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  • 1. Performance Management Strategy 2009-2014 Review Date: December 2014 Document Control Date Version Contents Author Simon Bokor- 9th October 2009 1.0 Initial outline Ingram Kathleen 3rd November 2009 2.0 Monitoring arrangements Carolan Clinical Services Additional refinement of Management monitoring arrangements and 10th November 2009 3.0 Team/Senior performance management Management reporting Team Item Table of Contents 2 1 Context 3 1.1 Introduction 3  Page 1 of 17 Version 3.0
  • 2. 1.2 Our Aspirations 3 1.3 Why Performance Management Is Important 3 1.3.1 Motivating Individuals 4 1.3.2 Improving Services 4 1.3.3 Value for Money 4 1.3.4 National Profile 5 1.3.5 Working with Partners 5 1.4 Purpose of this Strategy 5 1.5 The Balanced Performance Framework 5 1.5.1 Performance Framework 6 1.6 Monitoring Arrangements 6 Diagram 1 Organisational Alignment 8 Diagram 2 Balanced Performance Framework at NHS Shetland 9 2 Delivering the Performance Strategy 10 2.1 Key Performance Management Principles 10 2.1.2 Outcome Driven 10 2.1.3 Evidence based 10 2.1.4 Continuous Improvement 10 2.1.5 Transparent 10 2.1.6 Comprehensive yet Focussed 10 2.1.7 Rigorous Follow Up 11 2.1.8 Owned 11 3 Achieving our Vision 11 3.1 Building a performance Culture Inspired by Strong Leadership 11 3.2 How Will the Organisation Develop? 11 3.3 Vision & Objectives 12 3.4 Roles & Responsibilities of Key Staff 12 3.4.1 Chief Executive 12 3.4.2 Director of Clinical Services 12 3.4.3 Director of Human Resources & Support Services 12 3.4.4 Executive Directors & Senior Managers 13 3.4.5 Informatics Department & Public Health Services 13 3.4.6 All Staff 13 3.5 Performance Data 13 3.6 Communicating Performance 13 3.6.1 Disseminating Information to Staff about this Strategy 14 3.6.2 Monitoring & Review of this Strategy 14 4 Achieving our Vision 14 4.1 Key Outcomes expected from the Delivery of the Performance Strategy & Vision 14 4.2 Key Steps 15 Appendix A Key Performance Indicators for 2009-11 16 Appendix B Example of Corporate Performance Report in 2009-10 17  Page 2 of 17 Version 3.0
  • 3. 1. Context 1.1 Introduction This strategy aims to set out NHS Shetland’s vision for managing performance across the organisation and with partner agencies in order to achieve our goals. There are huge challenges ahead, not just for the Health Board within Shetland, but nationally across all public sector bodies as the drive for continual productivity and efficiency continues. NHS Shetland has high aspirations for delivering sustainable, quality services and this document sets out a context for performance management that will measure those improvements. The performance management framework described in this strategy has been developed to support the delivery of local and national targets set out in the NHS performance framework, which describes 30 HEAT targets and 33 HEAT key performance measures for health. Our Local Delivery Plan sets out a delivery agreement between the Scottish Government Health Department (SGHD) and the Board, based on the key Ministerial targets. The Local Delivery Plan reflects the HEAT Core Set - the key objectives, targets and measures that reflect Ministers' priorities for the Health portfolio. The key objectives are as follows: Health Improvement for the people of Scotland - improving life expectancy and healthy life expectancy; Efficiency and Governance Improvements - continually improve the efficiency and effectiveness of the NHS; Access to Services - recognising patients' need for quicker and easier use of NHS services; and Treatment Appropriate to Individuals - ensure patients receive high quality services that meet their needs. Progress against HEAT targets is published throughout the year by the SGHD and locally via performance reports to the Board. The information contained in this strategy outlines the main roles, responsibilities and objectives for performance management, together with the working principles by which all performance management should be undertaken. 1.2 Our Aspirations There are 14 territorial health boards in Scotland. NHS Shetland is proud of the services it delivers, and of the staff who work within those services. Whilst performance in most areas continues to be good, NHS Shetland aspires to providing the best services and being one of the top performing health boards. Being held in high esteem as an organisation is motivating for staff, and highly motivated staff deliver excellent services. Strong organisations are able to make a difference within communities, and to work positively with other statutory and voluntary agencies.  Page 3 of 17 Version 3.0
  • 4. Strong organisations can focus on developing services rather than having to be defensive and reacting to internal deficiencies. The Board seeks to develop an “open, just and non punitive” culture where all staff feel able to report adverse incidents, near misses and hazards in the knowledge that incidents/errors are not normally investigated through the disciplinary procedure. 1.3 Why Performance Management is Important Performance management is defined as taking action in response to actual performance to make outcomes for users and the public better than they would otherwise be. Performance management is integral to NHS Shetland’s overall operation in that it helps us to plan, monitor and manage delivery of our health improvement and health care services. Performance on the delivery of quality will be built into the framework, and the measurement of quality will become more sophisticated over time. Getting performance management right is important to us for a number of reasons:- 1.3.1 Motivating Individuals Individual members of staff need to know what is expected of them, and what part they play in the overall success of NHS Shetland. Effective performance management is about being positive and helping individuals to really excel at what they do best. The knowledge and skills framework is being embedded in the organisation, and this will assist the organisation to focus on the learning needs of individuals so that they can deliver the very best services to patients. 1.3.2 Improving Services We need to ensure that we are delivering services that meet patient needs, and performance management gives the organisation a way of making decisions about where to focus resources depending on needs at any one time. Over time, performance management allows relative measurement to be made so that we can see if improvements are being made, and if extra efforts need to be made in particular areas to achieve those improvements. Implementing robust appraisal systems is also linked to improved patient outcomes1. 1.3.3 Value for Money NHS Shetland wants to ensure that services are sustainable. The services are funded by tax payers. We need to ensure that every pound counts towards delivering services, and that we continue to be as efficient and productive as possible so that we remain sustainable and have as much resource as possible for front line services. Making clear links between resources and outcomes helps to put our performance into context so that we can demonstrate that we are delivering best value. 1 West, M. A., Borrill, C., Dawson, J., Scully, J., Carter, M., Anelay, S., Patterson, M., &Waring, J. (2002). The link between the management of employees and patient mortality in acute hospitals. The International Journal of Human Resource Management, 13, 1299–1310.  Page 4 of 17 Version 3.0
  • 5. 1.3.4 National Profile NHS Shetland’s performance is measured against that of other health boards. This not only informs an elected government of how we are delivering services, but also demonstrates our success relative to others. This is important, because where others may be doing better than we are in particular areas, we can learn from them to improve our performance. 1.3.5 Working with Partners NHS Shetland works closely with the Shetland Islands Council and many other statutory and voluntary agencies. As the amount of joined up working continues to increase, ways of measuring success across organisational boundaries becomes ever more important. Performance management of these arrangements creates clear lines of accountability and probity. Managing performance in partnership has become increasingly important. At Government and local level, partnerships are seen as a way of achieving better and more joined-up services. The Single Outcome Agreements are a major driver for agreeing joint objectives and outcomes with our Local Authority partners and NHS Shetland is also developing partnership arrangements with NHS Grampian to deliver a wide range of clinical and non-clinical services. 1.4 Purpose of this Strategy Effective performance management requires not only good management processes and systems, but also an organisational culture that supports these systems and integrates them with the day- to- day work of front-line staff and managers to encourage and support a culture of continuous service improvement. This document sets out the framework and approach we have put in place to support us in achieving our vision for performance management. 1.5 The Balanced Performance Framework The Balanced Performance Framework was first developed and implemented across the NHS Shetland in 2007. Since then there have been a number of reviews and improvements made to meet the changing needs of the local service as well as national requirements. The Framework adopts a balanced scorecard approach2. A balanced scorecard translates the organisation’s strategy into SMART objectives through the identification of strategic objectives, measures and targets across a number of strategic themes/perspectives. The scorecard is then used to track progress and ensure action is taken to address areas of under performance as appropriate. The national Local Delivery Plan HEAT targets and measures are aligned to NHS Shetland’s strategic objectives and incorporated into our balanced scorecard. An example of the current scorecard (executive summary), which includes national and locally derived performance indicators, is shown in Appendix A with position from September 2009. The full report can be found at the following link: http://www.shb.scot.nhs.uk/board/meetings/documents/BoardPaper200913.MonthlyP erformanceMonitoringReport.pdf 2 The balanced scorecard is based on the citistat template, but has been adapted to include local balancing measures. The data collection process is manual, but one of the key objectives in the strategy is to put in place an electronic data abstraction process, which make the performance data more accessible and over time will lead to prospective reporting.  Page 5 of 17 Version 3.0
  • 6. Performance management arrangements (both personal and organisational) are aligned to our Vision and Values as shown in Diagram 1. This demonstrates that the personal objectives of staff are aligned to directorate level objectives and in turn to our strategic objectives in the Corporate Action Plan, and the vision and values of the organisation. This ensures staff understand how they contribute towards delivery of the organisation’s goal and priorities. The table shown below describes the key sources of performance review information, the review function and frequency of the monitoring arrangements. 1.5.1 Performance Framework Review Type Review Body Frequency At least 1:1s with Individual Managers Individual performance quarterly Clinical Services Management Team business plans Monthly Team/CHCPMT Directorate Performance Scorecard Clinical Services Management Teams Monthly Performance Management Action Plan Clinical Services Management Teams Monthly Performance Management Action Plan Senior Management Team Quarterly Performance Management Action Plan Board Annually Corporate Performance Scorecard Senior Management Team/Board Monthly Review Type Review Body Frequency Operational business plan Senior Management Team Monthly Corporate Action Plan Board Quarterly Infection Control Report Board Monthly HAI Performance Scorecard Control of Infection Committee Monthly 1.6 Monitoring Arrangements In order to ensure that there is both horizontal and vertical communication across the organisation the performance framework describes the relationship between departments, teams, operational management arrangements and strategic functions. Diagram 2 shows the relationship and connections between personal performance arrangements, operational groups, tactical and strategic arrangements for assuring the Board of current performance and action plans to move forward. The information that each level would expect to see would be as follows: Board- Corporate scorecard and Corporate Action Plan. HAI Performance Report. Standing Committees- Corporate scorecard and Corporate Action Plan Senior Management Team- Corporate scorecard and Corporate Action Plan Directorates- Directorate scorecard and Directorate objectives Teams- Directorate scorecard and Team objectives The Board has taken a conscious decision to use the existing management structures to monitor and drive forward performance across the organisation, rather  Page 6 of 17 Version 3.0
  • 7. than put in place a specific performance review committee. The reasons for doing this include the fact that we are a small organisation and good functional arrangements and management structures already exist. In addition to this, it is noted that in order to embed the principles of excellence and performance into all aspects of the organisation, this is best achieved by mainstreaming the monitoring of performance into the existing structures. This means including the review of performance and outcomes in all clinical and management fora. This includes (but is not limited to the following management and governance arrangements): Board – where a wide range of organisational planning and performance discussion takes place Standing committees – Clinical Governance, Staff Governance, Service Redesign, Audit Committee, CHP Committee and Controls Assurance Group. Where corporate scorecards and directorate scorecards are discussed (in relation to the core business of the committee) as well as organisational planning and performance discussions take place. Operational and tactical groups – Senior Management Team, Clinical Services Management Team, Community Health and Care Partnership Management Team, Operational Waiting Times Meetings, Senior Charge Nurse Meetings, Infection Control Team, AHP Meetings, Health Care Scientist Meetings etc. All of the communication and management structures described above will receive reports on performance, appropriate to the type of meeting/structure in place. In many cases this will be a standard report (such as the risk register, quarterly summary of progress, corporate scorecard, or specific service improvement programme such as 18 weeks RTT, Scottish Patient Safety Programme, Long Term Conditions Collaborative, Mental Health Collaborative, Clinical Quality Indicators programme etc). In addition to this, work is being undertaken to further develop the balanced scorecard approach so that matrices are put in place to reflect performance at team or departmental level. For example, the development of a scorecard for infection control monitoring at ward level. Further development of the performance monitoring structures is one of the key objectives for 2009-10 and described in more detail in the following sections.  Page 7 of 17 Version 3.0
  • 8. Diagram 1 Organisational Alignment Vision & Values Strategic Themes P E R Organisation Corporate Plan F O R M A Strategic Objectives N C E M Allocation & Alignment of Resource A N A G E Directorate/Programme Objectives M E N T Personal Objectives Supporting Development Plans  Page 8 of 17 Version 3.0
  • 9. Provides assurance to the Diagram 2 NHS Board on overall Balanced Performance SENIOR performance and Framework at NHS MANAGEMENT performance systems. Shetland TEAM Receives assurance from governance committees on delivery of strategic objectives through the Corporate Action Plan. CORPORATE SCORECARD Reviews corporate scorecard delivery and organisational plans monthly. WTG monitors corporate WAITING TIMES scorecard delivery (access, GROUP & efficiency and treatment GOVERNANCE indicators) bi weekly. COMMITTEES Governance committees consider delivery, performance and outcomes at each committee CORPORATE SCORECARD meeting. Directorates contribute to delivery of Strategic SERVICE Objectives. MANAGEMENT Monitor the delivery of TEAMS (e.g. CSMT) team business plans on a monthly basis.   DIRECTORATE SCORECARD Individual performance reviews undertaken by OPERATIONAL Heads of Department TEAMS &   LOCALITIES DIRECTORATE SCORECARD  Page 9 of 17 Version 3.0
  • 10. 2. Delivering the Performance Strategy 2.1 Key Performance Management Principles NHS Shetland uses the Balanced Scorecard approach to identify, improve, assure and review all aspects of the Board’s performance. The general principles that govern all performance management arrangements are as follows: 2.1.2 Outcome driven Any process consists of three elements – inputs, outputs and outcomes. It is essential to measure all three, however it is the outcome that is all important to end- users. Our framework is based on a balanced set of measures at all levels – including the Health Plan, team plans, change programmes or development plans. Performance management arrangements at NHS Shetland are aligned with national outcomes and targets as described in the National Performance Framework. The monitoring arrangements that have been put in place also show the relationship between actions set out in the Corporate Action Plan, the Local Delivery Plan and Single Outcome Agreements with partners. 2.1.3 Evidence Based For performance management to be effective, decision makers must have confidence in the information they use to make decisions. This means information produced is based on good quality data and interpretation provided by the Informatics Department and from national sources such as Information Statistics Division (ISD) 2.1.4 Continuous Improvement The performance arrangements support and promote a culture of continuous performance improvement. This includes learning from good practice elsewhere and pro-active use of benchmarking information to identify ‘best in class’ and the setting of challenging but deliverable improvement plans. 2.1.5 Transparent Performance information must be objective and readily accessible to users and the public. The HEAT system and our continued development of reporting tools plays a key role in making data available to senior managers and clinicians. All performance reports are widely available to staff on the NHS Shetland intranet. 2.1.6 Comprehensive yet Focused Performance management systems must cover the whole organisation to reflect the entire agenda fairly. However performance management should be based on sound prioritisation in line with risk. NHS Shetland has identified a focused set of priorities meaning that we can maintain both focus, through a smaller number of key actions and targets and enjoy a sustainable performance management framework.  Page 10 of 17 Version 3.0
  • 11. Performance measures are continually subject to review to ensure relevancy and appropriateness- to reduce monitoring for monitoring sake. 2.1.7 Rigorous follow- up The process of performance management should be rigorous with strong scrutiny and accountability by Non Executives and Executives. Follow up of actions arising from performance reviews is a key component of the review process to ensure delivery. 2.1.8 Owned Everyone must accept a role in managing performance and take action to ensure improvement. 3. Achieving our Vision 3.1 Building a Performance Culture Inspired by Strong Leadership Good performance management motivates people. This requires strong and inspirational leadership to create the right environment to allow innovation and team and individual excellence, where success is celebrated and challenges are tackled proactively and positively. The performance framework puts front line delivery at the pinnacle of a strong underpinning system of support and leadership. Every member of staff needs to be able to see how their contribution is reflected in what the Board and public see for organisational performance. There will be a greater amount of transparency both within and outwith the organisation on how well we are delivering services. 3.2 How will the Organisation Develop? A step change in the way the organisation sets out how it will focus on performance management will result in a shift in culture. That culture needs to be fostered and developed in the right way by managers to ensure that the underpinning principles outlined in this strategy form the bedrock of that culture. Positive, forward thinking and developmental approaches will be needed to ensure that the whole team shifts up a gear together, as success depends on the whole organisation delivering excellence on everything it does. People need to hold each other to account, both up and down the line management chain, so that performance management creates an expectation within the organisation of how we will all behave. Striving for improvement and to be the best will be the de facto stance that we want to see from each and every individual. The purpose of this strategy is to promote the organisational vision and objectives in relation to performance management and the delivery of high quality services. The vision is summarised as five objectives to be achieved through the implementation of the performance framework. The measurement of achievement will be through review of key performance indicators, which will be refreshed on an annual basis. In the following section, the key outcomes in respect of the delivery of the strategy are described, along with the key steps for implementation.  Page 11 of 17 Version 3.0
  • 12. An action plan will be developed to take forward the high level actions set out in section 4, which shows the key steps for strategy implementation. This action plan will be regularly monitored and the schedule of monitoring is shown in section 1.5 under performance framework. 3.3 Vision and Objectives 1. Actively Managing Performance 2. Promoting a High Performance Culture 3. Ensuring Robust Performance Data and Intelligence Systems are in Place 4. Ensuring Integrated Planning and Performance Processes 5. Promoting Evaluation and Learning 3.4 Roles and Responsibilities of Key Staff Whilst it is everyone’s job to manage performance, the Board must drive a culture of performance with the primary leadership role lying with the Chief Executive, Directors and Heads of Service. Effective performance management requires defined roles and responsibilities and clear ownership of outcome measures. A summary of these roles and responsibilities is as follows: 3.4.1 Chief Executive • Overall statutory responsibility for patient safety, governance and performance management. • Accountable to the Board and the Scottish Government Health Directorate The Board has delegated responsibility for Performance Management to the Director of Clinical Services. In order to discharge this responsibility, the Director of Clinical Services works with the Senior Management Team to ensure effective performance management arrangements are in place across NHS Shetland. 3.4.2 Director of Clinical Services Leads the development and implementation of the performance management arrangements through the Information, Clinical Governance and Performance functions/teams, which sit within the Clinical Services Directorate. This includes functional links with organisational development and service redesign. 3.4.3 Director of Human Resources & Support Services Leads the development and implementation of the organisational development that creates individual staff ownership and departmental responsibility by line managers for the delivery of services that meets the expectations of the organisation. This includes functional links with national service improvement teams, and local performance and clinical governance teams.  Page 12 of 17 Version 3.0
  • 13. 3.4.4 Executive Directors and Senior Managers Responsible for driving forward the development and embedding performance management arrangements in their area of service/function and to ensure consistency of approach as defined by in the Performance Strategy and in accordance with the Balanced Performance Framework. 3.4.5 Informatics Department & Public Health Services The Informatics Department provides the accurate and timeous analysis and interpretation of performance data for performance review and follow up purposes. Public Health services provide epidemiological data to support service development and planning – which is also used as part of local performance reviews. 3.4.6 All Staff All staff contribute towards performance improvement and management by being encouraged and supported to identify improvement opportunities and to take the required action. It is important that staff own the data on their activity, and understand how that translates to the corporate performance of the organisation. 3.5 Performance Data It is important that when using performance data that each staff member has faith in what is being presented, and what is reported outside of the organisation to both government and our residents can stand up to rigorous scrutiny. If the organisational reputation is to be built on performance, then it is critical that the data is absolutely correct and is representative of what is being delivered by services. The organisation has invested in developing a robust informatics function, and will continue to ensure that data integrity is maintained. Data validation is undertaken via internal and external audit arrangements and a programme of data validation exercises is in place. The detail of this programme can be found in the Information Governance Policy. 3.6 Communicating Performance Communication of this policy will follow the principles and process outlined in the Shetland NHS Board Communication Strategy. The Information Technology (IT) Department maintains both Internet and intranet sites providing a portal for all staff, patients and service users to access related information. Reports, minutes of meetings and all appropriate documentation relating to performance management arrangements and outcomes will be published on the intranet and Internet. This includes changes to this strategy and associated policy documents, procedures and guidance. This also includes performance data shown in reports and scorecards. A summary will also be published in Team Brief enabling all  Page 13 of 17 Version 3.0
  • 14. staff to have access to updates. Some data will also be displayed in clinical areas and departments to ensure that our performance as an organisation is visible to staff, patients and visitors. 3.6.1 Disseminating Information to Staff about this Strategy The Board recognises the importance of ensuring staff are fully appraised of current performance arrangements and outcomes. All staff therefore: • Are encouraged to raise issues relating to performance management arrangements and performance with their line manager and/or through existing management structures • Will be able to view minutes and reports on the Intranet (e.g. board performance scorecard, annual reports and action plans from service improvement programmes etc) • Receive information at formal updates such as team meetings, via Team Brief and mandatory refresher days in respect of changes/revisions to the performance management arrangements 3.6.2 Monitoring and Review of this Strategy • The Strategy and associated action plan will be reviewed annually by the Board to ensure that the KPIs are reviewed and performance is noted. • The senior management team will review the performance action plan quarterly. • Operational matters (e.g. delivery of individual actions) will be monitored via the Clinical Services Management Team (CSMT) and other management teams on a monthly basis. 4. Achieving our Vision 4.1 Key Outcomes Expected from the Delivery of the Performance Strategy and Vision • All staff employed by NHS Shetland will have a clear understanding of the performance framework and believe that achieving good performance is important • The Board plays a key role in monitoring and managing performance • All employees have a demonstrable appreciation as to how their work contributes towards the Local Delivery Plan priorities • There are Integrated balanced scorecards at corporate and departmental level • There is integrated and timely reporting with high quality commentary for performance reviews • Data quality is take seriously with good arrangements in place at all levels  Page 14 of 17 Version 3.0
  • 15. • Local staff feel informed about the systems performance and progress in achieving priorities • There is more structured learning around performance management with all managers 4.2 Key Steps Short terms goals 2009-10 (within 1 year of strategy approval) • Greater challenge of areas of underperformance through rigorous review of performance at sector as well as corporate level • Enhanced access to performance data through automation of the Balanced Scorecard and development of local dashboard reporting with links to management information • Continue to promote and develop a culture of continuous performance improvement through integrated approach to Improvement activities using LEAN methodologies3. Medium terms goals 2010 – 2011 (1-2 years) • Undertake review of the effectiveness of our performance management arrangements • Review suite of performance measures in light of changes from both national HEAT targets and local indicators emerging from the LDP and corporate action plan updates Long term goals 2012 and beyond (3 years +) • Evaluate the effectiveness of changes to individual performance management arrangements on organisational performance • Evidence improvement in key areas with continuous improvement against the HEAT indicators • A culture of continuous performance improvement is embedded throughout the organisation 3 The European Framework for Quality Management (EFQM) is used in some external assessments facilitated by NHS Quality Improvement Scotland. Elements of Total Quality Management (TQM) approaches are also used by NHS Scotland through the national improvement programmes. Where appropriate these continuous improvement techniques are also used by NHS Shetland to drive up performance standards. The techniques commonly used (although not formally through an EFQM) include value stream analysis, study cycles such as PDSAs, review of capacity and demand management and other tools such as rapid improvement events (where the methodology is borrowed from business process re-engineering).  Page 15 of 17 Version 3.0
  • 16. Appendix A Key Performance Indicators for 2009 -2011 Objective Indicator/Measure Target An action plan will be Action plan reflects the key developed to ensure that Action plan in place by the steps set out in the the key stages of the end of 2009 strategy strategy are developed Systems in place to collect Informatics systems are Information corporate scorecard developed to facilitate system/process in place indicators, nursing and score card compilation AHPs by April 2010 All clinical services teams Individual scorecards are and departments will have Individual scorecards are in place for AHP, nursing individualised scorecards in place and dental by mid 2010 in place All Directors will ensure All standing committees Evidence that performance that performance review is will have a scorecard review is on standing a standing item at standing process and discussions in committee agendas committees place by the end of 2010 All teams and departments All operational groups will will ensure that Evidence that performance have a scorecard process performance review is a review is on operational and discussions in place standing item at group agendas by the end of 2010 operational meetings Performance data shown Performance measure Performance data will be in appropriate charts for outcomes will be displayed available in clinical areas, interpretation will be in prominent areas (e.g. other departments and on available in clinical hand hygiene compliance the internet and easily areas/other depts and on in ward areas) accessible the internet by mid 2010 Performance management will be become a key topic PM is discussed at Programme in place from at induction and induction and mandatory mid 2010 mandatory refresher refresher sessions for all staff Cross boundary Three reviews are performance reviews will Cross boundary review undertaken between now be put in place in at least process developed and March 2011 three areas The action plan will be Actions are set and All actions set are reviewed as per the monitored as per the delivered within the agreed schedule set out in the schedule timescales strategy KPIs will be reviewed KPI plan is approved and annually and the action measured via SMT plan updated  Page 16 of 17 Version 3.0
  • 17. NHS Shetland Appendix B Example of Corporate Status against plan Performance against previous period Performance Report in 2009-10 Not meeting and not within trajectory limit Red Improvement Not meeting but within trajectory limit Amber Same NHS Shetland Performance Report Meeting or Better Green Worse F N Summary for October 2009 Better than planned trajectory Blue Summary Sheet Health Improvement Efficiency Access Treatment H2 H3 H4 H5A H5B H6 E4A E4B E4C E4D E5A A8A A8B A9A A9B A10A T2 T3 T4 T6A HEAT Blue Green Green Green Green Green Green Amber Blue Blue Green Green Amber Green Green Blue Green Amber Green Green H7 H8 HS1 E5B E5C E6 E7 E8 A10B A10C A10D A10E A10F T6D T6E T7 T8 Green Amber Green Green Green Green Blue Amber Blue Blue Blue Green Green Green Green NEW Blue E9 E10 HS1 HS2 A11 A12 T11A T11B T12 HS1 Green Amber Green Red NEW NEW Red Green Green Blue BSC1 BSC2A BSC2B BSC2C BSC3A BSC3B BSC4A BSC4B BSC4C BSC5 BSC6 BSC7 Balanced Green Green Green Amber Green Green NEW Green Amber Amber NEW Green Scorecard HI1 HI2 HI3 HI4A HI4B EF1 EF2 A1 A2 A3 A4 A5 Others Green NEW Green Green Green Green Green Green Green Green Green Green HI5 HI6 HI7 HI8 HI9 A6 A7 Green Amber NEW Green NEW Green Green Version 0.2 Draft
  • 18. 1. Rapid Impact Checklist Which groups of the population do you think will be affected by this proposal? Other groups: • minority ethnic people (incl. gypsy/travellers, refugees & asylum seekers) • women and men • people in religious/faith groups • disabled people • older people, children and young people • lesbian, gay, bisexual and transgender people • people of low income • people with mental health problems • homeless people • people involved in criminal justice system • staff 1. Job Applicants 2. Contract Workers 3. Volunteers N.B. The word proposal is used below as shorthand for any policy, procedure, strategy or What positive and negative impacts do you think there may be? proposal that might be assessed. Which groups will be affected by these impacts? What impact will the proposal have on lifestyles? For example, will the changes affect: The positive impacts will be that NHS Shetland strives to achieve excellence in all service areas, ensuring that all HEAT targets are met, and all waiting times standards are achieved. The strategy is a driver for residents to receive the best possible services from the organisation. • Diet and nutrition? This will affect all residents who come into contact with health services. • Exercise and physical activity? • Substance use: tobacco, alcohol or drugs? • Risk taking behaviour? • Education and learning, or skills? Will the proposal have any impact on the social environment? Things that might be The focus is across all services, including those that deal with people in crises. By achieving waiting times standards those whose lifestyle and income may be affected, the shortest possible waits will reduce those periods of incapacity. affected include • Social status • Employment (paid or unpaid) • Social/family support • Stress • Income Will the proposal have any impact on • Discrimination? • Equality of opportunity? • The strategy will ensure that everyone benefits from the focus on getting it right each and every time. Relations between groups? Will the proposal have an impact on the physical environment? For example, will there be There will be a positive impact for patients and staff in ensuring that there is a focus on excellence and impacts on:• Living conditions? • Working conditions? • Pollution or climate change? • delivery. Accidental injuries or public safety? • Transmission of infectious disease? Will the proposal affect access to and experience of services? For example, The strategy aims to improve the experience of healthcare. • Health care • Transport • Social services • Housing services • Education
  • 19. Rapid Impact Checklist: Summary Sheet Positive Impacts (Note the groups affected) Equality Negative Impacts (Note the groups affected) No issues are placed at the forefront of planning and evidence of any potential negative impacts on any decision-making processes within the Board. The group. strategy aims to drive improvements across all services, speeding up access for all and raising the quality of the healthcare experience. Additional Information and Evidence Required From the outcome of the RIC, have negative impacts been identified for race or other equality groups? Has a full EQIA process been recommended? If not, why not? Simon Bokor Ingram, Director of Clinical Services  Manager’s Signature: January 2010  Date: