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					                                                                                                          dcfe0cc3-b7ea-4287-ab35-a96155835f3e.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             3rd party Strategy /             Initiation Completion         Person's)             RAG
         Stage    Key Tasks                   Ref        Actions to complete the key task                               key risks?             Low)    these 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                           Ensure
                                                                                                                        representatives are            representatives                                                                   Sam Oliver/ Cheryl
                                                     1.5 Book venue                                                                                                                                                            11/1/2008 Forrest/ Janet Heyes
                                                                                                                        unable to attend               are linked in      PCT and Local
                                                     1.6 Send agenda to stakeholders                                    pre-meeting         Medium     discussion         Authority Leads                                      11/4/2008 Cheryl Forrest

                                                         Establish 5 Boroughs Partnership NHS Trust representation on
                                                     1.7 all partnership forums.                                                                                                                                               On going Helen McColm
                                                                                                                        Some                           Ensure
                                                                                                                        representatives are            representatives
                                                         Confirm arrangements for the local GP and 5 Boroughs           unable to attend               are 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/
                                                                                                                        from existing                                                                                                    Debbie Hayes/
                                                     2.2 Update performance dataset as appropriate                      clinical systems to                                                                                     on going Suzanne Kippax
                                                                                                                                                                         Support
                                                                                                                        support dataset
                                                         Inform Performance to continue monthly reporting of project                                                     development of
                                                                                                                        and 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
                                                                                                                  dcfe0cc3-b7ea-4287-ab35-a96155835f3e.xls                                                                                               Agenda no. 11


                                                                                                                                                 Risk
                                                                                                                                                 Rating   How do you
         Phase/                                                                                                                                  (High    intend to                     Engagement
         Key                                                                                                                  What are the       Medium   mitigate            3rd party Strategy /   Initiation Completion       Person's)            RAG
         Stage    Key Tasks                         Ref       Actions to complete the key task                                key risks?          Low)    these 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                   Ensure that
                                                                                                                              undertake review            representatives                                                      Helen McColm/ Cheryl
                  Confirm current service                     Maintain engagement with GP and Service User stakeholders       with all                    are linked in                                                        Forrest/ Sam Oliver/
                  provision.                              3.1 about developments in service provision.                        stakeholders.      Medium   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
                                                                                                                   dcfe0cc3-b7ea-4287-ab35-a96155835f3e.xls                                                                                            Agenda no. 11


                                                                                                                                               Risk
                                                                                                                                               Rating   How do you
         Phase/                                                                                                                                (High    intend to                  Engagement
         Key                                                                                                                    What are the   Medium   mitigate         3rd party Strategy /   Initiation Completion       Person's)               RAG
         Stage    Key Tasks                         Ref        Actions to complete the key task                                 key risks?      Low)    these 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
                  over 65 who should be
                                                           1.2 provide service managers with figures.                                                                                               1/10/08      11/18/2008 Team managers
                  managed within adult services.
                                                               Agree minimum numbers of over 65s to be accommodated                                                                                                         Jane Walton/ Donna
                         c) Development of                 1.3 within redesigned 'ageless' CMHTs                                                                                                    1/10/08       12/1/2009 Griffiths
                  service description and
                  operational policy (acceptable               Commence preparation of draft proposal/operational policy for                                                                                                Jane Walton/ Donna
                  to commissioners) of                     1.4 redesign of CMHTs and identify pilot site.                                                                                           1/10/08       11/1/2008 Griffiths
                  redesigned CMHTs
                                                                                                                                                                                                                            Jane Walton/ Donna
                          d) Repeat of Case
                                                           1.5 Commence role out of service redesign in pilot site.                                                                                 1/10/08       12/1/2008 Griffiths
                  Load Audit to measure impact
                  of changes.                                  Repeat Case Load Audit and provide completed audit papers
                  e) Fully agreed pathways/                1.6 to Service Managers.                                                                                                                 30/3/09       3/31/2009 Team Managers
                  protocols between LES
                  practices and 5 Boroughs
                  agreed, in place and rolled out              Identify cases suitable for transfer of care back to LES for                                                                                                 Donna Griffiths/ Jane
                  for both Dementia and                    1.7 'Dementia' and/or 'Recovery & Depot'.                                                                                                1/10/08        7/1/2009 Walton/ Chris Maj
                  Recovery/ Depot LES’s                        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
                  Mental Health Commissioning
                                                               data - 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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                                                                                                                    dcfe0cc3-b7ea-4287-ab35-a96155835f3e.xls                                                                                         Agenda no. 11


                                                                                                                                                 Risk
                                                                                                                                                 Rating   How do you
         Phase/                                                                                                                                  (High    intend to                  Engagement
         Key                                                                                                                      What are the   Medium   mitigate         3rd party Strategy /   Initiation Completion   Person's)               RAG
         Stage    Key Tasks                           Ref       Actions to complete the key task                                  key risks?      Low)    these 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)                       3.2 Agree audit framework for NICE adherence.                                                                                             1/12/08     3/1/2009 MM/HOS
                  Commissioners will be
                  provided with an annual audit
                                                                                                                                                                                                                           MM/ team managers/
                  report.
                                                            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.                             Liaison with Gateway and Advice Services in order to                                                                                                     Jim Thomas/ Donna
                    c) 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
                                                                                                                                                                                                                         Jim Thomas/ Julie
                  utilisation of PD services
                                                                Identify current numbers of appropriately trained staff and                                                                                              Chadwick/ Team and
                  commissioned from a range of
                                                            4.3 current provision of training.                                                                                                        1/10/08        TBA Ward Managers
                  providers.
                                                                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                    Arrange first GP forum and issue invitations to relevant 5BP,
                  talk through service provision,               GPSIs, LA and PCT representatives to discuss proposed
                  job 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                5.3 call.                                                                                                                                 1/10/08    12/1/2008 Helen McColm
                  practice visits.
                       c) Establishment of GP / 5
                  Borough clinical forum                                                                                                                                                                                   Helen McColm/Robin
                                   d) Production of         5.4 Commence practice visits                                                                                                              1/10/08    11/1/2008 Evans
                  a communication strategy for
                  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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                                                                                                                     dcfe0cc3-b7ea-4287-ab35-a96155835f3e.xls                                                                                          Agenda no. 11


                                                                                                                                                  Risk
                                                                                                                                                  Rating   How do you
         Phase/                                                                                                                                   (High    intend to                  Engagement
         Key                                                                                                                       What are the   Medium   mitigate         3rd party Strategy /   Initiation Completion    Person's)               RAG
         Stage    Key Tasks                           Ref       Actions to complete the key task                                   key risks?      Low)    these risks?   involvement Comms Plan   date       date          responsible             status
         Work stream 6 - Implement Recommendations of Sir Jonathon Michael Report - Liz Price-Jones
                  a) The relevant
                                                                                                                                                                                                                            DG/ JW/ Karen
                  recommendations of the Sir
                                                                                                                                                                                                                            Green/ Stephanie
                  Jonathan Michael report.
                                                                Liaise with PCT and LD lead to identify relevant                                                                                                            McComb/ Peter
                  “Healthcare for all” are fully
                                                            6.1 recommendations in Health Care for All.                                                                                               01/10/08     1/1/2009 Harrison
                  implemented.
                     b) Evidence of                                                                                                                                                                                         DG/ JW/ Karen
                  implementation of the                                                                                                                                                                                     Green/ Stephanie
                  recommendations is reported               6.2 Implement relevant recommendations of 'Healthcare For All'.                                                                           01/10/08     4/1/2009 McComb/
                  to commissioners on a 6
                  monthly basis.        c) 5
                                                                Provide report to commissioners to show evidence of
                  Boroughs participate in the               6.3 implementation.                                                                                                                       01/10/08     4/1/2009 DG/ JW
                  Commissioner led working
                  group being established to
                  monitor implementation                        Identify local representatives to participate in monitoring                                                                                                 DG / JW/ Liz Price
                             d) Revised                     6.4 implementation via Commissioner-led working group.                                                                                    01/10/08    12/1/2008 Jones
                  protocols are in place between
                                                                                                                                                                                                                            DG/ JW/ Karen
                  Mental Health and local                                                                                                                                                                                   Green/ Stephanie
                  Learning disability services              6.5 Agree revised LD/Mental Health referral protocols.                                                                                    01/10/08     2/1/2009 McComb
                  concerning access to mental
         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
                                                            7.1 cover.                                                                                                                                01/10/08    10/1/2008 Costello
                  the 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                      Identify and agree maximum urgent and routine waiting times                                                                                                 Linda Kelli/ Barbara
                  provision of services to RAEI,            7.3 for access to CAHMs services.                                                                                                         01/10/08    12/1/2008 Costello/ Tessa Myatt
                  in line with the expectations of
                  “Making it Better”
                   e) To work collaboratively
                  within the above                                                                                                                                                                                          Linda Kelli/ Barbara
                  arrangements.                  f)         7.4 Agree CAHMs lead for the Wigan Borough                                                                                                01/10/08    12/1/2008 Costello/ Tessa Myatt
                  The development of a CAMHS
                  Borough wide workforce plan
                  in line CSIP/ SHA guidance
                  and the identification of a                                                                                                                                                                               Linda Kelli/ Barbara
                  relevant lead.                            7.5 Develop a workforce plan in line with CSIP/SHA Guidance.                                                                              01/10/08     1/1/2009 Costello/Tessa Myatt




Page 5                                                                                                                                                                                                                       Wigan Service Improvement Plan
                                                                                                                     dcfe0cc3-b7ea-4287-ab35-a96155835f3e.xls                                                                                                  Agenda no. 11


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




Page 6                                                                                                                                                                                                                              Wigan Service Improvement Plan
                                                                                                                       dcfe0cc3-b7ea-4287-ab35-a96155835f3e.xls                                                                                                    Agenda no. 11


                                                                                                                                                     Risk
                                                                                                                                                     Rating   How do you
         Phase/                                                                                                                                      (High    intend to                  Engagement
         Key                                                                                                                          What are the   Medium   mitigate         3rd party Strategy /   Initiation Completion           Person's)                 RAG
         Stage    Key Tasks                            Ref        Actions to complete the key task                                    key risks?      Low)    these 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             10.2 Continue participation in PCT Suicide Audit Group                                                                                      01/06/08 01/06/08 on going Cheryl Forrest/ C Maj
                  an agreement between the
                  Borough Chair of the Suicide
                                                                  Establishment of local 5bp SUI Oversight Group to respond                                                                                                         Cheryl Forrest/ Helen
                  Audit Group and the 5
                                                             10.3 and 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                    Agree revised data/information to be providied to PCT Suicide
                  of 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                                                                                                          McColm/ Alex
                                                             10.8 SUI 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                   11.1 practise.                                                                                                                              01/10/08 on going            Chilton
                  notification to GP’s of non –
                  urgent changes in medication,
                  dose or frequency within 2                      Medical staff will provide clear, written notification of changes
                  working days. Any urgent                   11.2 to non-urgent prescriptions within 2 working days.                                                                                     01/10/08            1/1/2009 Norman Harvey
                  notifications must take place                   Notification of urgent changes to medication will take place
                  within the working day.                    11.3 within the working day.                                                                                                                01/10/08            1/1/2009 Norman Harvey
                                     c) All
                  prescribing will be in line with                All proposed changes to current Shared Care arrangements to
                  jointly agreed protocols.                       be fully costed, including further resource costs re storage,
                                    d) Clinicians            11.4 dispensing, delivery e.t.c.                                                                                                            01/10/08         12/1/2008 Lorraine Prescott
                  will not deviate from the                       Shared Care' protocols to be agreed for all 'Amber' drugs.
                  agreements made between the                     disseminated to all medical staff for immediate implementation                                                                                                      Norman Harvey/
                  PCT and the 5 Boroughs.                    11.5 in prescribing practice.                                                                                                               01/10/08            1/1/2009 Lorraine Prescott
                               e) Annual audit of
                  compliance with the above
                  requirements.                   f)              Shared Care' protocols disseminated to all medical staff for
                  5 Boroughs contract will be                11.6 immediate implementation in prescribing practice.                                                                                      07/11/08            1/1/2009 Norman Harvey
                  amended to reflect the above               11.7 Plan for annual audit of compliance to be designed.                                                                                    01/10/08            6/1/2009 Lorraine Prescott
                  requirements.


                                                             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




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                                                                                                                                           Risk
                                                                                                                                           Rating   How do you
         Phase/                                                                                                                            (High    intend to                  Engagement
         Key                                                                                                                What are the   Medium   mitigate         3rd party Strategy /   Initiation Completion    Person's)            RAG
         Stage    Key Tasks                        Ref        Actions to complete the key task                              key risks?      Low)    these 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
                                                                                                                   dcfe0cc3-b7ea-4287-ab35-a96155835f3e.xls                                                                                         Agenda no. 11


                                                                                                                                              Risk
                                                                                                                                              Rating   How do you
         Phase/                                                                                                                               (High    intend to                  Engagement
         Key                                                                                                                   What are the   Medium   mitigate         3rd party Strategy /   Initiation Completion       Person's)             RAG
         Stage    Key Tasks                         Ref         Actions to complete the key task                               key risks?      Low)    these 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                     13.1 Identify baseline current activity and capacity                                                                                   01/10/09       11/1/2008 S.Eid/ Pat Smith
                  Mentally Disordered Offenders
                                                                Partcipate in meetings re Greater Manchester review of
                  services.                   b)
                                                           13.2 Mentally Disordered Offenders services.                                                                                           01/10/09       11/1/2008 S.Eid/ Pat Smith
                  Review Borough wide MDO
                  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                    Identify number of admissions, length of stay, occupancy and
                  to inpatient mental health                    readmissions to inpatient unit for two consecutive 12 month
                  services over a 12-month                 14.1 periods (Apr 07 to 08, and Apr 08 to 09)                                                                                          01/10/08        5/1/2009 IP Service manager
                  period.                      b)
                  Develop a costed business
                  case (to the satisfaction of
                  commissioners) which will be
                  publicly consulted upon, to                   Elicit service user and carer views via quarterly standard                                                                                   Jan 09 and 3 IP Service manager/
                  propose improvements to                  14.2 satisfaction questionnaires.                                                                                                      01/09/08 monthly on going SU & Carer reps
                  inpatient services that focus
                  upon improved quality and an
                  appropriate reduction in bed
                  numbers to national
                  benchmarks. The business
                                                                Develop costed business case to propose improvements to in                                                                                                 IP Service Manager/
                  case must reflect the
                                                           14.3 patient services.                                                                                                                 01/10/08       10/1/2009 HOS/ Ben Nuttall
                  commissioners’ specification
                  and be in line with best
                  practice.                    c)
                  The proposal will be revenue
                  neutral for commissioners and
                                                                Report any cost savings to commissioners to enable service
                  if savings are identified they
                                                           14.5 need/demographically appropriate reallocation of resources                                                                        01/10/08       10/1/2009 HOS
                  will be declared to




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                                                                                                                    dcfe0cc3-b7ea-4287-ab35-a96155835f3e.xls                                                                                            Agenda no. 11


                                                                                                                                                  Risk
                                                                                                                                                  Rating   How do you
          Phase/                                                                                                                                  (High    intend to                  Engagement
          Key                                                                                                                      What are the   Medium   mitigate         3rd party Strategy /   Initiation Completion     Person's)               RAG
          Stage    Key Tasks                          Ref        Actions to complete the key task                                  key risks?      Low)    these 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            1.1 Agree with informatics to develop appropriate recording system.                                                                      01/10/08    11/30/2008 Graham Spratt
                   position to submit the IAPT
                                                                 Liaise with PCT IT Dept to establish capacity of CORE NET to
                   Vital Signs Monitoring (VSM)
                                                             1.2 collect Vital Sign Data.                                                                                                             01/10/08    11/30/2008 Graham Spratt
                   data lines 3a, 3b and 4, 5,6
                   and 7 as outlined in the                      Establish 'best fit' of non-mental health PTS to data recording
                   detailed technical definition             1.3 requirements.                                                                                                                        01/10/08    11/30/2008 Liz Price Jones
                                      b)The 5                                                                                                                                                                                Janet Winstanley/
                   Boroughs will have developed                  Service managers to ensure data collection is delivered to                                                                                                  Jane Kenny/ Liz Price
                   a plan to market Psychological            1.4 acceptable quality and standards                                                                                                     01/10/08    11/30/2008 Jones
                   services as a 'Health service'
                   and not as a'mental health'
                                                                 Produce a policy/ philosophy statement to communicate the
                   service            c) Locally
                                                             1.5 concept of 'health' service.                                                                                                         01/10/08    12/31/2008 Graham Spratt
                   based psychological treatment
                   for people with a mild to
                   moderate learning disability                  Produce a business plan to demonstrate locality based
                   will be present in each of the            1.6 psychological treatment for LD service users.                                                                                        01/10/08     3/31/2009 Liz Price Jones
                   three localities supported by
                   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             1.7 Prepare for IAPT Data collection for LD Service users.                                                                               01/10/08      6/1/2009 Liz Price Jones
                   IAPT dtat set. d) the
                   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           1.9 specification.                                                                                                                       01/10/08     4/30/2009 Janet Winstanley
                   PTS will have developed 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




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                                                                                                                                                  Risk
                                                                                                                                                  Rating   How do you
          Phase/                                                                                                                                  (High    intend to                  Engagement
          Key                                                                                                                      What are the   Medium   mitigate         3rd party Strategy /   Initiation Completion    Person's)             RAG
          Stage    Key Tasks                          Ref       Actions to complete the key task                                   key risks?      Low)    these 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                     Identify baseline activity of A&E Liaison Services Apr 07 to Apr                                                                                            Jim Thomas/ Robin
                   ensure compliance with recent            2.1 08, including out of hours referrals to CRHT.                                                                                         01/10/08    11/1/2008 Evans
                   policy 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
                                                            2.2 service that do not comply with recent policy guidance.                                                                               01/10/08     1/1/2009 Hanson
                   E Liaison services, including
                   training, consultation and
                   assessment services.                         Produce business case for provision of comprehensive A&E
                                   c) Production of         2.3 Liaison Service to include training costs.                                                                                            01/10/08    11/1/2008 Jim Thomas
                   an Implementation plan for the
                   development of the service.
                                           d)               2.4 Produce service implementation plan                                                                                                   01/10/08    11/1/2008 Jim Thomas
                   Agreement on access to
                   psychological services where
                   appropriate.                                                                                                                                                                                             Jim Thomas/ Graham
                      e) Protocol developed with            2.5 Agree appropriate access to Psychological Services.                                                                                   01/10/08    11/1/2008 Spratt.
                   neighbouring A and E
                   departments regarding access                 Liaise with neighbouring A&E departments to develop transfer
                   and transfer to local services           2.6 protocols for ALW service users.                                                                                                      01/10/08     2/1/2009 Jim Thomas
                   for individuals registered with
                   ALW GP’s.
                                                                Design and agree provision of liaison services to Leigh
                       f) Arrangements should be
                                                            2.7 Infirmary Walk In centre.                                                                                                             01/10/08     1/1/2009 Jim Thomas.
                   made for the provision of
                   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,                    Include provision of appropriate medical input to RAE Infirmary                                                                                             Norman Harvey/ Jim
                   when 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 '.                                                                                                                                                                                Norman Harvey/ Jim
                                  c) Reporting of           3.2 Develop protocols to support appropriate medical input to A&E.                                                                        01/10/08    12/1/2008 Thomas
                   waiting times to access all
                   medical staff out of 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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                                                                                                                                               Risk
                                                                                                                                               Rating   How do you
          Phase/                                                                                                                               (High    intend to                  Engagement
          Key                                                                                                                   What are the   Medium   mitigate         3rd party Strategy /   Initiation Completion           Person's)                 RAG
          Stage    Key Tasks                         Ref       Actions to complete the key task                                 key risks?      Low)    these 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)                   4.2 Manage transition of existing staff (Beacon Day Hosp)                                                                               01/09/08          11/1/2008 C.Maj
                   Development of service
                   description for complex CMHT            4.3 Agree increased consultant input to Phase 1 Site (Wigan)                                                                            01/09/08          12/1/2008 C.Maj/Glynn Thomas
                   element of service
                                                           4.4 Begin recruitment of staff Phase 1 (Wigan)                                                                                          01/09/08          12/1/2008 C.Maj
                                c) Development of
                   operational 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             Record caseload and co working activity for Dual Diagnosis                                                                                     18/11/08 monthly Jim Thomas/ Dual
                   plan 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                       1.2 Agree baseline finance and activity                                                                                                 01/10/08          12/1/2008 Marshall
                   performance targets.

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




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                                                                                                                                              Risk
                                                                                                                                              Rating   How do you
          Phase/                                                                                                                              (High    intend to                  Engagement
          Key                                                                                                                  What are the   Medium   mitigate         3rd party Strategy /   Initiation Completion    Person's)                RAG
          Stage    Key Tasks                         Ref       Actions to complete the key task                                key risks?      Low)    these 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
                   activity data requested by the
                                                                                                                                                                                                                        Helen McColm/Ben
                   PCT.                        b)
                                                               Provide information re finances and activity as requested by                                                                                             Nuttall/ Informatics
                   Agreed baseline of finance and
                                                           1.1 PCT.                                                                                                                               01/10/08    12/1/2008 team
                   activity.
                     c) Agreement of                                                                                                                                                                                    Sam Oliver/ John
                   performance targets.                    1.2 Agree baseline finance and activity                                                                                                01/10/08    12/1/2008 Marshall
                                                                                                                                                                                                                        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          2.1 set.                                                                                                                               01/09/08     4/1/2009 Thompson
                   SLAs between practice
                   consortiums and the 5
                   Boroughs that outline the level             Agree outline expected level of service and Service Level                                                                                                HOS/ Cheryl Forrest/
                   of service they can expect.             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               3.1 dissatisfaction..                                                                                                                  01/10/08    12/1/2008 Walton/ Cheryl Forrest
                   targets against current
                   outcome measures e.g. User,                 Identify and agree an appropriate set of outcome measures                                                                                                Cheryl Forrest/ John
                   carer and GP satisfaction.              3.2 with commissioners.                                                                                                                01/10/08     3/1/2009 Marshall
                             c) To develop
                   appropriate systems to monitor
                   and report those outcomes at                                                                                                                                                                         Cheryl Forrest/
                   a PCT and 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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                                                                                                                                               Risk
                                                                                                                                               Rating   How do you
          Phase/                                                                                                                               (High    intend to                  Engagement
          Key                                                                                                                   What are the   Medium   mitigate         3rd party Strategy /   Initiation Completion          Person's)             RAG
          Stage    Key Tasks                         Ref         Actions to complete the key task                               key risks?      Low)    these 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                                                                                                             Jim Thomas/ Shirley
                   the Assertive outreach service.         1.2 actions to meet required number of 721.                                                                                             01/04/08          3/31/2009 Myers
                            d) Teams are staffed               Monitor Assertive Outreach Team caseload to ensure target                                                                                                       Jim Thomas/ Anthony
                   in line 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).                                                                                                                                                                                         Jim Thomas/ Shirley
                        f) Weekly reporting of                                                                                                                                                              01/12/08 weekly, Myers/ Chris Kelly/
                   progress against a) and b)              1.4 Weekly reporting of progress towards target figures.                                                                                01/04/08         on going Anthony Critchley
                                  g) Production of             Produce Action Plan to ensure target figures for LDP services
                   action plan to ensure                   1.5 are achieved.                                                                                                                       01/10/08          12/1/2008 Jim Thomas.
                   achievement of a) and b).
                                                               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




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