This document discusses compliance and the Carter metrics system for measuring hospital effectiveness and efficiency. It introduces the Carter domains that cluster measures into areas like costs, quality, safety, and governance. Risk assessments evaluate buildings, infrastructure, and operational processes. Compliance ensures conforming to rules, specifications, policies, standards, and law. Competence involves skills, knowledge, and experience that are developed and maintained over time. Compliance systems use engineering, enforcement, and education approaches like traffic safety. The compliance improvement loop involves accountability, processes, outcomes monitoring, and reviews. A compliance application software called CAAS is described that allows monitoring progress, rating compliance, and managing actions to meet targets. Compliance culture types range from generative to pathological

1. Cliff Price
Managing Director
CPA Solutions Ltd
Tel: 01928 734177
www.cpasolutions.co.uk
“Carter and compliance”

2. Carter Metrics
• Sets Targets for Effectiveness and Efficiency
Measures
• Compares against Model Hospital (median)
• EFM measures are clustered into 5 Domains
• Costs : Quality - Volume - location
• Effectiveness : Space type %- Cost - Fit for
Purpose
• Safety : risks - Incidents
• Quality : Patient Environs - Infrastructure
• Governance : Capital spend

3. Risk based System :-
Assessment – Buildings ,Plant,
Infrastructure
Operational processes – how the risk is
managed

4. COMPLIANCE ?
Conforming
Rule
Specification
Policy
Standard
Law
Ref: Wikipedia

5. Skills
Competency
Knowledge
ExperienceWorkplace
Competency Loop

6. Competence stages for the individual
Individual presented with a
new task
Not yet competent but
aware of limitations
Competent, through training,
development and experience
Key:
Natural deterioration
Effective competence management Ref: HSE
Unaware of limitations arising
from a changing environment
or from the development of
bad habits
Not yet competent and
unaware of limitations
Performs competently as a
matter of practice and habit

7. COMPLIANCE SYSTEMS
Traffic safety example
 Engineering
• Primary Safety: Road Surfaces, Street Lights
• Secondary Safety : Seat Belts, ABS, Air Bags
 Enforcement
• Formal : Laws, Highway Code, Speed Cameras
• Informal : Peer Pressure, Other Drivers
 Education
• Awareness / Attitude Change / Persuasion Campaigns

8. Compliance Improvement Loop
ACCOUNTABILITY
PROCESS
[What has to be done]
OUTCOMES
MONITOR
& REVIEW
Audit
Inspection
Capability
Training
Resources
Management Structure
Accountability
Policy and Procedures
Register
Incidents
Performance Logs
Risk Assessment
Control Measures

10. Not much mention of Compliance Pre 1990’s……….....….
Vested In Experienced and
Trained up staff with the right skills [COMPETENT]
Now need to demonstrate……
Controls
Review
Risks
Records
Actions

11. Features of the CAAS Application: 1
Monitor Progress
CAAS helps you to build an
overview of your Organisation’s
areas of strength and weakness
against areas of compliance and
allows you to track progress over
time.

12. Features of the CAAS Application: 2
Rate Compliance
Rate your organisation against statements from the CAAS compliance statement bank.
Responses can be given at both the organisational level, or per physical site

13. Features of the CAAS Application: 3
Manage Actions
The CAAS application allows you to create, allocate, track and manage actionable
Tasks, moving your organisation forward towards its compliance targets

14. Compliance Areas Average Score by Topic

15. Topic
Accountability
Process
Capacity
Outcomes
Monitoring
Average
73.46 74.67 81.85 65.11 76.42Water Hygiene and safety 87.00
Facilities Infection Control 80.00 75.00 66.25 72.66 61.88 71.16
Safe and Accessible Buildings 82.00 71.73 61.02 74.77 60.73 70.05
Piped Medical Gas systems 77.17 72.08 66.92 71.28 60.90 69.67
Electrical systems 64.19 77.16 68.92 76.02 59.36 69.13
Asbestos Management 73.52 73.60 62.47 74.59 58.13 68.46
Contractor Management 72.94 72.17 64.81 66.63 60.33 67.38
Health & Safety Management 73.73 67.11 68.22 63.47 58.31 66.17
Fire safety 70.00 65.17 64.43 66.88 64.17 66.13
Emergency and Contingency Planning 64.56 59.83 67.00 64.00 65.00 64.08
Mechanical Systems 67.70 67.10 62.39 60.50 59.70 63.48
Asset Management and Maintenance 62.50 62.68 55.00 69.25 55.00 60.89
Lifts 52.70 69.41 58.84 67.70 44.52 58.64
Mechanical Ventilation 48.00 56.97 54.35 58.51 50.10 53.59
Sustainability 55.83 51.77 47.46 56.67 50.83 52.51
Waste Management 47.94 58.62 47.14 57.92 50.71 52.47
Decontamination 51.85 46.84 48.63 42.75 44.52 46.92
Security Management 50.63 38.47 38.75 46.67 36.25 42.15
Medical Devices 49.52 41.61 46.00 32.50 35.71 41.07
Average 64.83 63.20 59.12 63.40 54.80
61.07
Compliance Areas Comparision

16. GENERATIVE [High Reliability Orgs]
HSE is how we do business round
here
PATHOLOGICAL
Who cares as long as we’re not
caught
PROACTIVE
Safety leadership and values drive
continuous improvement
CALCULATIVE
We have systems in place to manage all
hazards
REACTIVE
Safety is important, we do a lot every
time we have an accident
The Hearts and Minds Foundation

17. Messages…………………………..
 Pressure to show compliance will not abate
 System tools required to survive
 Influence of organisations culture, better understood
 Structure around competency

18. Sometimes-be careful how you
answer……….

19. !!!!!!!!!!!!!!