 Key pressure points in the entire patient pathway for most common multiple illnesses will be identified and actions agreed

15 Through more detailed analysis of existing data, people will be identified as ‘at risk’ and anticipatory plans will be agreed

Health of the Population

Early Years 16 The world’s first national multi-agency quality improvement programme will be implemented across partner organisations

Health Inequalities

17 New focus on most deprived areas

18 ‘Deep-end’ GP practices approach rolled out more widely across relevant areas

Prevention 19 Early detection of cancer

20 New restrictions on tobacco advertising

Value and Sustainability

Workforce 21 2020 Vision for NHSScotland workforce

22 Detailed action plan agreed to deliver 2020 Workforce Vision

Innovation 23

A new fund to provide pump-priming for innovative approaches in healthcare

24 A new procurement portal will be established to encourage working with SMEs and third sector

Efficiency and Productivity

25 Recommendations to increase shared services

SHETLAND NHS BOARD – CORPORATE ACTION PLAN 2016/17

1. To continue to improve and protect the health of the people of Shetland

Key to Lead Responsibilities:

CExec - Chief Executive; DPH - Director of Public Health; DFin - Director of Finance; MD - Medical Director; DHR & SS - Director of Human Resources & Support Services; DN&AS –Director of Nursing &

Acute Services; DCH&SC – Director of Community Heath & Social Care; DP – Director of Pharmacy; CSM – Corporate Services Manager; EMT – Executive Management Team; HIM – Health Improvement

Manager, CHM – Child Health Manager; CPHM – Consultant in Public Health Medicine; HIT – Head of IM&T; HEF – Head of Estates & Facilities; OTM – Joint OT Manager; EMMH – Executive Manager, Mental

Health; SMPC – Service Manager Primary Care; CN(HSCD) – Chief Nurse Health & Social Care Directorate; DD – Dental Director; SDM – Staff Development Manager; HRSM – HR Services Manager; HF&P –

Head of Finance & Procurement; CLC – Choose Life Coordinator; EPO – Emergency Planning Officer; SP&IO – Senior Planning & Information Officer; CG&RM – Clinical Governance & Risk Manager;

CN(A&SS) - Chief Nurse Acute & Specialist Services; EMCCR – Executive Manager Community Care Resources; PHP – Public Health Principal; SHIA - Senior Health Improvement Advisor; HPM – Head of

Planning & Modernisation; ESM – Elective Services Manager; TLSD – Team Leader Staff Development

14/06/2016

1

Objectives Strategic

Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead

Actions / Completion Dates Outcomes H/M/L

Priority

Status of delivered action

point

(Blue – Complete; Green –

On Target; Amber –

progress behind target; Red

– risk of delivery)

KEY OUTCOMES: We live longer healthier lives. Shetland is the best place for children and young people to grow up. People are supported to be active and independent throughout adulthood and in older age.

We have strong, resilient and supportive communities. We have tackled inequalities by ensuring the needs of the most vulnerable and hard to reach groups are identified and met, and that services are targeted at those

most in need.

1. To maintain and update

Communicable Disease

and Environmental

management and response

plans

Unscheduled

& emergency

care

DPH CPHM 1.1 Review of Pandemic Flu plan following Silver Swan

Exercise in 2015 and national report produced in

2016. Complete by September 2016

Minimisation of risk from

Flu pandemic

H

Unscheduled

& emergency

care

DPH CPHM 1.2 Review and Update general Public Health Incident

and Outbreak Plan. Complete by September 2016 Minimisation of risk from

other PH incidents and

outbreaks

M

2. Increase the rates of early

detection of cancer

(HEAT)

Prevention

DN&

AS

HM /

CPHM

2.1 Audit of late presentations (complete by August

2016)

More cancers are detected

and treated at an early

stage resulting in better

treatment outcomes

M

Prevention

DN&

AS

HM /

CPHM

2.2 Local implementation of national DCE awareness

raising programmes (dependant on national

timetable)

More cancers are detected

and treated at an early

stage resulting in better

treatment outcomes

M

3. To improve the health of

the population of Shetland

through delivery of the 10

year Health Improvement

Strategy key milestones

for 2016/17

Health

Inequalities

DPH PHP 3.1 Black & Minority Ethnic Group Health Needs

Assessment by end December 2016 Local health services meet

the needs of BME groups

M

Prevention DPH PHP /

SHIA

3.2 Development of Physical Activity, Sport , Health &

Wellbeing Strategy by March 2017 Reduction in the number

of physically inactive

people in Shetland

H











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Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority


point





Prevention DPH PHP 3.3 Project to re-prioritise health improvement activity in

context of continued reduced funding to ensure that

health inequalities and prevention are prioritised by

October 2016

Health improvement

resources are targeted at

prevention and at those

most in need

H

Prevention DPH PHP /

SMMH /

SMPC

3.4 Progress second stage of a bid for funding for staff

training in behavioural activation Better trained staff M

Prevention /

care for

Chronic

illnesses

DPH /

DN &

AS

PHP /

SMPC /

CN

(HSCD)

3.5 Development of self management programmes by

end March 2017 (Secondary prevention) People with long term

conditions are supported to

self manage their condition

H

Prevention /

care for

Chronic

illnesses

DPH /

DCH

&SC

PHP/

SMPC

3.6 Development of a specific project to identify and

work with frequent primary care attenders using an

asset based bio-psycho-social approach to promote

self management

People with long term

conditions are supported to

self manage their condition

M

Prevention DPH SHIA (&

dietetics)

3.7 Development of a weight management programme

for those with a BMI of 35 or greater; or greater than

30 if have co-morbidities. By end December 2016

Reduction of number of

people who are obese in

Shetland

M

Prevention DPH SHIA 3.8 Review and relaunch of Drink Better Campaign with

more targeted marketing. Relaunched by September

2016.

Fewer people within target

groups drinking at risky or

dangerous levels.

M

4. To protect the population

from vaccine preventable

diseases

Prevention

DPH CPHM 4.1 Further local campaign on MMR at age 12/13

months and pre-school during June – August 2016

with a focus on nursery and other pre-school settings

– to achieve target of 95% uptake of one dose by age

2 and 95% uptake 2 doses by age 5 (carried forward)

Prevention of infections

(measles specifically),

resultant complications,

deaths and potential

outbreaks

H











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3


Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority


point





5. To reduce the incidence

and impact of Gender

Based Violence

Health

Inequalities

DPH CPHM 5.1 Review and revise the Shetland Domestic Abuse

Strategy and Action Plan, including a health and care

needs assessment by August 2016 (carried forward)

Raised awareness of

Domestic Abuse, reduced

incidence (particularly of

repeated violence for those

at highest risk), and

evidenced based support

for victims.

M


2. To provide quality, effective and safe services, delivered in the most appropriate setting for the patient









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Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority

Status of delivered

action point

KEY OUTCOMES: : (@ 1 Year, 3 year & 5 Year )

Improved patient satisfaction (as measured through Inpatient & Primary care experience surveys)

Positive Inspection reports (as measured through a reduction in Improvement actions)

Maintain performance against Acute Access targets

Continue Improvement in access to Lerwick Health Centre / Primary care and Dental services

Maintain reduction in MH transfers to Aberdeen

Sustained performance against Patient safety measures / Quality scorecard

1. Develop a plan for winter

16/17

Unscheduled

& Emergency

Care

DN&

AS

DN&AS /

DCH&SC

1.1 Develop the winter plan through the Joint Health &

Social care Strategic Group (by October 2016)

Patients continue to

receive appropriate access

to services through winter

period/during adverse

weather and over seasonal

public holidays

H

Unscheduled

& Emergency

Care

DN&

AS

DN&AS /

DCH&SC

1.2 Undertake a review of winter plan outcomes by

February 2017 (or in line with SG requirements) As above H

2. Patients receive care in the

right setting

Unscheduled

& Emergency

Care

DN&

AS /

DCH

&SC

DN&AS /

DCH&SC

2.1 Develop a local unscheduled care action plan which

reflects local and national priority areas by July 2016

(for inclusion in the joint strategic plans)

Actions on the plan are

delivered in 2016-17

H

3. Increase access to health and

care support in most remote

communities, including the

islands.

Person-

centred care

DCH

&SC

CN

(HSDC)

3.1 Develop community solutions with the Scottish

Ambulance Service (SAS) to implement priorities

identified in the Strategic Options Framework and

through locality needs based assessments.

More resilient and

responsive local services

H

Person-

centred care

MD DN&AS /

DCH&SC

3.2 Implement Air Ambulance Action plan in conjunction

with SAS ; Ensure SAS progress required actions and

improve reporting on activity and outcomes (ongoing)

More resilient and

responsive local services

M











14/06/2016

5


Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority

Status of delivered

action point

4. Increase the number of

people who have an

anticipatory care plan in the

community

Care for

Chronic

Illnesses

DCH

&SC

SM PC /

CN

(HSDC)

4.1 Continue to improve the rate at which ACPs are being

developed, and implement solutions that widen the

sharing of ACPs within primary care and between

community and acute services.

More people able to be

cared for in their

community

Better support for carers

Reduction in unscheduled

care needs being met by

hospital admission

H

5. Reduce patients waiting in

hospital where they are

medically ready for discharge

(HEAT)

Safe Care DCH

&SC

SM PC /

CN

(HSDC)

5.1 Agree use of Integrated Care Fund & “additionality”

fund (with rapid access to resources which avoid

unnecessary hospital admission and expedite timely

discharge. July 16

Maintain reduction in

delayed discharges

Support shift in the

balance of care and

reduction in use of

emergency bed days

H

Safe Care DCH

&SC

SM PC /

CN

(HSDC)

5.2 Implement plans for ICF & “additionality” funds

Sept 16 Maintain reduction in

delayed discharges

Support shift in the

balance of care and

reduction in use of

emergency bed days

H

Safe Care DCH

&SC

DCH&S/

DN&AS

5.3 Delays to be reviewed daily by DCH&SC and DN&AS

Target and delayed discharges will be reduced to 3 or

less (which equates to 5% of bed occupancy)

As above H .

6. More effective use of

Inpatient capacity

Innovation DN&

AS

CN

(A&SS)

6.1 Reduce overall Length of hospital stay through

improved discharge processes / effective bed

management – targets to be reflected in the

unscheduled care plan for 2016-17

Improved utilisation of

inpatient beds, reduction in

delays to discharge

planning

HEAT: T.12

H

Innovation DN&

AS

CN

(A&SS)

6.2 Implement Nurse led discharge in all wards (March 17) Improved utilisation of


delays to discharge

planning

HEAT: T.12

H











14/06/2016

6


Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority

Status of delivered

action point

Innovation DCHS

DN&

AS

CN

(A&SS)

/ CN

(HSDC) /

AHP Lead

6.3 Implement intensive rehabilitation pathway in the

community (through 2016-17) Improved utilisation of


delays to discharge

planning

Improved outcomes for

patients

H

7. Ensure good access to

primary care services,

particularly in Lerwick where

there has been patient

dissatisfaction and the Non

Doctor islands

Primary Care DCH

&SC

SM PC 7.1 Monitor access for all practices with at least one audit

cycle each month

Ensure that all patients

have good access to

primary care services

H

Primary Care DCH

&SC

SM PC 7.2 Review ongoing impact of ANPs and ensure continuous

review of organisational arrangements (Dec 16) Continuous improvement

in patient access and

satisfaction

H

Primary Care DCH

&SC

SM PC 7.3 Put in place a sustainable solution for LHC Practice

management (Nov 16) Improvement in patient

access / satisfaction;

Improved staff morale

M

8. Implement patient safety

programmes and further

develop the organisational

safety culture

Safe Care DCH

&SC/

MD

SMMH 8.1 Continue to implement updated mental health

interventions and measures as per the patient safety

programme timeline

Reduce harm and improve

patient outcomes

Performance visible on

Board Quality Scorecard

SPSP Performance

Measures Compliance

increases

H

Safe Care DCH

&SC/

MD

SMPC 8.2 Continue to Implement primary care interventions and

measures as per the patient safety programme timeline

Reduce harm and improve

patient outcomes

Performance visible on

Board Quality Scorecard

SPSP Performance

Measures Compliance

increases

H











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7


Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority

Status of delivered

action point

Safe Care MD/C

PHM?

CG&RM 8.3 Ensure procedures for sharing mortality data from local

governance meetings are robust as part of the overall

review of HSMR / Clinical Governance (Dec 2016)

As above H

Safe Care MD CG&RM 8.4 Develop a clear system for monitoring actions from

adverse events, sharing lessons learnt at team level and

demonstrating organisational learning from SEAs by

March 2016

As above M

Safe Care DN&

AS /

MD/C

SWO

CGM 8.5 Implement a clinical, care and professional framework

to support governance arrangements across Health and

Social Care Services

Action plan

completed/delivered

Care standards are

compliant

H

Safe Care DN&

AS /

MD

CN

(A&SS)

8.6 Implement actions arising from the OPAH inspection

of older peoples services (ongoing) Action plan

completed/delivered

Care standards are

compliant

H

Safe Care DN&

AS /

MD

ICM 8.7 Implement actions arising from the HEI inspection of

healthcare associated infection programme (ongoing) Work plan for HAI is

completed/delivered

Practice standards are

compliant

H

Safe Care CE EMT 8.8 Implement revised structure for oversight / leadership

of Quality & Patient safety across the Board (Oct 16) Improved patient care /

outcomes

H

Safe Care CE EMT 8.9 Develop & finalise plans for Quality / celebrating

success event (Oct 16) Improved patient care /

outcomes

M

Safe Care CE EMT 8.10 Implement plan for Quality / celebrating success event

(March 17) Improved patient care /

outcomes

M

9. Implement Scottish Patient

Safety Index (SPSI)

Safe Care DN&

AS /

MD

CN

(A&SS)

9.1 Implement local systems care assurance in line with

national model development by September 2016 Reduce harm and improve

patient outcomes

M











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Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority

Status of delivered

action point

10. Implement the person centred

health and care collaborative

targets

Person-

centred Care

DN&

AS /

MD

CN

(A&SS)

10.1 Evaluate care experience and personal outcomes

measures (in the form of real time feedback) across

hospital services (September 2016)

By December 2015, 90%

of people using services

will have a positive

experience of care and get

the outcomes they expect

M

Person-

centred Care

DN&

AS /

MD

CN

(A&SS)

CN

(HSDC)

10.2 Support staff to move to asset based model through roll

out of training for personal outcome approaches

(ongoing)

By December 2015, all

health and care services

will support people’s right

to independent living and

good health

M

Person-

centred Care

DN&

AS /

MD

CN

(A&SS)

10.3 Early identification and management of delirium (using

the same screening tools) in all wards by September

2016

Measured compliance with

all elements of the

delirium bundle

H

Person-

centred Care

DN&

AS /

MD

CN

(A&SS)

10.4 Identification and management of frailty (using

screening tools) that are appropriate in Shetland context

September 2016

Improving the

identification, management

and outcomes for people

aged over 75

M

11. Improve the Board’s Capital

estate

Efficiency &

Productivity

CE HEF 11.1 Deliver Board’s Capital programme, on Budget and to

meet agreed timescales (March 17) Reduction in backlog

maintenance

Increase in % of suitable

accommodation

H

Person-

centred Care

DN&

AS

DN&AS

& HEF

11.2 Develop IA for refurbishment of Day Surgical Unit by

Aug 16 and submit to SG for consideration Improved patient flow

Return on investment

Necessary work to meet

JAG compliance

H

Person-

centred Care

DN&

AS

DN&AS

& HEF

11.3 Subject to agreement of IA with SG progress Business

case to agreed timescales (March 17) Improved patient flow

Return on investment

Necessary work to meet

JAG compliance

H

Person-

centred Care

DN&

AS

HEF 11.4 Implement plans for new Emergency Psychiatric

Accommodation at front door of GBH (Dec 16) Improved staff and patient

experience

H











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9


Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority

Status of delivered

action point

Person-

centred Care

CE HEF 11.5 Agree accommodation plan for Breiwick House (Aug

16) Improved staff and patient

experience

M

Person-

centred Care

CE HEF 11.6 Finalise & implement plans for improved MH staff

accommodation (Nov 16) Improved long term use of

Property & Assets

M

12. Maintain (Improve) Facilities

services

Person-

centred Care

CE HEF 12.1 Continue systematic review of Facilities services to

ensure both effectiveness and efficiency of service

(March 17)

Effective and affordable

Laundry services

M

13. Delivery of Health and Safety

and Risk Management Action

Plans 2014-15

Safe Care DHR

&SS

SRM 13.1 Rewrite the Serious Adverse Event Policy & agree with

staff (Oct 16)

Policy & procedures

support improved patient

safety & learning from

SEAs

Improved quality of care

(measured through Quality

scorecard / Complaints &

feedback / Inspection /

Cultural surveys)

H

Safe Care DHR

&SS

SRM 13.2 Develop a risk appetite process and include in updated

Risk management strategy by Dec 16 Effective risk management L

Safe Care DHR

&SS

SRM 13.3 Update & agree revised Risk Management Strategy;

Agreed by Dec 16 Improved Risk

Management and learning

from Incidents / risks

M

Safe Care DHR

&SS

SRM 13.4 Update process of Health and Safety inspections and

management & ensure learning cascaded across the

organisation – Dec 16

All employees, patients,

visitors and contractors are

provided with an improved

and safe working

environment

L

Safe Care DHR

&SS

SRM 13.5 Develop the DATIX web system with engagement

from stakeholders to be focused and user friendly –

provide training and education use of system as

appropriate – Dec 16

A trained and aware

workforce which

contributes to the

continuing development of

a positive safety culture

and is key to reducing and

L











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Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority

Status of delivered

action point

tackling workplace hazards

Improved health, safety

and welfare of staff,

patients and others who

use the Board’s services

and buildings

14. Improve the use of Patient

Feedback & Complaints

Person-

centred Care

CE CSM 14.1 Publish Patient Feedback & Complaints report (June

16)

Developing culture as a

“learning organisation”

H

Person-

centred Care

CE /

DN&

AS

CSM 14.2 Continuously improve approach to disseminating and

improving services using the themes from the Patient

Feedback & Complaints report / information (Dec 16)

Developing culture as a

“learning organisation”

M


3. To redesign services where appropriate, in partnership, to ensure a modern sustainable local health service


CExec - Chief Executive; DPH - Director of Public Health; DFin - Director of Finance; MD - Medical Director; DHR & SS - Director of Human Resources & Support Services; DN&AS –Director of Nursing & Acute

Services; DCH&SC – Director of Community Heath & Social Care; DP – Director of Pharmacy; CSM – Corporate Services Manager; EMT – Executive Management Team; HIM – Health Improvement Manager,

CHM – Child Health Manager; CPHM – Consultant in Public Health Medicine; HIT – Head of IM&T; HEF – Head of Estates & Facilities; OTM – Joint OT Manager; EMMH – Executive Manager, Mental Health;

SMPC – Service Manager Primary Care; CN(HSCD) – Chief Nurse Health & Social Care Directorate; DD – Dental Director; SDM – Staff Development Manager; HRSM – HR Services Manager; HF&P – Head of

Finance & Procurement; CLC – Choose Life Coordinator; EPO – Emergency Planning Officer; SP&IO – Senior Planning & Information Officer; CG&RM – Clinical Governance & Risk Manager; CN(A&SS) - Chief

Nurse Acute & Specialist Services; EMCCR – Executive Manager Community Care Resources; PHP – Public Health Principal; SHIA - Senior Health Improvement Advisor; HPM – Head of Planning &

Modernisation; ESM – Elective Services Manager; TLSD – Team Leader Staff Development

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11


Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority


point

KEY OUTCOMES: (@ 1 Year, 3 year & 5 Year)

By the end of 16/17 we will have updated the Strategic plan in place and have an established & developed Integrated Joint Board; During the next 3 years there will be demonstrable improvements in the

services we provide, with better access particularly to Dental services and Mental Health. Locality working will develop during 16/17, with defined resources and local decision making on how to make the

best use of those resources with full community participation. How we use local Acute Hospital Services will begin to be discussed within each locality, and the joint working between localities and acute

services will strengthen the support that can be provided closer to peoples own homes, through the use of technology such as telehealthcare.

Establishment of Baseline for H&W Outcomes and demonstrate improvement over 3 year cycle

1. Provide a modern,

sustainable dental service

with increased

registrations

Prevention

DCH

&SC

DD 1.1 Develop & agree Oral Health Strategy for Shetland

(agreed at IJB in June 16)

Clear strategic direction

for Dental services with an

emphasis on

Sustaining and where

appropriate improving

Oral Health

Improved access to local

dental services including

specialist services

Improved responsiveness

of local dental services

H

Person-

centred Care

DCH

&SC

DD 1.2 Develop an action plan alongside the Oral Health

Strategy that describes how access will be improved.

25% of actions to be completed by Q4.

Dental registrations

continue to rise

H

Person-

centred Care

DCH

&SC

DD 1.3 Review appointment system within the PDS to ensure we

maximise the effectiveness and responsiveness of the

service

Improved Dental access H

Efficiency &

Productivity

DCH

&SC

DD 1.4 Review Dental budget to ensure maximum benefit

obtained from local dental budget, including the delivery

of specialist services eg. oral surgery; orthodontics

Maximise use of Dental

budget to deliver local care

H

Person-

centred Care

DCH

&SC

DD 1.5 Promote availability of local access grants to support the

provision of NHS committed Independent Dental

practices in Shetland

Improved Dental access H











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12


Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority


point

Person-

centred Care

DCH

&SC

DD 1.6 Support Independent Dental practitioners that make

applications to start / provide local NHS practices Improved Dental access

H .

2. Improved Patient assessment

& support to meet

identified needs

Person-

centred Care

DCH

&SC

EMASW 2.1 Further embed use of With you For You (WYFY) to

ensure effective information sharing / decisions on

client/patient care needs so that provision is timely and

appropriate , with improvements in time taken for all

assessments to be completed.

More effective / responsive

services

Improvement in Measure

PM11

H

3. Repatriate services, where

appropriate, to Shetland

Innovation MD /

DFin

DN&AS 3.1 Progress Pathways project (as part of E&R

programme). An outline of potential pathways has been

produced and further scoping of priorities with clinical

engagement locally (ongoing) with view to

implementation starting September 2016. Project leads

established for pathway to ensure ownership of each

particular scheme.

Increased local access to

services

H

Innovation MD MD 3.2 Revise model for provision of local Obstetric &

Gynaecology services (July 16) Increased local access /

sustainable Obstetric &

Gynaecology service

H

Innovation MD MD;

& CHM

3.3 Appoint relevant staffing (Obstetric & Gynaecology)

(Sept 16) Increased local access /


Gynaecology service

H

Innovation MD;

DN&

AS

CHM 3.4 Establish local elective Gynaecology service &

evaluate impact on local access / repatriation of activity

(March 17)

Increased local access /


Gynaecology service

H

Innovation DN&

AS

ESM 3.5 Put in place systems to reduce variation across elective

services (using interventions identified in the DOIT

improvement programme and the national planned care

programme)

Reducing unnecessary

appointments for patients,

reducing unnecessary

travel/costs and promoting

evidence based care

H











14/06/2016

13


Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority


point

4. Develop a sustainable

Clinical Staffing model

for NHSS

Workforce DN&

AS/

MD

CN

(A&SS) /

CN

(HSDC)

4.1 Continue development of Advance Nurse Practice

across the Board Improved sustainability of

clinical staffing

M

Workforce DCH

&SC

CN

(HSDC)

4.2 Produce development plan for Advanced Nurse

practice in Community services Improved sustainability of

clinical staffing

M

Workforce MD MD 4.3 Develop options for use alternative Middle & Junior

grade staffing (incl Clinical Development fellows) Improved sustainability of

clinical staffing

M

Workforce MD MD 4.4 Develop proposals for sustainable staffing model for

OOHs medical staffing (Sept 16) Improved sustainability of

clinical staffing

H

Workforce MD MD 4.5 Plan in place for Junior grade medical staffing for each

staffing rotation (July & Nov 15) Improved sustainability of

clinical staffing

H

Workforce MD MD 4.6 Develop succession plan for Senior medical staff (Sept

16) Improved sustainability of

clinical staffing

H

Workforce CE MD /

DNAS

4.7 Produce an updated Clinical staffing development plan

by October 2016. Improved sustainability of

clinical staffing

H

5. Redesign & strengthened

Mental Health services

Person-

centred Care

DHRS

S /

DCH

&SC

DM/MS 5.1 Agree and Confirm activity to be ‘In Scope’ and agree

MH OD plan (by end Sept 16) Agreed OD plan H

Person-

centred Care

DHRS

S /

DCH

&SC

TLSD/SH

/DM/MS

5.2 as part of MH OD plan, develop and implement

Mental Health management arrangements

a) Confirming roles & responsibilities

b) Implementing agreed structure of Team &

service meetings

c) Coaching (supporting) team through new

meetings / processes

Improved management

arrangements within MH

Increased staff satisfaction

H

Person-

centred Care

DHRS

S /

DCH

&SC

TLSD/SH

/DM/MS


Management & Leadership Skills development in MH

Service

Improved management



H











14/06/2016

14


Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority


point

Person-

centred Care

DHRS

S /

DCH

&SC

TLSD/SH

/DM/MS


Culture & behaviours assessment & development plan

(as appropriate)

Improved management



H

Person-

centred Care

DHRS

S /

DCH

&SC

EMMH 5.5 Implement Psychiatric Emergency Plan / Crisis service

arrangements including staffing and appropriate

training

Enhanced patient safety

and satisfaction

Increased staff safety

H

Person-

centred Care

DHRS

S /

DCH

&SC

EMMH 5.6 Ensure stable SMRS service and effective replacement

of services commissioned from CADSS Safe service provision H

Person-

centred Care

DHRS

S /

DCH

&SC

EMMH 5.7 Implement enhanced Psychology service with

appointment of new Psychology staff (Consultant

Clinical Psychologist and Applied Psychology Trainee

Increased patient

satisfaction

Improved service access

H

Person-

centred Care

DHRS

S /

DCH

&SC

EMMH 5.8 Develop, agree and implement Psychological Therapies

training plan Increased patient

satisfaction


H

Person-

centred Care

DN&

AS

C&FHM 5.9 Implement workforce plan to support CAMHS services

delivery within national access targets Increased patient

satisfaction


H

6. Improved Dementia

services

Prevention DCH

&SC

EMMH 6.1 100% of People with a confirmed Dementia diagnosis

will have been offered post diagnostic support. Improved Dementia

services

HEAT: T.9S + new target

H

Prevention DCH

&SC

EMMH 6.2 By Q2 80% of actions in Dementia Strategy

implementation plan should be completed or underway Improved Dementia

services

HEAT: T.9S + new target

H

7. Re-design Prisoner Custody

Services

Safe Care MD PCM 7.1 Evaluate effectiveness of redesigned service for

Prisoners in Police Custody and implement appropriate

changes (as required)

Delivery of affordable &

effective service

L











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15


Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority


point

8. Implement Primary Care

Strategy

Innovation /

workforce

DCH

&SC

SM PC 8.1 Agree Primary Care Strategy and implementation plan

(May 16) Agreement of strategy with

appropriate engagement

H

Innovation /

workforce

DCH

&SC

SM PC 8.2 Agree Implementation structure and establish Project

Board / Engagement strategy (July 16) Effective Implementation

arrangements &

Engagement

H

Innovation /

workforce

DCH

&SC

SM PC 8.3 Progress development of revised PC practice model (in

conjunction with staff and communities (Nov 16) Improved PC access

Improved PC staffing &

sustainability

H

Innovation /

workforce

DCH

&SC

SM PC 8.4 Implementation of PC Strategy (as per Implementation

timescales / milestones) (March 16) Improved PC access


sustainability

H

Innovation /

workforce

DCH

&SC

SM PC 8.5 Implementation of new Practice model for Unst

Practice / revised GP staffing (in agreement with local

staff) (Aug 16)

Improved PC access


sustainability

H

9 Older People’s Services Innovation /

workforce /

Integrated

care

DCH

&SC

EMCCR 9.1 Develop the model of care that promotes reablement

and care at home, quantifying what the residential care

bed base needs are for the future.

Clear capacity plan and

strategic direction as part

of Older Peoples Strategy

H

Innovation /

workforce /

Integrated

care

DCH

&SC

EMCCR 9.2 Progress implementation of OP strategy Improved outcomes for OP

(H&W Outcomes)

H


4. To provide best value for resources and deliver financial balance









14/06/2016

16


Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority


point

KEY OUTCOMES: : (@ 1 Year, 3 year & 5 Year )

Year 1 – Deliver In year Financial balance / achieve agreed Recurrent & Non Recurrent savings targets

Year 3 – Return to Recurrent Financial Balance / Agree Long term plan for the future development of the GBH

Year 5 – Maintain Recurrent Financial Balance

1. To ensure that the Capital

Resource Limit (CRL) and

expenditure remain in

balance

Efficiency &

Productivity

CE IHEF

1.1 Final Capital plan for 16/17 to be agreed (April 16) Achievement of balanced

financial position

H

Efficiency &

Productivity

CE IHEF

1.2 Draft Capital plan for 2017-18 to be agreed by the end

of March 2017 Achievement of balanced

financial position

M

2. To ensure that the

Revenue Resource Limit

(RRL) and expenditure

remain in balance

Efficiency &

Productivity

DFin EMT 2.1 Confirm balanced 2016-17 Revenue budget for Year

including detailed efficiency plan by May 16 Achievement of balanced

financial position

Delivery of Efficiency

plan

H

Efficiency &

Productivity

DFin EMT 2.2 Agree 5 Year financial plan with outline efficiency

targets (at service / Directorate level) by Oct 16 Achievement of balanced

financial position

Delivery of Efficiency

plan

Indicative 3 year budgets

for IJB to support

Strategic planning

H

Efficiency &

Productivity

DFin EMT 2.3 Agree Outline Efficiency plan for 2017/18 by

December 2016. Achievement of balanced

financial position

Delivery of Savings plan

H

Efficiency &

Productivity

DFin DFin 2.4 Finalise 2017/18 Financial Plan including savings plan

by March 2017. Achievement of Balanced

financial position

Delivery of Savings plan

H











14/06/2016

17


Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority


point

3. To ensure that medicines

are used effectively and

wastage reduced to a

minimum

Efficiency &

Productivity

DCH

&SC/

MD

DP 3.1 Deliver further efficiencies through effective and

efficient Prescribing focusing on:

More accurate forecasting of high cost drug

expenditure

Focusing on variances and implementing corrective

actions

Working across health and social care to ensure

that older people’s medicines are properly managed

Effective and efficient use

of medicines

H

Efficiency &

Productivity

DCH

&SC/

DN&

AS

DP 3.2 Work with hospital and community pharmacies to

reduce medicines wastage on an ongoing basis

throughout the year with evidence of campaign success

Reduction of funding used

on wasted medicines

M

Efficiency &

Productivity

DCH

&SC

DP 3.3 Continue to raise profile of issue through local

campaigns and local media Patients better informed

about managing their

medicines

M

4. To have robust and fit for

purpose planning in place

for effective local strategic

planning

Efficiency &

Productivity

DPH HP&M

SP&IO

4.1 Local Delivery Plan 16/17 signed off by May 2016

Effective local service

planning

H

Efficiency &

Productivity

DPH HP&M

SP&IO

4.2 LDP 17/18 draft agreed by March 2017

Effective local service

planning

H

Innovation

DPH HP&M

SP&IO

4.3 LOIP 16/20 finalised and signed off by end June 2016

Effective partnership

planning & contribution to

Shetland Partnership

M

5. Deliver the eHealth Plan

as agreed by the eISG

Strategy Group

Efficiency &

Productivity

DHR

& SS HIT/ eHealth

5.1 Ensure appropriate focus and approval route for

eHealth and Information Governance plan 2016-17 by

April 2017

Effective IT provision H











14/06/2016

18


Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority


point

6. Deliver 16/17 IT Capital

Projects Programme as

agreed by CMG

Efficiency &

Productivity

DHR

& SS HIT/ eHealth

6.1 Deliver programme activities by July 17 Ensure fit for purpose IT

infrastructure

Increase robustness and

availability of information

systems

H

7. Review the IM&T

Business Continuity plan

in light of review of all

other service BCPs

Efficiency &

Productivity

DHR

& SS eISG 7.1 Agree IM&T Disaster Recovery Plan August 2016 Assured integrity of Board

data and systems

H

8. Develop a Health

Intelligence function

within the ehealth

Department

Efficiency &

Productivity

DHR

& SS HIT/ eHealth

8.1 Agree priorities and KPIs – July 2016 Improved clarity on

approach and use of data /

information

Greater clarity on key

Information needs

H

9. Implement Efficiency &

Redesign programme

Efficiency &

Productivity

CE EMT 9.1 Recruit Head of Planning & Modernisation (July 16) Effective support and

overall co-ordination of

programme

H

Efficiency &

Productivity

CE EMT 9.2 Review reporting and governance arrangements for

E&R programme (Oct 16) Effective support and


programme

H

Efficiency &

Productivity

CE EMT 9.3 Create additional Management capacity to support

programme (Sept 16) Effective support and


programme

H

Efficiency &

Productivity

CE EMT 9.4 Ensure appropriate documentation in place for agreed

projects (Sept 16) Effective support and


programme

H

Efficiency &

Productivity

CE EMT 9.5 Agree process for identifying next stage of E&R

programme (Aug 16) Effective support and


programme

H

Efficiency &

Productivity

CE EMT 9.6 Develop plans for future E&R programme (Dec 16) Effective support and


programme

H











14/06/2016

19


Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority


point

Efficiency &

Productivity

CE HEF 9.7 Complete sale of surplus properties Delivery of Financial

balance

H

10. Improve effectiveness and

efficiency of Patient

transport arrangements

Efficiency &

Productivity

DFin HF&P 10.1 Progress project to redesign and improve efficiency of

Boards Patient transport arrangements and use of HITS

funding in line with project PID (March 2017)

Improved value for money M

Efficiency &

Productivity

DFin HF&P 10.2 Implement revised Patient travel arrangements (using

ferries) (Dec 16) Improved value for money H

Efficiency &

Productivity

DFin HF&P 10.3 Develop proposals for revised Patient travel

arrangements for escorts (Sept 16) Improved value for money H

Efficiency &

Productivity

DFin HF&P 10.4 Agree new Policies for Patient travel (HITS) in

conjunction with other NoS Boards & agree at Board

(Oct 16)

Improved value for money H


5. To ensure sufficient organisational capacity and resilience









14/06/2016

20


Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority


point

KEY OUTCOMES: : (@ 1 Year, 3 year & 5 Year ?)

Delivery of agreed Organisational Targets and Corporate Objectives (i.e. HEAT / Relevant SOA targets)

Greater than 75 % of CAP actions complete / On target year on year

Increase in Positive Board members returns on Corporate Governance / work of the Board (through Board self evaluation)

Increased Staff satisfaction (measured through Staff surveys & Employee engagement index (iMatters)): Year 1 – Establish / agree Baseline and Targets; Year 3 – Meet Interim Targets; Year 5 – Meet Target

1. Progress Integration of

Community Health &

Social Care services

Integrated

Care

DCH

&SC

DCH&SC

/ SIC -

DCS

1.1 Establish and run Induction programme for new

members of the IJB Effective Governance H

Integrated

Care

DCH

&SC

DCH&SC

1.2 Carry out self assessment and review of effectiveness

of IJB arrangements (Dec 16) Effective Governance H

Integrated

Care

DCH

&SC

DCH&SC 1.3 Develop and implement ongoing development plan for

IJB (March 17) Effective Governance H

Integrated

Care

DCH

&SC

HP&M 1.4 Develop arrangements for Locality Planning

infrastructure – arrangements for ongoing locality

meetings to be agreed and implemented to support next

Strategic (Commissioning) Plan (Sept 16)

Strategic Plan informed by

locality population needs

M

Integrated

Care

DCH

&SC

HP&M 1.5 Update & confirm arrangements for Joint Strategic

Planning within the IJB (Aug 16) Effective engagement and

planning for Health & SC

services

H

Integrated

Care

DCH

&SC

HP&M 1.6 Update & agree Joint Strategic Plan (Jan 17) Strategic Plan informed by

locality population needs

H

Integrated

Care

DHSC DHSC 1.7 Progress options for Integrated locality services with a

management structure and professional structure that

supports quality; safety and delivery by Q3.

More effective joint

service provision

H

Integrated

Care

DFin HF&P 1.8 Confirm updated Joint Budget process for 16./17

budgets (Aug 16) Effective management of

services / Improved Joint

Management & Decision

making

H











14/06/2016

21


Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority


point

Integrated

Care

CE DFin 1.9 Aree Joint Budgets for 17/18 (Draft for December

2016; final for March 2017) Effective management of

services / Improved Joint

Management & Decision

making

H

Integrated

Care

CE CSM 1.10 Review updated Board Governance structures &

committee arrangements in response to Integration

agenda by Dec 16

Streamlined Governance H

Integrated

Care

CE CSM 1.11 Evaluate impact of IJB on Governance arrangements

and implement continuous improvement to Board

governance (March 17)

Streamlined Governance L

2. Improve the use of the

performance management

system to drive

improvements and focus

on areas that need more

attention

Efficiency &

Productivity

CE HP&M 2.1 Introduce new performance system to support NHS and

IJB by Sept 2016 Assisting decision making

and accountability around

priorities

H

Efficiency &

Productivity

CE HP&M 2.2 Develop approach to reporting performance to improve

use of Dashboards and use of appropriate information to

support decision making (March 17)

Reduced bureaucracy

More efficient use of

resources

Improved system for added

functionality (eg for audit

purposes)

M

3. To ensure compliance

with the board’s statutory

duties under the Data

Protection Act (1998) and

Public Records Scotland

Act (2011)

Efficiency &

Productivity

DFin HIT 3.1 Updated Information Governance Action plan produced

by end of July 16 Ensures legislative

compliance, mitigating

ICO (Information

Commissioner Office)

penalties for the Board

H











14/06/2016

22


Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority


point

Efficiency &

Productivity

DFin HIT 3.2 Monitor progress against action plan and adjust plan to

respond to changes (March 2017). Annual information

governance report for 2015-16 to be produced

Ensures legislative


ICO (Information



M

4. To ensure compliance

with the board’s statutory

duties under the Public

Records Act (Scotland)

Efficiency &

Productivity

DFin t.b.a. 4.1 Appoint PM to support implementation of Records

management plan (in response to Public Records Act

(Scotland) (July 16)

Compliance with

Legislation

M

Efficiency &

Productivity

DFin Project

Manager

4.2 Draft Records Management Plan & Implementation

action plan (Dec 16) Compliance with

Legislation

M

Efficiency &

Productivity

DFin Project

Manager

4.3 Submit Records management scheme (in line with act)

by March 2017 Compliance with

Legislation

M

Efficiency &

Productivity

DFin Project

Manager

4.4 Monitor progress against action plan and adjust plan to

respond to changes (March 2017) Ensures legislative


ICO (Information



M

5. Progress Service

Improvement Methods

within the Board ensuring

strategic direction is clear

as part of HR&OD

Strategy

Innovation DHR

&SS

IDM 5.1 Develop approach to education and training for Service

Improvement methods and tools; update OD Strategy Tools and methods ready

for staff to utilise in their

areas

M

6. Deliver the Staff

Governance Action Plan

2016/17

Workforce DHR

&SS

All

Directorat

e HODs

6.1 Deliver staff Governance action Plan (March 17) Improved staff

engagement

Improved staff training and

skills

H

7. Improve management

arrangements across NHS

Shetland

Efficiency &

Productivity

CE MD 7.1 Agree & implement revised approach to clinical

leadership in Acute services (Oct 16) Improved clinical

involvement

H











14/06/2016

23


Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority


point

Efficiency &

Productivity

CE EMT 7.2 Develop clinical engagement through use of ACF &

Advisory committees Improved clinical

involvement

H

Efficiency &

Productivity

CE CSM 7.3 Deliver Communication strategy Implementation plan Improved stakeholder

engagement

M

Efficiency &

Productivity

CE EMT 7.4 Develop approach to Leadership / management

meetings Improved management

effectiveness

M

Efficiency &

Productivity

CE EMT 7.5 Develop approach to engagement with Middle

managers Improved management

effectiveness

M

8. Development of EMT as

leadership team

Efficiency &

Productivity

CE DHRSS 8.1 Agree updated EMT development plan (following

EMT session and iMatters (Sept 16) Continuous Improvement

in EMT leadership

M

Efficiency &

Productivity

CE DHR&SS 8.2 Implement EMT development plan (December 2016) Continuous Improvement

in EMT leadership

M

9. Development of Board Efficiency &

Productivity

Chair DHR&SS 9.1 Progress Board development sessions (September

2016) Continuous improvement

in Board leadership

M

Efficiency &

Productivity

Chair DHR&SS

/ CSM

9.2 Agree action plan in response to Board self assessment

(Sept 16) Continuous improvement

in Board leadership

L

Efficiency &

Productivity

Chair DHR&SS

/ CSM

9.3 Implement action plan in response to Board self

assessment (Dec 16) Continuous improvement

in Board leadership

L

Efficiency &

Productivity

Chair CSM 9.4 Carry out further Board self assessment exercise (Dec

16) Continuous improvement

in Board leadership

L

10. Development of HR /

Staff Information

Workforce DHR

&SS

HRSM 10.1 Develop HR Dashboards

Improved visibility of Staff

information

Improved staff

management &

engagement

H

Workforce DHR

&SS

HRSM 10.2 Progress implementation of eESS in line with updated

national programme (Dec 16) Visibility of performance

planning needs

H

Workforce DHR

&SS

HRSM 10.3 Further develop Board’s workforce planning (Dec 16) Improved Staff

management and

workforce development

H











14/06/2016

24


Landscape

Priority

Areas

Exec.

Lead

Oper-

ational

Lead


Priority


point

11. Improve organisational

resilience to business

threats

Efficiency & Productivity

CE HP&M 11.1 Stocktake of Board’s position with Business Continuity

planning (Dec 16)

Ensuring no gaps in

business continuity

planning

Ensuring plans are aligned,

and mutually supportive

M


CE HP&M 11.2 Finalise implementation of BCP Audit report action

plan (Oct 16) Ensuring no gaps in

business continuity

planning

Ensuring plans are aligned,

and mutually supportive

M

Safe Care DPH DPH /

EMT

11.3 Progress and implement action plan for “Prevent

Strategy ” in conjunction with partners (March 16) Effective governance

Security of staff and

patients

L


DFin HF&P 11.4 Review & agree updated policy & procedures for Asset

Verification (Oct 16) Effective governance

H


DFin HF&P 11.5 Implement revised Asset Verification process Effective governance

H


DFin

& CE

EMT 11.6 Review & implement improved implementation of

audit recommendations Increased rate of delivery

on audit recommendations

Effective Governance

H


DFin

& CE

HF&P 11.7 Review of effectiveness of Internal Annual accounts

process Effective Governance

Clean Audit certificate

H

shetland nhs board

Documents