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					                                                                                                            6fda9ffa-071c-4e66-93fc-03ed30f7ee94.xls                                                                                                                    Agenda no. 11

         5 Boroughs Partnership NHS Trust

         Updated: 1/13/2009

         Programme area: Service Improvement and Redesign                                                              Programme Board / Stakeholder Group                                       Project Group: Sam Oliver / Sharon Eid
         Work stream :Wigan Development Plan                                                  PCT Commissioner         John Marshall                                                             Dr Ramamurthy / Dr Harvey
         Accountable Directors:                                                                Programme Leads         S Oliver / S Eid                                                          C Forrest / Phil Bullock
         Hilary Fenton, Louise Sutton                                                         Primary Care Leads       Al Thompson                                                               Helen McColm / G Spratt
         Programme Leads: Sam Oliver, Sharon Eid                                                Project Managers       C Forrest / Phil Bullock                                                  Donna Griffiths / Jane Walton
         Project Managers:                                                                         Medical Leads       Dr N Harvey                                                               Chris Molyneux /Jim Thomas/ Chris Maj
         Cheryl Forrest / Phil Bullock                                                         Service User Reps       Vince Jackson                                                             Linda Kellie
                                                                                                           HOS's       H McHolm / G Spratt                                                       Liz Price Jones
         Progress                                                                                        CAMHS         Linda Kellie                                                              finance ad hoc
         Issues                                                                                                                                                                                  HR rep trust and LA BE/AMcC + S Gore
         Next Steps                                                                                                                                                                              Performance - EB / SL/ JA
                                                                                                                                                                                                 Staffside rep - Ann Cunliffe / C Coltman
         Phase (number)                                                                                                                                                                          Information Governance- Dave Kelsall
         Key Tasks (number)                                                                                                                                                                      Neil Chillton
         Actions (number)

         PID Method of Approach
                                                                                                                                             Risk
                                                                                                                                             Rating   How do you
         Phase/                                                                                                                              (High    intend to                  Engagement
         Key                                                                                                           What are the          Medium   mitigate these 3rd party Strategy /                       Initiation Completion         Person's)               RAG
         Stage    Key Tasks                   Ref        Actions to complete the key task                              key risks?            Low)     risks?         involvement Comms Plan                     date       date               responsible            status
         Initiation :                                1.1 Compile list of representatives                                                                                                                                         10/21/2008
                  Set up pre meeting group           1.2 Contact attendees                                                                                                                                                       10/17/2008


                                                     1.3 Send PID to all stakeholders for information and comment
                                                     1.4 Set date for pre meeting                                      Some
                                                                                                                       representatives are            Ensure                                                                                Sam Oliver/ Cheryl
                                                     1.5 Book venue                                                                                                                                                               11/1/2008 Forrest/ Janet Heyes
                                                                                                                       unable to attend               representatives are PCT and Local
                                                     1.6 Send agenda to stakeholders                                   pre-meeting         Medium     linked in discussion Authority Leads                                        11/4/2008 Cheryl Forrest

                                                         Establish 5 Boroughs Partnership NHS Trust representation on
                                                                                                                      Some                            Ensure
                                                     1.7 all partnership forums.                                                                                                                                                  On going Helen McColm
                                                                                                                      representatives are             representatives are
                                                         Confirm arrangements for the local GP and 5 Boroughs         unable to attend                linked into
                  Supporting engagement and          1.8 Partnership NHS Trust clinical / management forum                                                                                                                        11/1/2008 Helen McColm
                                                                                                                      pre-meeting                     discussions                                                    1/10/08
                  communication financial
                  baselines and monthly                  Review existing performance data for data requirements of
                  performance report                 2.1 purpose for project                                                                 High                                                                                 12/1/2008 Stakeholder group
                                                                                                                       Quality of data
                                                                                                                       being available                                                                                                      Cheryl Forrest/ Debbie
                                                                                                                       from existing                                                                                                        Hayes/ Suzanne
                                                     2.2 Update performance dataset as appropriate                     clinical systems to                                                                                         on going Kippax
                                                                                                                                                                            Support
                                                                                                                       support dataset and
                                                         Inform Performance to continue monthly reporting of project                                                        development of
                                                                                                                       local authority
                                                         dataset including outcome measures and share with                                                                  existing systems                                                Cheryl Forrest/ Sam
                                                                                                                       performance
                                                     2.3 stakeholders.                                                                                                      and develop                                          10/15/2008 Oliver
                                                                                                                       requirements
                                                                                                                                                                            templates with
                                                                                                                                                                            Performance                                                     Cheryl Forrest/ Helen
                                                         Establish performance links in on-going development of data                                                        Section to capture                                              McColm/ Suzanne
                                                    2.3a set as negotiated with commissioners/stakeholders.                                                                 dataset manually                                       on going Kippax




                                                                                                                                                                                                                     1/10/08



Page 1                                                                                                                                                                                                                                        Wigan Service Improvement Plan
                                                                                                                    6fda9ffa-071c-4e66-93fc-03ed30f7ee94.xls                                                                                           Agenda no. 11


                                                                                                                                                 Risk
                                                                                                                                                 Rating   How do you
         Phase/                                                                                                                                  (High    intend to                  Engagement
         Key                                                                                                                  What are the       Medium   mitigate these 3rd party Strategy /      Initiation Completion       Person's)             RAG
         Stage    Key Tasks                         Ref       Actions to complete the key task                                key risks?         Low)     risks?         involvement Comms Plan    date       date             responsible          status
                                                                                                                                                                                                                             Cheryl Forrest/ work
                                                          2.4 Use information to monitor activity and financial performance                                                                                         on going stream leads
                                                          2.5 Develop trajectories of activity and outcome measures
                                                              Establish monthly performance reporting to illustrate project
                                                          2.6 progress and risk areas                                                                                                                  1/10/08     10/1/2008 Cheryl Forrest

                                                                                                                              Unable to
                                                                                                                              undertake review            Ensure that                                                        Helen McColm/ Cheryl
                  Confirm current service                     Maintain engagement with GP and Service User stakeholders       with all                    representatives are                                                Forrest/ Sam Oliver/
                  provision.                              3.1 about developments in service provision.                        stakeholders.      Medium   linked in discussion                         1/10/08      on going Robin Evans
                                                          4.1 Compile list of representatives                                                                                                                     11/27/2008
                                                          4.2 Contact attendees                                                                                                                                   11/28/2008
                                                          4.3 Set dates for stakeholder meetings.                                                      Ensure that                                                11/28/2008
                                                                                                                              Some stakeholders        attendees are                                                         Sam Oliver/ Cheryl
                                                          4.4 Book venue                                                                                                                                          11/28/2008
                  Establish stakeholder project                                                                               are unable to            linked in with            PCT and Local                               Forrest/ Debbie
                  group                                   4.5 Send agendas to stakeholder                                     attend.           Medium discussion                Authority Leads       1/10/08    11/18/2008 Wilkins

                                                              Review, agree and list development goals with reference to                                                                                                     Cheryl Forrest/ Work
         Consultation:                                    5.1 PID using SMART objectives                                                                                                                          10/31/2008 Stream leads
                                                              Present current baseline activity, financial position and
                                                          5.2 trajectories to Stakeholder and Project Group.                                                                                                       11/1/2008 Sam Oliver

                  Stakeholder project group to
                  review mapping exercise and
                  develop strategy to meet goals.         5.3 Discuss and agree project group's work streams                                                                                                      10/21/2008 Work Stream leads
                                                          5.4 Discuss further monitoring criteria as required.                                                                                                      on going Project group

                                                                                                                                                                                                                             Helen McColm/
                                                              Engage clinical team managers regarding project development                                                                                                    Service Managers/
                                                          5.5 goals and review as appropriate                                                                                                                      12/1/2008 Cheryl Forrest


                                                              Establish regular engagement with GPs and User Groups                                                                                                          Helen McColm/ Cheryl
                                                          5.6 regarding project development goals.                                                     Ensure that                                                 10/1/2008 Forrest/ Robin Evans
                                                                                                                              Some stakeholders        attendees are
                                                              Project team sign off of project development goals and          are unable to            linked in with
                                                          5.7 communicate to all stakeholders                                 attend.           Medium discussion                                      1/10/08     11/4/2008 Project Group




Page 2                                                                                                                                                                                                                         Wigan Service Improvement Plan
                                                                                                                      6fda9ffa-071c-4e66-93fc-03ed30f7ee94.xls                                                                                          Agenda no. 11


                                                                                                                                                Risk
                                                                                                                                                Rating   How do you
         Phase/                                                                                                                                 (High    intend to                  Engagement
         Key                                                                                                                     What are the   Medium   mitigate these 3rd party Strategy /     Initiation Completion       Person's)                RAG
         Stage    Key Tasks                         Ref        Actions to complete the key task                                  key risks?     Low)     risks?         involvement Comms Plan   date       date             responsible             status
         Developmental:
         Work stream 1 - Redesign CMHT Resources to respond to Caseload Audit and Personalisation Agenda - Donna Griffiths/Jane Walton
                  a) Continued recording of
                  previously agreed performance                Establish monthly reporting of data set figures to Project
                  measures                    b)           1.1 Manager by 10 th of every month.                                                                                                       1/5/08    on going     Ward/Team managers
                  Agreement reached on
                                                               Identify current numbers of over 65s open to 'Adult' CMHTs:
                  performance measure of the
                                                               numbers of over 65s, complex/non-complex functional mental
                  minimum number of people
                                                               illness; referred to 'OP' CMHTs over last 12 months and provide
                  over 65 who should be
                                                           1.2 service managers with figures.                                                                                                        1/10/08      11/18/2008 Team managers
                  managed within adult services.
                  c) Development of service                    Agree minimum numbers of over 65s to be accommodated                                                                                                          Jane Walton/ Donna
                  description and operational              1.3 within redesigned 'ageless' CMHTs                                                                                                     1/10/08       12/1/2009 Griffiths
                  policy (acceptable to
                  commissioners) of redesigned                 Commence preparation of draft proposal/operational policy for                                                                                                 Jane Walton/ Donna
                  CMHTs                       d)           1.4 redesign of CMHTs and identify pilot site.                                                                                            1/10/08       11/1/2008 Griffiths
                  Repeat of Case Load Audit to
                                                                                                                                                                                                                             Jane Walton/ Donna
                  measure impact of changes.
                                                           1.5 Commence role out of service redesign in pilot site.                                                                                  1/10/08       12/1/2008 Griffiths
                  e) Fully agreed pathways/
                  protocols between LES                        Repeat Case Load Audit and provide completed audit papers to
                  practices and 5 Boroughs                 1.6 Service Managers.                                                                                                                     30/3/09       3/31/2009 Team Managers
                  agreed, in place and rolled out
                  for both Dementia and
                  Recovery/ Depot LES’s                        Identify cases suitable for transfer of care back to LES for                                                                                                  Donna Griffiths/ Jane
                                                           1.7 'Dementia' and/or 'Recovery & Depot'.                                                                                                 1/10/08        7/1/2009 Walton/ Chris Maj

                                                               Set up meeting with Consultant medical staff, GPSI and 5BP
                                                               service leads to agree local protocols around Service
                                                           1.8 Specification for LES                                                                                                                 1/10/08       12/1/2008 Louise Buffey
                                                               Review activity from pilot site and make necessary adjustments                                                                                                DG/ JW/ CF/Cmaj/
                                                           1.9 to pathways and protocols.                                                                                                           01/12/08        4/1/2009 GPSI
                                                          1.10 Begin borough wide roll out of service.                                                                                              01/04/09        9/1/2009 DG/ JW/ CMaj
                                                               Elicit service user and carer views via quarterly standard                                                                                       Dec 08 and 3 DG/ JW/ SU & Carer
                                                          1.11 satisfaction questionnaires.                                                                                                         01/09/08 monthly on going reps

         Work stream 2 - Develop referral pathways into community mental health service - Donna Griffiths/Jane Walton
                  a) 6 monthly review of
                  pathways with commissioners
                                                               Review and agree arrangements to maintain Gateway and                                                                                                         Donna Griffiths/ Jane
                  and other relevant
                                                           2.1 Advice Service in the event of staff shortages/sickness.                                                                              1/10/08       12/1/2008 Walton
                  stakeholders.
                  b) Submission of report on the
                  above for the Wigan Joint
                                                               Review, compare and interpret Gateway and Advice Team data
                  Mental Health Commissioning
                                                               - including waiting times, GP, SU and Carer satisfaction                                                                                                      Donna Griffiths/ Jane
                  forum.                      c)
                                                           2.2 surveys, feedback from Practise visits - and prepare report.                                                                          1/10/08        3/1/2009 Walton
                  Development of contingency
                  plans to maintain service
                  provision at times of staff
                  shortages or other significant
                  disruption.


                                                           2.3 Present report to Stakeholders/Commissioning Forum                                                                                    1/10/08        4/1/2009 HOS




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                                                                                                                    6fda9ffa-071c-4e66-93fc-03ed30f7ee94.xls                                                                                         Agenda no. 11


                                                                                                                                                Risk
                                                                                                                                                Rating   How do you
         Phase/                                                                                                                                 (High    intend to                  Engagement
         Key                                                                                                                     What are the   Medium   mitigate these 3rd party Strategy /     Initiation Completion    Person's)                RAG
         Stage    Key Tasks                          Ref       Actions to complete the key task                                  key risks?     Low)     risks?         involvement Comms Plan   date       date          responsible             status
         Work stream 3 - Ensure NICE Guidance is fully implemented - Cheryl Forrest
                  a) Conformity to relevant NICE               Compile index of relevant NICE guidelines and make available
                  guidance is evidenced and                3.1 to workstream leads.                                                                                                                  1/10/08     12/1/2008 MM
                  Audited on an annual basis.
                  b) Commissioners will be                 3.2 Agree audit framework for NICE adherence.                                                                                             1/12/08      3/1/2009 MM/HOS
                  provided with an annual audit
                  report.
                                                                                                                                                                                                                           MM/ team managers/
                                                           3.3 Audit adherence to NICE guidelines                                                                                                     1/6/09      7/1/2009 Ward Managers

                                                           3.4 Prepare and present report to Commissioners                                                                                            1/7/09      8/1/2009 MM

         Work stream 4 - Support Development of integrated Personality Disorder Service - Jim Thomas
                  a) Participation in PCT                                                                                                                                                                                  Jim Thomas/ Joe
                  commissioned development of                  Attend PCT meetings re development of PD services and                                                                                                       Johnson/ John
                  exemplar PD service.                     4.1 feedback to Project Group.                                                                                                            1/10/08      on-going Marshall
                  b) Adjustment of pathways to
                  reflect model when
                  implemented.                 c)              Liaison with Gateway and Advice Services in order to                                                                                                      Jim Thomas/ Donna
                  Participation in training                4.2 accommodate pathways in to developed PD Services.                                                                                     1/10/08         TBA Griffiths/ Jane Walton
                  programmes for staff.
                  d) 5 boroughs utilisation of PD
                                                                                                                                                                                                                         Jim Thomas/ Julie
                  services commissioned from a
                                                               Identify current numbers of appropriately trained staff and                                                                                               Chadwick/ Team and
                  range of providers.
                                                           4.3 current provision of training.                                                                                                        1/10/08         TBA Ward Managers
                                                               Identify any gaps in training provision and produce a plan to                                                                                             Jim Thomas/ Julie
                                                           4.4 address these gaps.                                                                                                                   1/10/08         TBA Chadwick


                                                                                                                                                                                                                           Jim Thomas/ Team
                                                           4.5 Identify current uptake of commissioned services.                                                                                     1/10/08     10/1/2008 and Ward Managers

         Work stream 5 - Implement Strategy for GP engagement and communication - Helen McColm
                  a) All practices are offered the         5.1 Produce draft communication strategy                                                                                                  1/10/08     11/1/2008 Helen McColm
                  opportunity of a visit by a 5
                  Boroughs representative to talk              Arrange first GP forum and issue invitations to relevant 5BP,
                  through service provision, job               GPSIs, LA and PCT representatives to discuss proposed
                  roles and pathways, and                      communication strategy, care pathways and information
                  subsequent visits are offered            5.2 recording/distribution                                                                                                                1/10/08     12/1/2008 Helen McColm
                  on a 6 monthly basis                         Send out letter to offer GP visits and follow up with telephone
                  b) Recording of practice visits.         5.3 call.                                                                                                                                 1/10/08     12/1/2008 Helen McColm
                  c) Establishment of GP / 5
                  Borough clinical forum
                  d) Production of a                                                                                                                                                                                       Helen McColm/Robin
                  communication strategy for               5.4 Commence practice visits                                                                                                              1/10/08     11/1/2008 Evans
                  engaging with GP’s
                                                               Produce record of practice visits and timetable for continued/6
                                                           5.5 monthly contact.                                                                                                                      1/10/08      2/1/2009 Helen McColm




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                                                                                                                        6fda9ffa-071c-4e66-93fc-03ed30f7ee94.xls                                                                                         Agenda no. 11


                                                                                                                                                   Risk
                                                                                                                                                   Rating   How do you
         Phase/                                                                                                                                    (High    intend to                  Engagement
         Key                                                                                                                        What are the   Medium   mitigate these 3rd party Strategy /     Initiation Completion     Person's)                RAG
         Stage    Key Tasks                            Ref       Actions to complete the key task                                   key risks?     Low)     risks?         involvement Comms Plan   date       date           responsible             status
         Work stream 6 - Implement Recommendations of Sir Jonathon Michael Report - Liz Price-Jones
                  a) The relevant
                  recommendations of the Sir
                                                                                                                                                                                                                              DG/ JW/ Karen Green/
                  Jonathan Michael report.
                                                                 Liaise with PCT and LD lead to identify relevant                                                                                                             Stephanie McComb/
                  “Healthcare for all” are fully
                                                             6.1 recommendations in Health Care for All.                                                                                               01/10/08      1/1/2009 Peter Harrison
                  implemented.
                  b) Evidence of implementation
                  of the recommendations is                                                                                                                                                                                   DG/ JW/ Karen Green/
                  reported to commissioners on a             6.2 Implement relevant recommendations of 'Healthcare For All'.                                                                           01/10/08      4/1/2009 Stephanie McComb/
                  6 monthly basis.        c) 5
                  Boroughs participate in the
                                                                 Provide report to commissioners to show evidence of
                  Commissioner led working                   6.3 implementation.                                                                                                                       01/10/08      4/1/2009 DG/ JW
                  group being established to
                  monitor implementation
                  d) Revised protocols are in                    Identify local representatives to participate in monitoring                                                                                                  DG / JW/ Liz Price
                  place between Mental Health                6.4 implementation via Commissioner-led working group.                                                                                    01/10/08     12/1/2008 Jones
                  and local Learning disability
                  services concerning access to                                                                                                                                                                               DG/ JW/ Karen Green/
                  mental health services.                    6.5 Agree revised LD/Mental Health referral protocols.                                                                                    01/10/08      2/1/2009 Stephanie McComb

         Work stream 7 - CAMHs developments - Tarnia Woods
                  a) Full implementation of out of
                  hours practitioner and 24 hour
                  medical cover.
                                                                 CAMHs practitioner available for weekend and bank holiday                                                                                                    Linda Kellie/ Barbara
                  b) Implementation of the
                                                             7.1 cover.                                                                                                                                01/10/08     10/1/2008 Costello
                  commissioned practitioner
                  cover for weekends and bank
                  holidays.         c) Agreement                 Implement plan to provide 24hr availability of CAMHS
                  of maximum waiting times for                   practitioner and specialist medical cover to inpatient units and                                                                                             Linda Kelli/ Barbara
                  access to a CAMHS                          7.2 A&E department in line with 'Making It Better'.                                                                                       01/10/08     12/1/2008 Costello/ Tessa Myatt
                  practitioner or medic i.e. urgent
                  and routine)
                  d) Delivery of minimum service
                  requirements for provision of                  Identify and agree maximum urgent and routine waiting times                                                                                                  Linda Kelli/ Barbara
                  services to RAEI, in line with             7.3 for access to CAHMs services.                                                                                                         01/10/08     12/1/2008 Costello/ Tessa Myatt
                  the expectations of “Making it
                  Better”                 e) To
                  work collaboratively within the
                  above arrangements.                                                                                                                                                                                         Linda Kelli/ Barbara
                  f) The development of a                    7.4 Agree CAHMs lead for the Wigan Borough                                                                                                01/10/08     12/1/2008 Costello/ Tessa Myatt
                  CAMHS Borough wide
                  workforce plan in line CSIP/
                  SHA guidance and the
                  identification of a relevant lead.                                                                                                                                                                          Linda Kelli/ Barbara
                                                             7.5 Develop a workforce plan in line with CSIP/SHA Guidance.                                                                              01/10/08      1/1/2009 Costello/Tessa Myatt




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                                                                                                                      6fda9ffa-071c-4e66-93fc-03ed30f7ee94.xls                                                                                           Agenda no. 11


                                                                                                                                                  Risk
                                                                                                                                                  Rating   How do you
         Phase/                                                                                                                                   (High    intend to                  Engagement
         Key                                                                                                                   What are the       Medium   mitigate these 3rd party Strategy /     Initiation Completion     Person's)                 RAG
         Stage    Key Tasks                          Ref       Actions to complete the key task                                key risks?         Low)     risks?         involvement Comms Plan   date       date           responsible              status
         Work stream objective 8 - Carers Strategy - Cheryl Forrest
                  a) Participation in the Wigan
                  Borough carers strategy group.
                  b) Action plan developed                                                                                     unable to attend
                  outlining Implementation of                                                                                  meetings due to             diary ahead and
                  appropriate elements of the                  Attend and particpate in locality Carers Strategy Group         other work                  nominate deputy to
                  Wigan carer’s strategy.                  8.1 meetings (first meeting 20.10.08).                              commitments        medium   attend.                                    01/10/08     11/1/2008 Cheryl Forrest
                  c) All carers should be offered
                  a carers assessment focusing
                  on their health and emotional
                  well being.     d) All carers                Identify specific actions relevant to 5BP within local carers                                                                                                 Cheryl Forrest/ Carers
                  declining a carer’s assessment           8.2 strategy and produce implementation plan.                                                                                              01/10/08     12/1/2008 Social workers
                  should have this recorded on
                  case files and reported as a
                  KPI. e) Carers who decline an
                  assessment should be offered
                                                               Agree local 5BP protocol to ensure all identified carers are
                  another within a 6-month
                                                               offered a carer's assessment ( and reoffered at specified 6                                                                                                   Cheryl Forrest/ Carers
                  period.                       f)
                                                           8.3 monthly interval if declined).                                                                                                         01/10/08     11/1/2008 Social workers
                  One recording system should
                  be developed between the                                                                                     Failure to reach
                  Trust and DAS to record                                                                                      agreement with all          ensure regular       Members of local
                  activity and level of                        Design and agree shared LA/5BP recording system to ensure       parties within              liaison with         Carers Strategy                              Cheryl Forrest/ Carers
                  intervention.                            8.4 carer's activity is recorded accurately.                        agreed time scales medium   relevant parties.    Group.                01/10/08      2/1/2009 Social Workers

         Work stream objective 9 - Annual needs assessment based on schedule of demographic info - Cheryl Forrest
                  a) Agreement reached on
                  a schedule of
                  demographic and other
                  information that will                        Identify and agree with Commissioners, Performance and other
                  enable commissioners                         Stakeholders, demographic information for collection,                                                                                                         Cheryl Forrest/ HOS/
                  and providers to assess                  9.1 comparison and cross referencing.                                                                                                      01/10/08      5/1/2009 John Marshall
                  service usage and need.
                  Examples of information
                  would include, Age,
                  gender, Ethnicity data,
                  Accommodation and
                                                               Agree/adjust reporting format for annual delivery to                                                                                                          Cheryl Forrest/ HOS/
                  employment status, carer
                                                           9.2 commissioners.                                                                                                                                                Informatics
                  status, diagnosis etc;
                  cross referenced with
                  LOS, readmission rates,
                  type of service etc
                  b) The production of such
                  information should be
                  delivered within an                                                                                          Failure to access
                  annual report.                                                                                               accurate
                                                               Agree systematic sharing of demographic information (with       demographic                 ensure regular
                                                               operational managers) in order to inform and influence future   information within          liaison with
                                                           9.3 service development, training and resource allocation.          agreed timescales. low      relevant parties.                          01/10/08      9/1/2009 Cheryl Forrest/ HOS




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                                                                                                                         6fda9ffa-071c-4e66-93fc-03ed30f7ee94.xls                                                                                                     Agenda no. 11


                                                                                                                                                        Risk
                                                                                                                                                        Rating   How do you
         Phase/                                                                                                                                         (High    intend to                  Engagement
         Key                                                                                                                             What are the   Medium   mitigate these 3rd party Strategy /     Initiation Completion           Person's)                  RAG
         Stage    Key Tasks                            Ref        Actions to complete the key task                                       key risks?     Low)     risks?         involvement Comms Plan   date       date                 responsible               status

         Work stream 10 - Ensure statutory requirements regarding SUI are met - Cheryl Forrest
                  a) Continued delivery of
                  previously agreed performance                   Establish monthly recording of SUI data and provide quarterly
                  measures.                                  10.1 reports.                                                                                                                                  01/10/08 01/10/08 on going Governance dept
                  b) Implementation of SUI action
                  plan. c) Development of an                 10.2 Continue participation in PCT Suicide Audit Group                                                                                         01/06/08 01/06/08 on going Cheryl Forrest/ C Maj
                  agreement between the
                  Borough Chair of the Suicide
                                                                  Establishment of local 5bp SUI Oversight Group to respond and                                                                                                        Cheryl Forrest/ Helen
                  Audit Group and the 5
                                                             10.3 implement actions indicated by completed SUI reviews.                                                                                     14/10/08         11/1/2008 McColm/ C Maj
                  Boroughs as to what
                  information should be provided
                  to the group.    d) Protocol to
                  be developed for the process of                 Agree revised data/information to be providied to PCT Suicide
                  GP engagement in SUI                       10.6 Audit group                                                                                                                               14/10/08 on going monthly HOS/ MM/ C Maj
                  processes and for the provision
                  of feedback.




                                                                                                                                                                                                                                         Cheryl Forrest/ Helen
                                                                  Agree with GPSI, local protocol for GP engagement in local SUI                                                                                                         McColm/ Alex
                                                             10.8 processes and feedback.                                                                                                                   14/10/08            4/1/2009 Turnbull/ C Maj

         Work stream 11 - Prescribing practices - Norman Harvey TBC (supported by Lorraine Prescott )
                  a) Shared care protocols in                     All medical staff will demonstrate adherence to current                                                                                                                Norman Harvey/
                  place for all “Amber” drugs.                    prescribing PCT/5Boroughs Partnership agreements in their                                                                                                              Lorraine Prescott/ Neil
                  b) Written notification to GP’s            11.1 practise.                                                                                                                                 01/10/08 on going            Chilton
                  of non – urgent changes in
                  medication, dose or frequency
                  within 2 working days. Any                      Medical staff will provide clear, written notification of changes to
                  urgent notifications must take             11.2 non-urgent prescriptions within 2 working days.                                                                                           01/10/08            1/1/2009 Norman Harvey
                  place within the working day.                   Notification of urgent changes to medication will take place
                  c) All prescribing will be in line         11.3 within the working day.                                                                                                                   01/10/08            1/1/2009 Norman Harvey
                  with jointly agreed protocols.
                  d) Clinicians will not deviate                  All proposed changes to current Shared Care arrangements to
                  from the agreements made                        be fully costed, including further resource costs re storage,
                  between the PCT and the 5                  11.4 dispensing, delivery e.t.c.                                                                                                               01/10/08         12/1/2008 Lorraine Prescott
                  Boroughs.                      e)               Shared Care' protocols to be agreed for all 'Amber' drugs.
                  Annual audit of compliance                      disseminated to all medical staff for immediate implementation                                                                                                         Norman Harvey/
                  with the above requirements.               11.5 in prescribing practice.                                                                                                                  01/10/08            1/1/2009 Lorraine Prescott
                  f) 5 Boroughs contract will be
                  amended to reflect the above
                  requirements.                                   Shared Care' protocols disseminated to all medical staff for
                                                             11.6 immediate implementation in prescribing practice.                                                                                         07/11/08            1/1/2009 Norman Harvey
                                                             11.7 Plan for annual audit of compliance to be designed.                                                                                       01/10/08            6/1/2009 Lorraine Prescott




                                                             11.8 Annual audit of compliance to be completed.                                                                                               01/10/08            7/1/2009 Lorraine Prescott

         Work stream 12 - Mental Health Act / Mental capacity Act Training and Business Plan - Peter Acton / Ann Cunliffe / LPJ




Page 7                                                                                                                                                                                                                                    Wigan Service Improvement Plan
                                                                                                                   6fda9ffa-071c-4e66-93fc-03ed30f7ee94.xls                                                                                      Agenda no. 11


                                                                                                                                           Risk
                                                                                                                                           Rating   How do you
         Phase/                                                                                                                            (High    intend to                  Engagement
         Key                                                                                                                What are the   Medium   mitigate these 3rd party Strategy /     Initiation Completion     Person's)             RAG
         Stage    Key Tasks                        Ref        Actions to complete the key task                              key risks?     Low)     risks?         involvement Comms Plan   date       date           responsible          status
                  a) Production of an
                  implementation plan, including              Identify current numbers of appropriately trained staff and                                                                                             Ann Cunlife/ Peter
                  training and development, to           12.1 current provision of training.                                                                                                   01/10/08     12/1/2008 Acton
                  support these requirements
                                                                                                                                                                                                                      Ann Cunlife/ Peter
                  within the borough.
                                                         12.2 Identify any gaps in training provision.                                                                                         01/10/08     12/1/2008 Acton
                  b) The development of a
                  business plan outlining any
                  additional resource
                  requirements.
                                                              Develop a business case to identify any additional resource                                                                                             Ann Cunlife/ Peter
                                                         12.3 requirements.                                                                                                                    01/10/08      1/1/2009 Acton                N/A




Page 8                                                                                                                                                                                                                 Wigan Service Improvement Plan
                                                                                                                         6fda9ffa-071c-4e66-93fc-03ed30f7ee94.xls                                                                                        Agenda no. 11


                                                                                                                                                  Risk
                                                                                                                                                  Rating   How do you
         Phase/                                                                                                                                   (High    intend to                  Engagement
         Key                                                                                                                       What are the   Medium   mitigate these 3rd party Strategy /     Initiation Completion        Person's)              RAG
         Stage    Key Tasks                             Ref         Actions to complete the key task                               key risks?     Low)     risks?         involvement Comms Plan   date       date              responsible           status
         Work stream 13 - Conduct MDO service review and implement improvement plan - Sharon Eid
                  a) Participate in the Greater
                  Manchester Review of Mentally                13.1 Identify baseline current activity and capacity                                                                                   01/10/09        11/1/2008 S.Eid/ Pat Smith
                  Disordered Offenders services.
                                                                    Partcipate in meetings re Greater Manchester review of
                  b) Review Borough wide MDO
                                                               13.2 Mentally Disordered Offenders services.                                                                                           01/10/09        11/1/2008 S.Eid/ Pat Smith
                  services.

                                                               13.3 Identify any gaps in service provision.                                                                                           01/10/09         4/1/2009 S.Eid/ Pat Smith


                                                              13.4 Present report to project Stakeholder Group                                                                                        01/10/09         4/1/2009 S.Eid/ Pat Smith


         Work stream 14 - Improve performance of In-Patient Services and write a business case for redesign - Chris Molyneux
                  a) Demonstrate a sustained
                  reduction in the number of
                  admissions, length of stay,
                  occupancy and readmissions to                     Identify number of admissions, length of stay, occupancy and
                  inpatient mental health services                  readmissions to inpatient unit for two consecutive 12 month
                  over a 12-month period.                      14.1 periods (Apr 07 to 08, and Apr 08 to 09)                                                                                          01/10/08         5/1/2009 IP Service manager
                  b) Develop a costed business
                  case (to the satisfaction of
                  commissioners) which will be
                  publicly consulted upon, to
                  propose improvements to                           Elicit service user and carer views via quarterly standard                                                                                    Jan 09 and 3 IP Service manager/
                  inpatient services that focus                14.2 satisfaction questionnaires.                                                                                                      01/09/08 monthly on going SU & Carer reps
                  upon improved quality and an
                  appropriate reduction in bed
                  numbers to national
                  benchmarks. The business
                  case must reflect the
                                                                    Develop costed business case to propose improvements to in                                                                                                  IP Service Manager/
                  commissioners’ specification
                                                               14.3 patient services.                                                                                                                 01/10/08        10/1/2009 HOS/ Ben Nuttall
                  and be in line with best
                  practice.                    c)
                  The proposal will be revenue
                  neutral for commissioners and
                  if savings are identified they will
                                                                    Report any cost savings to commissioners to enable service
                  be declared to commissioners,
                                                               14.5 need/demographically appropriate reallocation of resources                                                                        01/10/08        10/1/2009 HOS
                  who will determine their usage.




Page 9                                                                                                                                                                                                                           Wigan Service Improvement Plan
                                                                                                                        6fda9ffa-071c-4e66-93fc-03ed30f7ee94.xls                                                                                          Agenda no. 11


                                                                                                                                                    Risk
                                                                                                                                                    Rating   How do you
          Phase/                                                                                                                                    (High    intend to                  Engagement
          Key                                                                                                                        What are the   Medium   mitigate these 3rd party Strategy /     Initiation Completion     Person's)                RAG
          Stage    Key Tasks                            Ref        Actions to complete the key task                                  key risks?     Low)     risks?         involvement Comms Plan   date       date           responsible             status
          Investments:

          Work stream 1 - Illustrate PTS Service capacity v activity and develop business plan to address gaps - Graham Spratt
                   a) The Psychological Therapies
                   Service will be in a position to            1.1 Agree with informatics to develop appropriate recording system.                                                                      01/10/08    11/30/2008 Graham Spratt
                   submit the IAPT Vital Signs
                                                                   Liaise with PCT IT Dept to establish capacity of CORE NET to
                   Monitoring (VSM) data lines 3a,
                                                               1.2 collect Vital Sign Data.                                                                                                             01/10/08    11/30/2008 Graham Spratt
                   3b and 4, 5,6 and 7 as outlined
                   in the detailed technical                       Establish 'best fit' of non-mental health PTS to data recording
                   definition                                  1.3 requirements.                                                                                                                        01/10/08    11/30/2008 Liz Price Jones
                   b)The 5 Boroughs will have                                                                                                                                                                                  Janet Winstanley/
                   developed a plan to market                      Service managers to ensure data collection is delivered to                                                                                                  Jane Kenny/ Liz Price
                   Psychological services as a                 1.4 acceptable quality and standards                                                                                                     01/10/08    11/30/2008 Jones
                   'Health service' and not as
                   a'mental health' service
                                                                   Produce a policy/ philosophy statement to communicate the
                   c) Locally based psychological
                                                               1.5 concept of 'health' service.                                                                                                         01/10/08    12/31/2008 Graham Spratt
                   treatment for people with a mild
                   to moderate learning disability
                   will be present in each of the                  Produce a business plan to demonstrate locality based
                   three localities supported by               1.6 psychological treatment for LD service users.                                                                                        01/10/08     3/31/2009 Liz Price Jones
                   robust arrangements for the
                   delivery of that function of the
                   service. Tha activity for the
                   people that access this service
                   will be identifiable from the
                   IAPT dtat set. d) the                       1.7 Prepare for IAPT Data collection for LD Service users.                                                                               01/10/08      6/1/2009 Liz Price Jones
                   Psychological Therapies
                   Service will have identified the
                   resource required to deliver the
                   provision of step two and three
                   clinics to all general practices
                   in the ALW area.
                                                                   Produce a business plan to identify resource requirements
                                                                   which includes current service capacity and additional
                                                               1.8 investments required to reflect local needs.                                                                                         01/10/08     3/31/2009 Jane Kenny
                   e) The 5 boroughs
                   Psychological Therapies
                   Service will be participating in a
                   Psychological Therapies hub
                   along with other provider
                   designed to assist in the
                   development of psychological                    Liaise with PCT and other providers to establish mechanisms
                   services for health in Wigan                    for a psychological therapies hub and write service
                   f) The PTS will have developed              1.9 specification.                                                                                                                       01/10/08     4/30/2009 Janet Winstanley
                   an outline plan to deliver
                   clinical supervision and
                   developmental support for third
                   sector providers of
                   psychological therapies

                                                                   Map third sector PTS delivery in order to identify
                                                                   supervision/support requirements. Produce a plan to meet
                                                              1.10 identified supervision/support requirements.                                                                                         01/10/08      7/1/2009 Mike Valentine




Page 10                                                                                                                                                                                                                         Wigan Service Improvement Plan
                                                                                                                     6fda9ffa-071c-4e66-93fc-03ed30f7ee94.xls                                                                                         Agenda no. 11


                                                                                                                                                  Risk
                                                                                                                                                  Rating   How do you
          Phase/                                                                                                                                  (High    intend to                  Engagement
          Key                                                                                                                      What are the   Medium   mitigate these 3rd party Strategy /     Initiation Completion     Person's)              RAG
          Stage    Key Tasks                          Ref       Actions to complete the key task                                   key risks?     Low)     risks?         involvement Comms Plan   date       date           responsible           status
          Work stream 2 - Develop Business case and implementation plan "Mental Health Hospital Liaison Service" for Adults and Older People - Jim
          Thomas
                   a) Review of Older persons A
                   and E Liaison service to ensure              Identify baseline activity of A&E Liaison Services Apr 07 to Apr                                                                                             Jim Thomas/ Robin
                   compliance with recent policy            2.1 08, including out of hours referrals to CRHT.                                                                                         01/10/08     11/1/2008 Evans
                   guidance               b)
                   Production of a business case
                                                                Review current A&E Liaison Service (OP), identify gaps in                                                                                                    Jim Thomas/ Mandy
                   to provide hospital and A and E
                                                            2.2 service that do not comply with recent policy guidance.                                                                               01/10/08      1/1/2009 Hanson
                   Liaison services, including
                   training, consultation and
                   assessment services.                         Produce business case for provision of comprehensive A&E
                   c) Production of an                      2.3 Liaison Service to include training costs.                                                                                            01/10/08     11/1/2008 Jim Thomas
                   Implementation plan for the
                   development of the service.
                   d) Agreement on access to                2.4 Produce service implementation plan                                                                                                   01/10/08     11/1/2008 Jim Thomas
                   psychological services where
                   appropriate.
                   e) Protocol developed with                                                                                                                                                                                Jim Thomas/ Graham
                   neighbouring A and E                     2.5 Agree appropriate access to Psychological Services.                                                                                   01/10/08     11/1/2008 Spratt.
                   departments regarding access
                   and transfer to local services               Liaise with neighbouring A&E departments to develop transfer
                   for individuals registered with          2.6 protocols for ALW service users.                                                                                                      01/10/08      2/1/2009 Jim Thomas
                   ALW GP’s.
                   f) Arrangements should be
                                                                Design and agree provision of liaison services to Leigh
                   made for the provision of
                                                            2.7 Infirmary Walk In centre.                                                                                                             01/10/08      1/1/2009 Jim Thomas.
                   liaison services to Leigh Walk
                   in centre.
                                                            2.8 Present business case to commissioners.                                                                                               01/10/08      2/1/2009 HOS/ Sam Oliver

          Work stream 3 - Medical cover developments - Norman Harvey / Jim Thomas
                   a) A developed plan to provide
                   medical cover in A and E, when               Include provision of appropriate medical input to RAE Infirmary                                                                                              Norman Harvey/ Jim
                   it is appropriate.                       3.1 A&E department in A&E development proposal.                                                                                           01/10/08     12/1/2008 Thomas
                   b) Development of protocol
                   between RAEI, commissioners
                   and 5 Boroughs to define ' a '.
                   c) Reporting of waiting times to                                                                                                                                                                          Norman Harvey/ Jim
                   access all medical staff out of          3.2 Develop protocols to support appropriate medical input to A&E.                                                                        01/10/08     12/1/2008 Thomas
                   hours and for A and E
                   attendance (grouped into
                   relevant grades i.e. SHO, SPR,
                   Consultant)

                                                                Agree recording and reporting system to identify out-of-hours
                                                                and A&E waiting times for access to appropriate grade of face                                                                                                Norman Harvey/ Jim
                                                            3.3 to face medical support.                                                                                                              01/10/08      2/1/2009 Thomas/ Informatics




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                                                                                                                   6fda9ffa-071c-4e66-93fc-03ed30f7ee94.xls                                                                                                Agenda no. 11


                                                                                                                                              Risk
                                                                                                                                              Rating   How do you
          Phase/                                                                                                                              (High    intend to                  Engagement
          Key                                                                                                                  What are the   Medium   mitigate these 3rd party Strategy /     Initiation Completion          Person's)                  RAG
          Stage    Key Tasks                        Ref       Actions to complete the key task                                 key risks?     Low)     risks?         involvement Comms Plan   date       date                responsible               status
          Work stream 4 - Fully implement ATC business case (Organic and Complex MH Services) - Chris Maj
                   a) Implementation plan                     Establish Implementation Working Group (to develop service
                   developed for the                      4.1 description and operational policies)                                                                                               01/09/08          12/1/2008 C.Maj
                   commencement of this service.
                   b) Development of service              4.2 Manage transition of existing staff (Beacon Day Hosp)                                                                               01/09/08          11/1/2008 C.Maj
                   description for complex CMHT
                   element of service                     4.3 Agree increased consultant input to Phase 1 Site (Wigan)                                                                            01/09/08          12/1/2008 C.Maj/Glynn Thomas
                   c) Development of operational
                                                          4.4 Begin recruitment of staff Phase 1 (Wigan)                                                                                          01/09/08          12/1/2008 C.Maj
                   policies.
                                                          4.5 Agree Shared Care arrangements with PCT                                                                                             01/09/08          12/1/2008 C.Maj


                                                          4.6 Produce plan to engage with GPs to promote new service                                                                              01/09/08          12/1/2008 C.Maj
                                                          4.7 Phase 2 Service roll out to Ashton and Leigh localities.                                                                            01/03/09           9/1/2009 C.Maj

          Work stream 5 - Develop Dual Diagnosis Service based upon agreed business case - Jim Thomas
                   a) Continued reporting of
                   agreed performance measures                Review baseline numbers of service users with dual diagnosis                                                                                                   Jim Thomas/ Dual
                   in this area.                          5.1 open to CMHTs.                                                                                                                      01/10/08        11/18/2008 Diagnosis Practitioners
                   b) Development of a business
                   case, acceptable to
                   commissioners, for the                     Set up separate function for Dual Diagnosis activity on IT                                                                                     18/11/08 monthly Jim Thomas/
                   expansion of the Dual                  5.2 system.                                                                                                                             01/10/08           on going Informatics
                   Diagnosis service.
                   c) Implementation plan                     Record caseload and co working activity for Dual Diagnosis                                                                                     18/11/08 monthly Jim Thomas/ Dual
                   developed.                             5.3 Practitioners.                                                                                                                      01/10/08           on going Diagnosis Practitioners


                                                                                                                                                                                                             18/11/08 monthly Jim Thomas/ Dual
                                                          5.4 Record consultation activity for Dual Diagnosis practitioners.                                                                      01/10/08           on going Diagnosis Practitioners
                                                              Produce a business case for the expansion of Dual Diagnosis
                                                          5.5 Services.                                                                                                                           01/10/08          12/1/2008 Jim Thomas
                                                              Produce implementation plan for expanded Dual Diagnosis
                                                          5.6 Service                                                                                                                             01/10/08          12/1/2008 Jim Thomas

          Information:

          Work stream 1- Ensure that the reporting of PTS performance outcomes/outputs meets expectations of the PCT / LA - Graham Spratt
                   a) Provision of financial and                                                                                                                                                                              Graham Spratt/ Ben
                   activity data requested by the             Provide information re finances and activity as requested by                                                                                                    Nuttall/ Performance
                   PCT.                        b)         1.1 PCT.                                                                                                                                01/10/08          12/1/2008 Team
                   Agreed baseline of finance and
                   activity.                                                                                                                                                                                                  Sam Oliver/ John
                   c) Agreement of performance            1.2 Agree baseline finance and activity                                                                                                 01/10/08          12/1/2008 Marshall
                   targets.

                                                                                                                                                                                                                              Graham Spratt/ John
                                                          1.3 Agree performance targets.                                                                                                          01/10/08          12/1/2008 Marshall




Page 12                                                                                                                                                                                                                        Wigan Service Improvement Plan
                                                                                                                   6fda9ffa-071c-4e66-93fc-03ed30f7ee94.xls                                                                                           Agenda no. 11


                                                                                                                                               Risk
                                                                                                                                               Rating   How do you
          Phase/                                                                                                                               (High    intend to                  Engagement
          Key                                                                                                                   What are the   Medium   mitigate these 3rd party Strategy /     Initiation Completion     Person's)                 RAG
          Stage    Key Tasks                         Ref       Actions to complete the key task                                 key risks?     Low)     risks?         involvement Comms Plan   date       date           responsible              status

          Work stream 1a - Ensure that the reporting of service performance MH outcomes/outputs meets expectations of the PCT / LA - Helen McColm
                   a) Provision of financial and                                                                                                                                                                          Helen McColm/Ben
                   activity data requested by the              Provide information re finances and activity as requested by                                                                                               Nuttall/ Informatics
                   PCT.                        b)          1.1 PCT.                                                                                                                                01/10/08     12/1/2008 team
                   Agreed baseline of finance and
                   activity.                                                                                                                                                                                              Sam Oliver/ John
                   c) Agreement of performance             1.2 Agree baseline finance and activity                                                                                                 01/10/08     12/1/2008 Marshall
                   targets.                                                                                                                                                                                               Helen McColm/ John
                                                           1.3 Agree performance targets.                                                                                                          01/10/08     12/1/2008 Marshall

          Work stream 2 - GP Data Set - Cheryl Forrest
                   a) Issue practices with agreed
                   financial and activity data.                Meet with GPSI to agree content and presentation of GP data                                                                                                Cheryl Forrest/ Al
                   b) Agreed SLAs between                  2.1 set.                                                                                                                                01/09/08      4/1/2009 Thompson
                   practice consortiums and the 5
                   Boroughs that outline the level
                   of service they can expect.                 Agree outline expected level of service and Service Level                                                                                                  HOS/ Cheryl Forrest/
                                                           2.2 Agreements with GP Practice Consortiums.                                                                                            01/09/08      4/1/2009 Al Thompson

          Work stream 3 - Outcome Measures - Cheryl Forrest
                   a) To agree with the PCT a full             Agree targeted areas of service improvement based on current
                   set of outcome measures.                    Service User, Carer and GP experience/areas of                                                                                                             Donna Griffiths/ Jane
                   b) To set targets against               3.1 dissatisfaction..                                                                                                                   01/10/08     12/1/2008 Walton/ Cheryl Forrest
                   current outcome measures e.g.
                   User, carer and GP                          Identify and agree an appropriate set of outcome measures with                                                                                             Cheryl Forrest/ John
                   satisfaction.             c)            3.2 commissioners.                                                                                                                      01/10/08      3/1/2009 Marshall
                   To develop appropriate
                   systems to monitor and report
                   those outcomes at a PCT and                                                                                                                                                                            Cheryl Forrest/
                   practice level.                                                                                                                                                                                        Informatics/ Debbie
                                                               Develop effective reporting systems to enable feedback to PCT                                                                                              Hayes/ Nigel
                                                           3.3 and GP consortia.                                                                                                                   01/10/08      4/1/2009 O'Gorman




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                                                                                                                      6fda9ffa-071c-4e66-93fc-03ed30f7ee94.xls                                                                                          Agenda no. 11


                                                                                                                                               Risk
                                                                                                                                               Rating   How do you
          Phase/                                                                                                                               (High    intend to                  Engagement
          Key                                                                                                                   What are the   Medium   mitigate these 3rd party Strategy /     Initiation Completion          Person's)              RAG
          Stage    Key Tasks                         Ref         Actions to complete the key task                               key risks?     Low)     risks?         involvement Comms Plan   date       date                responsible           status
          Target performance:
          Work stream 1 - Ensure design & performance of LDP services develop to meet all expectations of PCT & national targets - Jim Thomas
                   a) A minimum of 54 people per               Monitor numbers of accepted referrals to Early Intervention
                   year are admitted to EI                     Team and take appropriate actions to meet required annual                                                                                                       Jim Thomas/ Chris
                   services.         b) A minimum          1.1 number of 54                                                                                                                        01/04/08          3/31/2009 Kelly
                   of 721 people receive Crisis
                   Resolution services per year                Monitor numbers of accepted referrals to Crisis
                   c) 144 people in contact with               Resolution/Home Treatment Team and take appropriate actions                                                                                                     Jim Thomas/ Shirley
                   the Assertive outreach service.         1.2 to meet required number of 721.                                                                                                     01/04/08          3/31/2009 Myers
                   d) Teams are staffed in line                Monitor Assertive Outreach Team caseload to ensure target                                                                                                       Jim Thomas/ Anthony
                   with PIG requirements.                  1.3 figure of 144 is met.                                                                                                               01/04/08           3/1/2009 Critchley
                   e) Production of a monthly
                   report demonstrating d).
                   f) Weekly reporting of progress                                                                                                                                                                           Jim Thomas/ Shirley
                   against a) and b)                                                                                                                                                                        01/12/08 weekly, Myers/ Chris Kelly/
                   g) Production of action plan to         1.4 Weekly reporting of progress towards target figures.                                                                                01/04/08         on going Anthony Critchley
                   ensure achievement of a) and                Produce Action Plan to ensure target figures for LDP services
                   b).                                     1.5 are achieved.                                                                                                                       01/10/08          12/1/2008 Jim Thomas.

                                                               Monitor numbers of service users open to Assertive Outreach
                                                               Team and take appropriate actions to meet required number of                                                                                                    Jim Thomas/ Anthony
                                                           1.6 144                                                                                                                                 01/04/08          3/31/2009 Critchley


                                                           1.7 LDP Teams are staffed as per Policy Implementation Guidance                                                                         01/04/08          12/1/2008 Jim Thomas

                                                                 Monthly report to Project Development Group and
                                                                 commissioners to demonstrate appropriate staffing levels are                                                                                 01/12/08 monthly,
                                                           1.8   achieved.                                                                                                                         01/04/08            on going Jim Thomas




Page 14                                                                                                                                                                                                                         Wigan Service Improvement Plan
                                                                                                                       6fda9ffa-071c-4e66-93fc-03ed30f7ee94.xls                                                                                                  Agenda no. 11


                                                                                                                                                          Risk
                                                                                                                                                          Rating   How do you
          Phase/                                                                                                                                          (High    intend to                  Engagement
          Key                                                                                                                        What are the         Medium   mitigate these 3rd party Strategy /     Initiation Completion     Person's)                 RAG
          Stage    Key Tasks                          Ref        Actions to complete the key task                                    key risks?           Low)     risks?         involvement Comms Plan   date       date           responsible              status
          Work stream 2 - Reporting and Achievement of Waiting time targets - Helen McColm / Graham Spratt
                   a) Reporting of waiting times
                   for all services for first                    Establish and report current baseline waiting times for all                                                                                                         Helen McColm /
                   assessment and first treatment.           2.1 elements of service.                                                                                                                         01/10/08    11/18/2008 Graham Spratt
                   b) With the exception of
                   psychological therapy services                Identify areas in 'non-urgent' services where 18 week target is                                                                                                     Helen McColm /
                   and the ATC, all non-urgent               2.2 not being met.                                                                                                                               01/10/08     1/13/2008 Graham Spratt
                   services should have a                        Identify causes/contributing factors around failure to meet 18
                   maximum waiting time, which                   week target and develop draft action plan to address these                                                                                                          Helen McColm/ Donna
                   includes, 1st treatment, within           2.3 issues. (MH Services)                                                                                                                        01/10/08     1/27/2009 Griffiths/ Jane Walton
                   18 weeks.
                   c) An agreement will be in
                   place with commissioners for              2.4 Agree and implement action plan. (MH Services)                                                                                               01/10/08     2/10/2008 Helen McColm
                   acceptable waiting times for the
                   steps of the psychological
                   therapies pathways, which will            2.5 Review and report waiting times to project group (MH Services)                                                                               01/10/08      4/1/2008 Helen McColm
                   be expected to be significantly
                   shorter than the 18week target,                                                                                                                                                                                   Graham Spratt/ Peter
                   however there will be a cap on            2.6 Agree specific acceptable waiting times for PTS service.                                                                                     01/10/08      7/1/2009 Harrison
                   the maximum waiting time of 18
                   weeks including first treatment.




                                                                                                                                                                                                                                     Helen McColm/
                                                             2.7 Report waiting times to Commissioners                                                                                                        16/12/08     10/1/2009 Graham Spratt

          Review
                                                            12.1 Contact attendees
                                                                 Send report of mapped service to all stakeholders for
                                                            12.2 information and comment
                                                            12.3 Set dates for project meeting
                                                                                                                                                                   Ensure that they
                   Project Group reconvene to               12.4 Book venue                                                          Not all attendees             are engaged in the
                   review performance                       12.5 Send agendas to stakeholder                                         are able to attend   Medium   discussion.


                                                            13.1 Compare current activity and financial information with baseline.


                   Project group to review                  13.2 Agree measures that can initiate improvement if required                                          Risk
                   performance                              13.3 Agree action plan to implement measures.                            Quality of data      Medium   apportionment.


                                                            14.1 Compare current activity and financial information with baseline.
                                                            14.2 Review any outstanding audit issues


                   Project group to review                  14.3 Agree measures that can initiate improvement if required                                          Risk
                   performance                              14.4 Agree action plan to implement measures.                            Quality of data      Medium   apportionment.




Page 15                                                                                                                                                                                                                               Wigan Service Improvement Plan

				
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