1.1 Action should be taken to provide support, guidance and clear strategic intent to staff regarding the Trust’s aspirations for all components of clinical governance so that the principles of clinical governance become embedded across the organisation (pg 4).

Clinical Governance is embedded in the culture of the organisation.

Complexity and lack of understanding /

Quality of care compromised.

Develop and implement an integrated governance training programme that meets the specific needs of each directorate.

Evaluate attendance and the effectiveness of the programme.

Quality of patient care is continuously improved.

Records of attendance.

Review of attendance and feedback questionnaires

Governance Manager (R. Jones)

Governance Manager (R. Jones)

Sept 2003

Mar 2004

1.2 Action should be taken to improve communication channels between the operational management and corporate levels of the organisation (pg 4).

Clear and effective mechanisms exist to disseminate and assimilate information.

Skills of line managers.

Time element.

Staffing levels.

Develop policy for team briefing.

Implement robust team briefing throughout the Trust.

Agreed communication methodology.

Timely and effective communication within the Trust.

Approved policy

Documentation for team briefings.

Staff survey

Director of Personnel & Corporate Resources (J. Bloomfield)

Director of Personnel & Corporate Resources (J. Bloomfield)

Jun 2003

Dec 2003

1.3 The Trust should take action to ensure that staff and members of the health community are consulted on the development and delivery of services at all levels (pg 4).

Staff: Staff consulted on decisions that directly impact upon them.

Members of the health care community: A clear policy to engage with service users and partners.

Impact if not taken will be that staff feel unvalued.

Changes to CHC arrangements.

Establish communications manager post.

Develop a communications strategy.

Review external consultation arrangement.

Establish and review a policy to ensure appropriate future communication.

Establish resource for communication management.

Staff participation in planning and developments.

Understand the current process and improvements required.

Regular and appropriate communication with all parties regarding service developments.

Person in post

Approved strategy

Policy and feedback from partners and users.

Consistent involvement in capital planning

Director of Personnel & Corporate Resources (J. Bloomfield)

Communications Manager (D. Matthews)

Director of Strategy (J. Watts)

Director of Strategy (J. Watts)

Jan 2003

Oct 2003

Apr 2003

Jun 2003

1.4 The Trust should continue to collaborate and work towards improving relationships with health community partners. Further work should be done to establish improved communication links with partners outside the immediate locality to help in reducing delayed discharges (pg 4).

To reduce delayed discharge through improved collaboration and communication.

Organisational boundaries.

If no action levels of delayed discharge will be maintained or increase.

Improved discharge documentation.

Establish integrated care unit.

Agree a programme of care pathways development.

Provision of alternative accommodation.

Establish cross border communications by working with Local Capacity Planning Group, Emergency Care Commissioning Group (PCT led) & StHA Local Modernisation Access and Capacity Planning Group.

Improved communication.

Achieve targets. Improved pt outcome.

Refinement of pathway/dev. or new ones.

Increase in bed complement/stock.

Appropriate and timely discharge.

Audit of documentation.

Activity of new unit. User/feedback.

Directorate work programmes.

Number and beds available, type and usage (occupancy).

Performance management of Local Delivery Plan. Delayed transfers of care action plan. Evaluation of the newly established integrated care unit.

Discharge Planning Group (N. Day)

Director of Nursing (N. Day)

Clinical Directors (N. Adams, R. Bannon, M. Judd & A. Nicolson)

Director of Modernisation, SWPCT (M. Crawley)

Director of Strategy (J. Watts)

Aug 2003

Sept 2003

Sept 2003

Apr 2004

Dec 2003

1.5 The Trust should continue to work with the rest of the health community and implement proposed plans to relocate and build a new hospital in Sudbury, as an alternative to the Walnuttree Hospital.

In the interim, action should be taken to improve patient safety and privacy at the Walnuttree hospital. (pg 4).

To agree an implementation plan for the long term provision services at Sudbury.

Funding required to meet the timescale for privacy and dignity development.

Satisfactory completion of outstanding Outline Business Case (OBC) issues. Meet shortfalls on affordability. Check the robustness of the specification against modernisation.

Complete interim work on privacy & dignity and review on six monthly basis.

Complete the Health Advisory Service review. 

In conjunction with community partners and the public produce a long-term strategy based on case of need. 

Ensure that services at Walnuttree are safe and respect the privacy and dignity of patients.

Meeting affordability & modernisation within the OBC allows the scheme to proceed to the PFI procurement stage.

Work will allow continued use of the building safely and effectively until 2006.

Project Steering Group and Trust Management Team.

Report to Project Steering Group.

Project Steering Group and Trust Management Team.

Director of Facilities (S. Moore)

Director of Finance (K. Mansfield)

Chief Executive (J. Parkes)

Sept 2003

Aug 2003

Sept 2004

2.1 The Trust should continue to try to establish why fewer patients admitted with a hip fracture are receiving an operation within 24 hours of being transferred to an orthopaedic ward (pg 5).

Patients receive the appropriate treatment in a timely manner.

Need for cross directorate working

Potentially inappropriate delay in treatment.

Review underlying cause behind trend and develop action plan to reduce inappropriate delay.

Agree clinical guideline for treatment pathway and provide necessary training.

Implement and monitor change.

Clearly understand the causes behind the change in time to operation.

Deliver best possible care for this patient group.

Report to Clinical Governance Committee.

Pink Book Committee.

Audit report to the Directorate Governance Steering Group.

Clinical Director, Surgical Directorate (N. Adams)

Clinical Director, Surgical Directorate (N. Adams)

Clinical Director, Surgical Directorate (N. Adams)

Dec 2002

May 2003

Mar 2004

2.2 The Trust should continue to take action to improve the level of basic nursing care available to patients (pg 5).

To set out clear definition of what “basic nursing care” and ensure it is delivered.

Time and availability of staff and recruitment

Public expectation Communication

Impact of not doing:

Poor care

Increased length of stay

Complaints.

Agree competencies.

Written into staff objectives.

Establish modern matron roles within directorate structures.

Pilot and evaluate housekeeper roles.

Develop competency assessment tool and training programme.

High quality basic care using appropriate staff to undertake appropriate tasks.

Competency policy reported to the Quality Council.

Staff objectives.

Modern matrons in post.

Evaluation report to Shared Governance Group.

Completed assessment tool and attendance at training reported to Quality Council.

Director of Nursing & Community Relations (N. Day)

Director of Personnel & Corporate Resources (J. Bloomfield)

Director of Nursing & Community Relations (N. Day)

Director of Nursing & Community Relations (N. Day)

Director of Nursing & Community Relations (N. Day)

Aug 2003

Sep 2003

Sep 2003

Sept 2003

Dec 2003

2.3 The Trust should review the availability of out of hours x-ray services, with specific reference to patients admitted to A&E (pg 5).

Appropriate provision of x-ray service to A&E department.

Funding for development.

Implement an interim service provision for out-of-hour x-ray.

Monitor interim service on a regular basis.

Develop case of need for x-ray within A&E.

Provision of appropriate x-ray service to A&E department.

Develop long-term solution to the provision of service.

Activity data.

Directorate Clinical Gov. Steering Group.

Trust Management Team.

Head of Radiology (N. Beeton).

Head of Radiology (N. Beeton).

Assistant Director Modernisation (J. Canning)

Apr 2003

Sept 2003

Sept 2003

2.4 The Trust should review arrangements for patients entering A&E by ambulance (pg 5).

Provide emergency services that meet clinical needs whilst protecting patients’ privacy and dignity.

Space and cost constraints.

Review the current arrangements taking into account the views of staff and patients and act on findings.

Case of need for separate entrance produced.

Report to Trust Management Team.

Director of Facilities (S. Moore)

Sept 2003

2.5 Whilst colposcopy patients are treated as individuals with dignity and respect within the genito urinary (GU) department, the Trust should keep this arrangement under review (pg 6).

Ensure that colposcopy patients within the GU department are treated with dignity and respect.

None.

Peer review how these patients managed in other organisations and consider any remedial action.

To ensure that colposcopy patients within the GU department are treated with dignity and respect.

Directorate Clinical Governance Steering Group.

Clinical Director, Medicine (A. Nicolson)

Sep 2003

2.6 The Trust should review the availability of storage facilities across the organisation and make the necessary improvements  (pg 6).

Equipment and other supplies should be available in a timely manner.

Funding capital and revenue requirement

Undertake site review including “just-in-time” supply to clinical areas.

Establish and monitor a comprehensive central store with a communication strategy for staff.

Accessible equipment and supplies with minimal storage in clinical areas.

Report to Trust Management Team.

Central store Operational.

Director of Facilities (S. Moore)

Director of Facilities (S. Moore)

Oct 2003

Jan 2004

2.7 The Trust is in the process of restructuring the occupational therapy service and should continue to consult with staff to improve provision of these facilities (pg 7).

Provision of appropriate facility for occupational therapy.

Scale of building programme currently in progress on premises. Recruitment to the head of OT vacancy.

In consultation with staff establish appropriate new accommodation for staff.

Appoint head of OT.

Service provided by appropriately led team within suitable accommodation.

Team briefing.

Person in post.

Assistant Director Modernisation (J. Canning)

Assistant Director Modernisation (J. Canning)

Mar 2003

Apr 2003

2.8 A review of discharge planning should be undertaken across the organisation, including the organisation of care surrounding medical outlier patients (pg 7).

Ensure the timely and safe discharge of patients to the appropriate place.

Adequacy of communication between all agencies. Shift in roles and responsibilities in patient management.

Appoint project co-ordinator.

Review discharge policy and launch with training and education.

Evaluate attendance at the training and the impact of programme.

Establish resource for discharge management.

A clear mechanism exists to support the patient discharge in a safe and timely manner.

Person in post.

New policy.

Delivery of training.

Report to Trust Management Team / Clinical Governance Committee.

Director of Nursing & Community Relations (N. Day)

Director of Nursing & Community Relations (N. Day)

Director of Nursing & Community Relations (N. Day)

Jan 2003

Dec 2003

Dec 2004

3.1 The Trust should fully implement the strategy for patient and public involvement across all levels of the organisation (pg 9).

Patient and public involvement is embedded within the organisation’s culture (overlaps with 3.2).

Organisational understanding of the role that patients and the public can play.

Engaging with patients and the public.

Review membership of Patient & Public Partnership and Participation (PPPP) steering group.

Review links between PPPP and directorate governance steering groups.

Develop patient/carers involvement in committee activity.

Communicate strategy within Trust and with partners/users.

The PPPP steering group is constituted to meet its purpose.

Clear lines of communication exist on issues of patient and public involvement.

Trust organisational structure provide a voice for patients and the public.

Clear understanding of the role that patients and carers can play.

Revised terms of reference.

Agenda and terms of reference of directorate governance steering groups.

Representation within committees.

Access to policy and annual staff survey.

Director of Nursing & Community Relations (N. Day)

Director of Nursing & Community Relations (N. Day)

Director of Nursing & Community Relations (N. Day)

Director of Nursing & Community Relations (N. Day)

Apr 2003

Sept 2003

Apr 2004

Apr 2004

3.2 The Trust should provide guidance to directorates and clinical teams on the development of a systematic approach to involving patients and the public in service delivery and development (pg 9).

Clear understanding amongst all staff of how to engage users in reviewing/developing services and the benefits that can be achieved  (overlaps with 3.1).

Organisational understanding of the role that patients and the public can play.

Engaging with patients and the public.

Develop and communicate patient and public involvement “tool kit”.

Develop and implement patient and public involvement educational programme.

Evaluate programme

Patients and the public are actively engaged in service development.

Tool kit and evidence of dissemination.

Agreed content and timetable of training programme.

Attendance and annual staff survey.

Director of Nursing & Community Relations (N. Day)

Director of Nursing & Community Relations (N. Day)

Director of Nursing & Community Relations (N. Day)

Sep 2003

Oct 2003

Mar 2004

3.3 The Trust should take action to secure the long-term future of the PALS service (pg 9).

To ensure patients have access to an effective advice and liaison service.

Financial.

Competing priorities at SAFF level.

Working with the Primary Care Trust, LHPT, Social Services, private hospitals and CHC develop a business plan to secure long-term funding for the service.

Secure service to improve patient experience.

Trust Management Team

Director of Nursing & Community Relations (N. Day)

Sept 2003

3.4 Urgent action should be taken to implement the new consent policy and to provide the necessary training and support for staff across the Trust (pg 9).

Timely and consistent provision of consent based on appropriate patient information.

Need for comprehensive patient information

Misunderstanding of the requirements to take consent.

Agree and implement the consent policy.

Develop a training/communication programme.

Audit implementation of the policy considering practice, staff comprehension, patient perception and quality of patient information.

Robust procedures for taking consent in place across the Trust to promote informed patient choice and to optimise recovery.

Ratified by Clinical Governance Committee.

Report to Education Co-ordinating Group - structured programme and attendance log.

Audit report to Clinical Governance Committee (including CNST assessment).

Medical Director (K. Matheson)

Medical Director (K. Matheson)

Governance Manager (R. Jones)

Oct 2002

Oct 2003

Apr 2004

4.1 It is important that the Trust continues to work towards developing a comprehensive Trust wide risk register and universal risk assessment system (pg 11).

A clear process exists to identify, assess and manage risk.

Lack of clear guidance nationally.

Establish a central risk register to collate information on identified risks.

Agree a process for structured universal risk assessment.

Develop training and education programmes for universal risk assessment.

Implement and evaluate the universal risk assessment process.

A programme of risk assessment is embedded within the Trust that drives the business planning process through the risk register.

Reporting to Organisation Risk Committee.

Universal risk assessment policy.

Programmes and attendance.

Number of risk assessments undertaken.

Risk register informs business planning process (Trust Management Team / Board minutes).

Governance Manager (R. Jones)

Governance Manager (R. Jones)

Governance Manager (R. Jones)

Governance Manager (R. Jones)

Feb 2003

Sept 2003

Dec 2003

May 2004

4.2 Urgent action should be taken to implement the planned changes to incident reporting and coding and to provide all staff with the necessary training (pg 11).

Reporting system that comprehensively identifies and codes incidents and near missing within the Trust.

General understanding of the new system.

Change management.

Fully implement new system for incident reporting and coding.

Implement and evaluate structured education programme.

Provision of timely and accurate information to allow risks to be managed.

Review of incident reporting data.

Attendance and audit of the quality of incident data (e.g. number of re-grading).

Risk Manager (V. Dutton)

Governance Manager (R. Jones)

Oct 2002

Dec 2003

4.3 The Trust should provide all staff with regular feedback on incidents reported. The Trust should consider ways of improving dissemination of the lessons learnt from the analysis of incident reports (pg 11).

For staff to

believe that incident reporting is meaningful and that it drives prioritisation and change.

Confidentiality – learning not blame.

Effectiveness of communication systems.

Track current cascade processes across the organisation.

Clarify Directorate roles and responsibilities for dissemination of incident data.

Implement and evaluate dissemination process.

Information about incidents is cascaded within the Trust in a timely manner promoting organisational learning.

Report to Board.

Report to Organisational Risk Committee.

Reporting of information provision. Staff survey.

Director of Personnel & Corporate Resources (J. Bloomfield)

Governance Manager (R. Jones)

Governance Manager (R. Jones)

April 2003

June 2003

Feb 2004

4.4 Urgent action should be taken to implement the Trust policy on managing serious untoward incidents (SUIs) and to provide managers with the relevant training (pg 11).

All SUIs are reported in a timely and appropriate manner.

Ambiguity of SUI as opposed to other serious incidents

Review the policy and definition used for SUIs.

Communicate the revised policy and provide the appropriate training.

Audit of SUI reporting.

Comprehensive understanding of the SUI reporting policy within Trust.

Report to Clinical Governance Committee and Trust Management Team.

Dissemination of policy. Attendance of training.

Report to Clinical Governance Committee.

Risk Manager (V. Dutton)

Governance Manager (R. Jones)

Governance Manager (R. Jones)

Sept 2002

July 2003

July 2004

5.1 The Trust should monitor the level of increased support provided by the governance team to directorates for carrying out clinical audit (pg 13).

Demonstrate increased support to all directorates in undertaking audit.

Lack of clarity and resource requirements within the directorates.

Additional resource not best utilised and prioritised across the trust.

Agree directorate work programmes.

Implement the agreed programmes with access to support from Governance Support team.

Shared understanding of roles and responsibilities. Delivery of work programme with appropriate access to support from Governance Support.

Submission to Clinical Governance Committee.

Progress reports to the Clinical Governance Committee.

Clinical Directors (N. Adams, R. Bannon, M. Judd & A. Nicolson)

Clinical Directors (N. Adams, R. Bannon, M. Judd & A. Nicolson)

April 2003

Oct 2003

(6 monthly follow-up)

5.2 The Trust should encourage and guide directorates on the development of a systematic approach to planning audit programmes. Directorates should be encouraged to prioritise audit programmes from their own specialty-based data including analysis of incidents, complaints and other clinical governance activities (pg 13).

Audit programmes at a directorate level are directed to address local and national priorities.

Need for systematic access to relevant data to support prioritisation.

Provide relevant information to support prioritisation with directorates. This will include monthly reports on incidents and complaints and feedback from the Clinical Governance Committee.

Ensure directorates have mechanisms in place to use this information and a shared understanding of how to do this.

Ensuring audit programmes are geared to Trust priorities. Reduction of risks to patients.

Minutes of the directorate meetings.

Terms of reference of Directorate Clinical Governance Steering Groups. Directorate governance programmes.

Governance Manager (R. Jones)

Clinical Directors (N. Adams, R. Bannon, M. Judd & A. Nicolson)

Feb 2003

April 2003

5.3 The Trust should develop a systematic approach to sharing audit results across the organisation (pg 13).

A systematic dissemination of audit results.

Lack of timely and accurate record of audit activity / Not sharing lessons learnt.

Mechanism in place to facilitate audits to be reported to and monitored by Governance Support.

Identify mechanisms to disseminate information (e.g. Intranet).

Shared learning and avoidance of inappropriate duplication.

Directorate reports to Clinical Governance Committee.

Dissemination, minutes and access to Intranet.

Clinical Directors (N. Adams, R. Bannon, M. Judd & A. Nicolson)

Governance Manager (R. Jones)

Jul 2003

Sept 2003

5.4 Action should be taken to promote the involvement of health community partners and patients in the design and implementation of clinical audit programmes (pg 13).

Involvement of health community partners and patients in the design and implement of audit programmes.

Suitable patient and PCT representation. Implementation of patient involvement at early stages.

Cultural acceptance of role of patients in the audit process.

Identify effective ways of engaging partners and users in audit.

Develop user involvement in audit

Develop collaboration and links with Suffolk West PCT.

Agree a shared programme of work with Suffolk West PCT.

More collaborative working with patient and primary care partners.

Minutes of steering groups and review of attendees.

Audit report and programmes.

Representation across Trust and PCT.

Collaborative audits.

Assistant Nurse Director (J. Holmes)

Clinical Directors (N. Adams, R. Bannon, M. Judd & A. Nicolson)

Governance Manager (R. Jones)

Governance Manager (R. Jones)

July 2003

Jan 2004

July 2003

Apr 2004

6.1 Urgent action should be taken to review the numbers and skill mix of nursing staff in the A&E department out of hours and ensure appropriate action is taken (pg 4 & pg 15).

Provision of a safe and effective service within the department to meet the needs users.

Restricted labour market.

Funding needed as part of business planning process.

Review and address staffing levels within A&E department.

Release nursing staff to undertake Emergency Nurse Practitioner training.

Strengthen & modernise senior clinical management involved in emergency care.

Review skill mix and numbers on a regular basis.

Future developments to include new ways of working, internally and with external stakeholders.

Staff level reports

Workforce Planning process.

Staff starting training.

Report on management structure within department.

Report to Directorate Clinical Governance Steering Group.

Assistant Director of Modernisation (R. Bennett)

Assistant Director of Modernisation (R. Bennett)

Assistant Director of Modernisation (R. Bennett)

Assistant Director of Modernisation (R. Bennett)

Sep 2002

Feb 2003

Apr 2003

Nov 2003

6.2 A review of nurse staffing levels and skill mix alongside patient dependency and workload needs to be undertaken. This should be carried out in all areas with the Trust acting on the findings (pg 4 & pg 15).

Staffing levels within the Trust support delivery of a sustainable and safe service.

Labour force restrictions

Capacity to absorb / assimilation nurses.

Impact of doing nothing equals reduction in quality of care, increased turnover, sickness/absence, reduction in capacity.

Loss of staff.

Implement the recommendations of the internal nurse staffing review and address agency spend through active returner  & overseas recruitment programmes.

Implement external review of nursing, AHP and medical staffing (see 6.3 below).

Assess the impact of these reviews from the staffs perspective

Establish absence management support team to increase absence management interviews and develop senior staff skills

Right staff with right skills in right place at the right time.

Reduce nursing sickness absence levels.

Nursing Directorate monitoring reports.

Report to Board.

Annual staff survey.

Occupational health central absence reporting to Board. Delivery & evaluation of absence management training.

Director of Nursing & Community Relations (N. Day)

Chief Executive (J. Parkes)

Director of Personnel & Corporate Resources (J. Bloomfield)

Deputy Director of Personnel (L. Houghton)

Jun 2003

Dec 2003

Mar 2004

Mar 2004

6.3 The Trust should continue to take action to review medical staffing establishments and workload needs across the organisation (pg 4 & pg 15).

Optimal medical staffing levels to deliver safe and high quality service.

Scarce labour market

Consultant Contract.

SHO modernisation.

Training requirements.

Increased flexible training/working.

Implement an external review (linked with nursing and AHP) that involves medical staff and partners (see 6.2 above).

Consider the findings of the external review, to include new ways of working.

Provision of a locum free service in compliance with working time directive.

Report to Board. Achieving new deal compliance.

Working time exercise.

Workforce planning processes.

Achieving junior doctor working regulation targets.

Chief Executive (J. Parkes)

Medical Director (K. Matheson)

Jun 2003

Sep 2004

6.4 Action should be taken to clarify and disseminate the appropriate procedure for staff to report concerns about low staffing levels (pg 15).

Appropriate staffing levels are achieved and maintained across the organisation.

Recruitment to posts

Funding.

Effectively disseminate procedure for reporting staffing shortages to all clinical areas.

Mechanism to identify staffing shortages in a timely and targeted manner. Perception from staff that issue is being addressed

Reporting from ward areas using appropriate reporting route. Reduction in ward closures.

Staff survey.

Director of Nursing & Community Relations (N. Day)

May 2003

6.5 The Trust should continue to implement appraisals for all staff - links with 3.4  (pg 15).

Every member of staff is appraised.

Sufficient skills to undertake appraisal.

Changing culture.

Making the appraisal process meaningful.

Agree an approach to appraisal implementation.

Undertake a Trust-wide communication exercise around the system of appraisal.

Implement agreed system across the Trust.

Appraisals will provide support, direction and development of staff through feedback and PDP process.

Report to Human Resources planning Group

Evidence of communication

.

Appraisal uptake monitored and evaluated centrally by the Personnel Dept and through staff survey.

Workforce Development Manager (D. Needle)

Workforce Development Manager (D. Needle)

Workforce Development Manager (D. Needle)

May 2003

Sept 2003

Sept 2004

7.1 Action should be taken to implement a systematic approach to the development of directorate education plans (pg 17).

Comprehensive education programmes exist within all areas of the Trust that will meet individual, professional and organisation needs.

Balance between education and delivery of operational service.

Establish senior lead for education (proposed Associate Director of Learning and Training).

With directorates and professional groups review the Trust’s education strategy.

Implement and review the education strategy.

Establish and evaluate a Leadership Development Programme for clinical directors and senior managers.

Comprehensively implement PDPs.

Education and training programmes take into account research, audit and risk management activities.

Improving safety and quality of care for patients. Trust seen as a learning organisation.

Board monitoring

Updated strategy reported to Board

Education Co-ordinating Group. Updated strategy

Attendance and evaluation.

Number of staff with a PDP (centrally monitored by Personnel Dept and through staff survey).

Education programme development.

Chief Executive (J. Parkes)

Medical Director (K. Matheson)

Medical Director (K. Matheson)

Director of Education (K. Matheson)

Director of Personnel & Corporate Resources (J. Bloomfield)

Governance Manager (R. Jones) and Research & Development Manager (F Elender)

Oct 2003

Oct 2003

Mar 2005

Jan 2004

Sept 2004

Sept 2004

7.2 Action should be taken to improve access to multidisciplinary training programmes (pg 17).

To facilitate team working and new ways of working to deliver effective services.

Balance between education and delivery of operational service.

Changing culture.

Identify current multi-disciplinary programmes, both formal and "on-the-job".

Identify uni-disciplinary programmes that would benefit from being delivered through a multidisciplinary approach.

Develop a strategy for multi-professional training programmes

Facilitate uptake of newly configured programmes.

Maximising opportunity for shared learning by breaking  down inappropriate professional boundaries and encouraging team working.

Report to Education Co-ordinating Group.

Report to Education Co-ordinating Group.

Approved strategy

Delivery and Attendance.

Director of Education (K. Matheson)

Director of Education (K. Matheson)

Director of Education (K. Matheson)

Director of Education (K. Matheson)

Dec 2003

Dec 2003

Jul 2004

Mar 2005

7.3 The Trust should ensure that staff appraisals are consistently used to identify training needs through the development of personal development plans (pg 17).

Appraisal leads to the development of PDPs that contribute to the planning of training programmes that meet individual and organisation needs.

Sufficient skills to undertake appraisal.

Changing culture.

Making the appraisal process meaningful.

Agree an approach to PDP implementation.

Undertake a communication exercise around the system of PDPs and also their importance –include road shows and written information – a formal launch.

Implement agreed system across the Trust.

Needs identified through appraisal are meet through planned programmes of training and development.

Report to Human Resources Planning Group

Evidence of communication.

Comprehensive PDP uptake monitored and evaluated centrally and through staff survey.

Workforce Development Manager (D. Needle)

Workforce Development Manager (D. Needle)

Workforce Development Manager (D. Needle)

May 2003

Sept 2003

Sept 2004

8.1 The Trust should promote the development and implementation of evidence based practice at operational levels of the organisation (pg 19).

Provide an infrastructure to support the delivery of EBP.

Understanding

Acceptance

Accessibility of resources

Continue to develop a systematic approach to disseminating of key recommendation (e.g. NICE and confidential enquiries).

Respond to these key recommendations.

Directorate governance programmes prioritise the development of clinical guidelines based on need/risk.

Implement an educational and training programme to develop understanding and support implementation of EBP.

The use of robust evidence in day-to-day practice e.g. through integrated care pathways.

Log of documents disseminated.

Directorate reports to Clinical Governance Committee.

Reports to the Clinical Governance Committee

Records of attendance and evaluation of impact on clinical practice.

Governance Manager (R. Jones)

Clinical Directors (N. Adams, R. Bannon, M. Judd & A. Nicolson)

Clinical Directors (N. Adams, R. Bannon, M. Judd & A. Nicolson)

Head of Learning Resources Education Centre (J. Hunter) and Research & Development Manager (F. Elender)

July 2003

Sept 2003

Nov 2003

Feb 2004

8.2 Action should be taken to monitor the implementation of guidelines and protocols for medical outlier patients (pg 19).

The clinical care of medical patients on surgical wards is not compromised.

Dissemination of guidelines and staffing levels. Patients may not be managed according to agreed pathways of care.

Monitor adherence to the guidelines for the management of medical outliers and develop appropriate training for staff.

Patients are managed according to agreed pathways of care.

Report to the Clinical Governance Committee.

Clinical Governance Lead, Medicine (C. Laroche)

Jun 2003

8.3 The Trust should continue to work with health community partners to improve co-ordination, development and implementation of the requirements of the NSF for older people (pg 19).

The Trust provides a full contribution to the partnership arrangements for addressing the NSF.

Unlikely to make any useful changes unless all parties involved.

Complexity of the service arrangements.

In consultation with partners review the Trust's arrangements for contributing to the NSF and potential areas for improved co-ordination.

Implement the agreed arrangements from the review.

Achievement of NSF objectives

improved patient care

Improved involvement by key players and patients.

Through local delivery plan.

Through local delivery plan.

Clinical Lead for Older Peoples NSF (A. Nicolson)

Clinical Lead for Older Peoples NSF (A. Nicolson)

Sept 2003

Dec 2003

9.1 The Trust should continue to work in partnership with the rest of the health community to develop electronic links with GPs and implement the EPR (pg 20).

To streamline exchange of patient clinical information between 1^o and 2^o care. To support access to clinical information across the patient pathway when and where needed.

National definitions of the main clinical messages are not available (except for pathology). Funding for IM&T targets may be diverted to patient care.  Major EPR development is now subsumed into the national strategic programme for ICT, implemented at StHA level and requiring private sector participation.  Replacement Radiology system required to meet GP radiology report target.

Establish a forum that engages with all partners.

In collaboration with community partners develop a joint IM&T Strategy for the health community, which is actively reviewed against national delivery targets.

Increase information flows to all GP practices served by the Trust.

Joint IM&T Strategy Group.

Joint Strategy for electronic referrals and e-Booking.  Support of Norfolk, Suffolk & Cambridge and national targets.

Pathology and X-ray results are available electronically.

Terms of reference and minutes.

Approved strategy.

Joint IM&T Strategy Group.

Assistant Director IT (D. Milan)

Assistant Director IT (D. Milan)

Assistant Director IT (D. Milan)

June 2003

Sept 2003

Mar 2004

9.2 Action should be taken to ensure that all clinical team members have access to relevant activity based information (pg 20).

Appropriate dissemination of relevant, accessible and timely information regarding service activity.

Limitations of the Trust's information systems and personnel to access and present data.

Identify information needs at all levels of the Trust utilising internal and external information reviews.

Develop a validation process to ensure consistency and quality of data.

Conduct training needs analysis for key staff to deliver findings.

Establish information analysis working group to collate, validate and disseminate information.

Informed decision-making process to maximise patient access and outcome.

Audit and user survey.

Data quality reporting at Trust Management Team.

Reports to IM&T group and Education Co-ordinating Group.

Reports to Trust Management Team /Board and clinical teams.

Assistant Director IT (D. Milan)

Assistant Director IT (D. Milan)

Assistant Director IT (D. Milan)

Head of Planning & Performance  (M. Balaam)

Aug  2003

Oct 2003

Sept 2004

Dec 2003