Performance Management Framework - DOC by o6UId17


									                                                                           Agenda Item 11
                         Trust Board – 27 May 2011
PRESENTED BY:              Andy Graham, Interim Director of Performance

PREPARED BY:               Andy Graham, Interim Director of Performance
DATE PREPARED:             3rd May 2011
SUBJECT:                   Performance Management Framework
PURPOSE:                   For approval
STRATEGIC                  To continuously improve service quality and effectiveness through
OBJECTIVE:                 innovation, productivity and promoting wellbeing.
The paper sets out the Trust’s agreed priorities and proposes performance management
arrangements to support the delivery of these measures.

The proposals include principles updated from the Trust Operational Group discussion as well as
performance and project management support arrangements

Matters resulting from recommendations                           Present          Considered
made in this report
Financial Implications                                             No                No
Workforce Implications                                             No                No
Impact on Equality and Diversity impact                            No                No
Legislation, Regulations and other external directives             Yes               Yes
Internal policy or procedural issues                               Yes               Yes
Risk Implications for West Suffolk Hospital (including any    Mitigating Actions (Controls):
clinical and financial consequences): The proposed
arrangements mitigate risk of non delivery of performance     Performance management and
measures                                                      project   support    arrangements
                                                              contained in the paper
Level of Assurance that can be given to the Committee from the report based on the
evidence [significant, sufficient, limited, none]: Sufficient

Recommendation to the Committee: To approve the proposed performance management
Performance Management Framework

1.0       Purpose

The purpose of this paper is to set out proposed performance management
arrangements for West Suffolk Hospital.

2.0       Background

The next 5 years in the NHS will present unprecedented challenges, in short, we
must continue to improve the quality of services provided in a climate of
escalating financial constraint.

The contract signed by West Suffolk Hospital for 2011/12 with its main
commissioner NHS Suffolk will be challenging to deliver featuring a high number
of individual service targets with significant financial penalties for failure to deliver.
Some of these targets require immediate delivery.

2011/12 is also the final year in which West Suffolk Hospital will be supported to
progress to Foundation Trusts status. Achieving this will demand consistently
high service performance.

Internal Trust commentators cite poor quality performance information delivered
late, inconsistent attendance at performance reviews and a lack of clarity about
the priorities to deliver. This cannot continue if the above challenges are to be

This paper therefore sets out a performance management that will enable
directorates and the Trust overall to be successful in the delivery of high quality
and efficient services.

3.0       Principles

The following principles have been consulted on and agreed through the Trusts
Operational Group.

         The Trust provides clarity about what needs to be achieved and why
         Clear information is presented to support achievement of performance
          indicators in a timely fashion

The following principles were added as a result of the discussion:

         Patient focus – high quality services, and financial targets must be
          delivered. We will always consider the impact on services and patients
          when making financial decisions
         Earned autonomy – high performing directorates will earn freedoms from
          central control e.g. less frequent reviews

The following principle was amended to include workforce:

         The discussion on clinical quality, workforce, money and targets happens

4.0       Priorities

For 2011/12, the Trust’s priorities are as follows:

4.1       Quality

The Trusts quality priorities are as follows:

4.2       Operational

The Trust’s operational priorities are as follows:

         A&E Clinical Quality Indicators and including ambulance turnaround
         Choose and Book
         Discharge Summaries and out patient letters
         Stroke
         Cancer
         COPD
         Readmissions

In addition, all existing Operating Framework standards must be maintained.

4.3       Financial

For financial management:

All directorates will be required to deliver a negotiated Cost Improvement
Programme. This should be worked up with consideration to the impact on
patients, full clinical engagement and strong financial support.

Directorates will need to deliver balanced income and expenditure plans including
achieving the agreed percentage contribution.

In addition, during 2011/12 the Trust will develop regular productivity metrics that
will support directorates to deliver an improved level of productivity. These may
include for example benchmarked cost per bed day across wards.

4.4       CQUIN

In addition, the following Commissioning for Quality and Innovation (CQUIN)
targets must be delivered:

         Reduce avoidable death, disability and chronic ill health from venous-
          thromboembolism (VTE)
         Reduction in number of patients developing a pressure ulcer following
          admission to hospital
         Reduction in the number of inpatient falls and appropriate referral to an
          appropriate falls prevention service
         Improve responsiveness to personal needs of patients
         Capture monthly patient / carer experience data and evidence service
          improvements in response
         Improve the assessment and monitoring of nutrition in hospital and prior to
         To increase the understanding of hydration needs of patients and risk
          factors for over and under hydration.
         Prompt identification and management of the deteriorating patient in order
          to maintain patient safety and ensure the best clinical outcomes for the
         To deliver effective stop smoking advice to smokers and referral to the
          local NHS Stop Smoking Services
         EAU consultants advice and guidance service to support clinical
          management in the community
         To offer stroke patients active therapy to enable them to meet their
          rehabilitation goals

4.5       Workforce

The Trusts workforce priorities are:

         To reduce sickness absence to a maximum of 3.5%
         To achieve a 90% rate of appraisals
         To achieve mandatory training targets ranging from 80%-85%
         To ensure compliance with CRB requirements
         To manage Bank and Agency spend in accordance with CIP targets
5.0       Governance

The next sections of this paper describe the governance and the framework that
is proposed to support delivery:

5.1       Leadership

Directorate quality and performance reviews will be led by the Director of
Resources and the Interim Director of Performance supported by Executive
Directors including the Trusts Chief Executive participating as required. Clinical
leadership will be central to the model. Non executive Directors are invited to
experience directorate quality and performance reviews and to provide feedback
to inform the future development of the framework.

5.2       Structure

The following structure relates to the practical performance management
arrangements for the Trust. This does not cut across the line management and
accountability arrangements between individual directorates and their
accountable Director as described in the Trusts governance structure.

The performance management arrangements will be delivered as follows:

                                        Director of
                                        Director of

  Medicine          Surgery     Women’s &        Clinical   Estates and    Corporate
                                Children’s       Support     Facilities    Services

Each directorate will be supported by a Performance Manager and information

         Quality Report at department/ward and directorate level. Work is being
          undertaken to produce information at individual consultant level e.g. on
          VTE and this will continue to be progressed
         Performance Report
         Finance Report

The standard approach will be that meetings will take place monthly with more or
less frequent meetings according to delivery of agreed directorate level metrics.
This is congruent with the principle of earned autonomy.

5.3       Project Management Approach

It is recognised that delivering new priorities is both complex and challenging. It is
critical that both new and existing project leads are properly supported to deliver
new targets or those that have not been achieved through previous measures. To
do this, a Project Management Office (PMO) will be set up. The PMO will be led
by the Interim Director of Performance and will be serviced by staff specialising in
change management, administration and project management. Staff will be
seconded into the PMO office on a full or part time basis to support this.

The PMO will provide support to projects and report to TEG on progress.
Priorities are as follows:

         A&E CQIs and Ambulance turnaround
         Stroke Targets
         Choose and Book
         Discharge summaries
         Readmissions
         Hospital Discharge

Project support may be considered for other priorities as requested by
programme delivery leads e.g. to achieve specific CQUIN goals.

Consideration in due course should be given to integrating the PMO function with
the existing transformation programmes. The need for the PMO should also be
reconsidered when identified priorities are being confidently delivered.

The PMO is accountable to TEG and regular updates on the progress of each
project are proposed.


The PMO will be resourced from the existing Trust workforce.

5.4       Expectations of Directorates

To successfully deliver these priorities, directorates will need to develop ways of
working that achieve excellent clinical engagement as well as being able to
successfully communicate expectations to all levels of staff and to support them
to deliver. It is the province of directorates individually to consider how they will
achieve this however, proposals from each directorate will be requested.

General Managers and Clinical Directors or in very rare occasions their
representatives are required to attend directorate quality and performance review

The conclusions of directorate quality and performance reviews may inform job
planning and revalidation.

5.5    Role of Matrons

The role of the matron is unchanged as one that provides assurance of high
quality standards of care and one that is accountable for that assurance e.g. to
escalate areas of poor performance where they are not being resolved locally.

5.6    Supporting Information

Information provision will be reviewed to deliver these priorities. A daily report for
critical indicators will be implemented by Mid May and weekly and monthly
reporting of all critical indicators as well as a new style of Board report will be
developed for the May Board meeting.

6.0    Recommendation

The Board is recommended to approve the proposed Performance Management


To top