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Quality Management Office Balanced Scorecard

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					POWYS LOCAL HEALTH BOARD CORPORATE BALANCED SCORECARD 2005/06 (As at July 2005)


 Strategic
                                              Goals                                 Apr   May   Mth End Q1       Jul      Freq                                                  Comments
 Objective

                                                                                                                                 It is important to note that all T&O patient breaches have now been offered appointments
                Optimising Service Devlivery:
                                                                                                                                 under the orthopaedic development plan

                SaFF 4: IP/DC - All Pts. to be seen within 12 months
                                                                                     8    17        13            14       M
                (ex.Cataracts)
                                                                                                                                 (Ex. Powys provider) All waits relate to T&O. Waits at:     Gwent 7, C&V 6 & Swansea 1
                                                                                                                                 (Powys provider figures only) (Powys SC Figures only) All waits relate to Hereford W/L. Breaches
                                                                                                                                 have arisen due to the fact that the LHB has recently taken on responsibility of the Hereford Orthopaedic
                                                                                                                                 W/L but are restricted to manage within the 2004/05 activity baseline.
                SaFF 4: IP/DC - LHB SC element should maintain & improve on
                                                                                     0     5        26            34       M     Two main factors have influeneced the delay in managment of these lists:
                March 2005 position. (March no waits > 12months)
                                                                                                                                 1) The LHB has only just received confirmation (12/07/05) of the value of T&O monies.
                                                                                                                                 2) The LHB is still negotiating 2nd Offer monies, WAG to be involved in the contracting process during
                                                                                                                                 2005/06.
                                                                                                                                 (Excludes Powys provider) All waits are at RSH. Arrangements in place to offer all patients
                SaFF 4: Cataracts - no one waiting more than 4 months               22    42        40            29       M
                                                                                                                                 alternative appointments under the 2nd Offer Scheme

                SaFF 4: LHB SC Cataracts - no one waiting more than 4 months         0     0        1                 0    M
                                                                                                                                 (Powys provider Figures only)
                SaFF 5: OP - All Pts. to be seen within 12 months for 1st                                                        (Ex. Powys provider)     Of which 131 are T&O waits at RJAH. These are all being addressed as part of
                                                                                    92    244      249           221       M
                appointment                                                                                                      2nd Offer

                SaFF 5: OP - LHB SC element should maintain or improve on                                                        (Powys provider figures only) (Powys SC Figures only) All waits are for orthodontics for the North of
                                                                                    44    52        69           88        M
                March 2005 position. (March waits =/>12 = 38 orthodontics)                                                       Powys. Commissioning & Operational Teams currently working together to resolve capacity problems

Equitable and SaFF 8: All Pts. To be seen within new cancer w/times standard
Timely Access from start of definitive treatment by 31st Dec '06 (1 month & 2                                                    (Self Reporting) Quarter 1 waits have been reported & targets were met. LHB working with cancer
 to Services months)                                                                                                             networks & information group to establish robust reporting mechanisms to comply with WHC(2005)027.
                                                                                                                           Q
                                                                                                                                 LHB to use CANISC as the tool to capture & report cancer waiting times (as recommended by WAG) This
                SaFF 8: WAG interim targets in respect of above SaFF, by 1st                                                     has been requested & agreed, LHB currently awaits implementation
                Sept '05
                SaFF 9: All Pts to have access to core sexual health services
                                                                                                                          Q2/Q
                within 2 working days by 31st March 2006
                                                                                                                                 (Self Reporting of progress on achievment of milestones in Action Plan, No. Pts waiting over 2 days)
                SaFF 9: Access to emergency contraception s/be provided within
                                                                                                                          Q2/Q
                24hrs by 31st March 2006

                SaFF 10: All Pts to have access to appropriate GMS's within                                                      (QOF return fom LHBs) 16 out of the 17 practices have confirmed all pts have appropriate access to
                                                                                                                           Q
                24hrs, or sonner in an emergency by 31st March 2006                                                              services

                SaFF 3: From April 2005 CAMHs teams should aim to provide
                consultation & advice to professionals in Tier 1 within 4 weeks -                                          Q     (Self Reporting) Access to information being investigated, work ongoing
                Target date full implementation March 2006

                SaFF 3: All pts to be seen within 6 months for routine
                assessment & intervention - Target date 31st March 2007.                                                   Q     (Self Reporting) No waits currently > 6 months
                Interim target to be set by WAG for Sept '05

                SaFF 15: 95% of patients to spend less than 4 hours in A&E
                from arrival until admission, transfer or discharge.                                                             Checking access to information with BSC - Likely that only Welsh Trust informaiton will be available
                (Commissioning)

                SaFF 15: No one should wait longer than 8 hrs for admission,
                                                                                                                                 Checking access to information with BSC - Likely that only Welsh Trust informaiton will be available
                discharge or transfer (Commissioning)




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POWYS LOCAL HEALTH BOARD CORPORATE BALANCED SCORECARD 2005/06 (As at July 2005)


 Strategic
                                               Goals                                 Apr     May     Mth End Q1         Jul      Freq                                                  Comments
 Objective


                Satisfied Patients - No. of formal compalints                         26      22         36              48       M     (Self Reporting) Of the 48, 24 were formal & 24 informal complaints


                                                                                                                                        Annual data available, investigating access to quarterly data with BSC. During '04/05 there was an
                Reduction in the number of procedures with limited effectiveness                                                  Q
                                                                                                                                        increase in the number compared to previous year. The figure in '03/04 was 233.

                                                                                                                                        It is important to note that the increase in numbers from previous quarter is largely due to
                                                                                                                                        improved monitoring & submission of returns from link nurses. It is also importtant to note
                                                                                                                                        that figures do not separately identify those screened positive with MRSA on admission to
                Reduction in healthcare associated infection rates (secondary
                                                                                                         85                       Q     Powys.Period covered mid March - we 3rd June Figure relates to total number of acquired hospital
                care services within LHB)
                                                                                                                                        infections. Last quarter number = 37. Period covered Mid March - we 3rd June 2005. In relation to MRSA
                                                                                                                                        & Clostridium, there were 34 cases MRSA & 10 cases Clostridium, last quarter figures for these
                                                                                                                                        organisms were 68.

                SaFF 19: Health communities to work together to ensure that
                processes are in place & placements are available in order to
High Quality    reduce the delayed transfers of care in mental health services for     1       3          3                  2    M     Figures relate to Old Age Psychiatry
  and Safe      adults of working age & older people by 15% compared with a
  Services      2004/05 average by 31st March 2006

                                                                                                                                        Based on 2004/05 achievement the quality & outcomes framework gives the LHB a cost pressure for
                SaFF 20: 80% of GP practices to achieve at least 700 points in
                                                                                                                                  Q     2005/06 . This cost pressure is likely to increase in year as practices strive to achieve the maximum
                the GMS Quality & Outcomes Framework by 31st March 2006
                                                                                                                                        number of points per practice. (1050 per practice)

                SaFF 21: To implement the 6 directed enhanced services as
Equitable and outlined in WAG guidance on 14/10/03 & 31/03/04 & to
Timely Access commission at least 4 from the national or local lists in line with
                                                                                                                                  Q     (Self Reporting)
 to Services local health needs by 31st March 2006

                SaFF 26: Health communities to work together to achieve a
                15% reduction in delayed transfers of care for all reasons            12      10          9                  5    M     (Figures exclude the Old Age Psychiatry DToC figures shown above)
                (excluding mental health) against a baseline 14
                                                                                                                                        (Self Reporting) Powys LHB achieved an overall score of 67% compliance in the 2004/05 WRP audit.This
                Compliance with Welsh Risk Management Standards                                         67%                       Q     is a 4% improvement on last years score of 63%. The LHB is required to achieve a 75% overall
                                                                                                                                        compliance score. Quarterly monitoring of action plans will be undertaken

                Low staff turnover rates                                             1.22%   1.01%     1.34%          0.91%       M     (Excludes BSC & CHC figures)
 Engaged
 Workforce      Low sickness rates (Target 4.2%)                                     7.24%   6.64%     5.01%          4.33%       M     (Excludes BSC & CHC figures)

                Positive staff satisfaction surveys                                                                               Q2

                Childhood immunisation - Higher take up of Immunisation
                services compared to end of 04/05 baseline

                % uptake range of children reaching their 1st birthday during
                                                                                                      92 - 93.6%                  Q     D3,T3, P3, HiB 93.6%, Po3 94%, Men C 92%.
                quarter.
 Preventive % uptake range of children reaching their 2nd birthday during
   Health                                                                                            76.9 - 94.3%                 Q     D3, T3 94.3%, ,P3 93.2%, Hib 93.6%, MenC 93.9%, Po3 93.9%, MMR(1 dose) 76.9%
              quarter.
Initiatives &
Health Gain % uptake range of children reaching 5th birthday during                                  74.6 - 93.8%                 Q
                                                                                                                                        D3 93.2%, T3 93.8%, P3 91.3%, Po3 93.5%, Hib3 93.2%,         Men C 92.6%, MMR (1 dose) 12%, MMR(2
                quarter.                                                                                                                doses) 74.6%, D4 86%, T4 85.8%, aP 83.3%, Po4 85.4%

                % uptake range of children reaching 6th birthday during quarter.                      71 - 83.1%                  Q     MMR(1dose) 14.4%, MMR(2 doses) 71.2, D4, T4 83.1%, aP 78.7%, Po4 82.8%

                % uptake range of girls reaching 13/14th birthday during
                                                                                                     86.2 & 83.7%                 Q     86.2% immunised by 13th birthday, 83.7% by 14th birthday
                quarter.




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POWYS LOCAL HEALTH BOARD CORPORATE BALANCED SCORECARD 2005/06 (As at July 2005)


 Strategic
                                              Goals                                 Apr       May       Mth End Q1         Jul        Freq                                                  Comments
 Objective


 Adherence      Remain within Resource limit (forecast out-turn)                                                                       M     Financial Monitoring Return Table A
 with Core
  Financial     Remain within Cash limit (forecast out-turn)                                                                           M     Financial Monitoring Return
   Duties
                Accurate forecasting                                                                                                   M     Financial Monitoring Return .

                Reduced use of Agency Staff in respect of secondary care                       -20.9%
                                                                                                                                             A positive figure indicates an increase from the same period in the previous yr and a minus figure
                                                                                                                         -95.6%        Q
                services within LHB                                                                                                          indicates a decrease.

                Efficient Operational Performance including Estates:

                (1) % achievement against 5 NPI's                                                                    To be provided    Q

                (2i) % cancelled outpatient appointments (ex. DNA's)                10.0%     10.2%       10.9%         11.63%         M     (Powys provider element )

                (2i) % cancelled outpatient appointments (inc. DNA's)               9.3%      9.5%        10.0%         10.72%         M     (Powys provider element )

                (3) EFFICIENCY REQUIREMENT: SC element to ensure the actual         82.9%     75.7%       87.3%          84.5%         M     Brecon % - In July planned hours = 48, actual used hours = 41
                run hours of theatre lists as a % of their session planned hours
                are at least 90% for elective by 31st March 2006 (Number
                planned sessions s/be 100%)                                         75.0%     81.3%       80.5%          75.9%         M     Llandrindod Wells % - In July planned hours = 29, actual used hours = 22. 2

                (4) Number of operations cancelled within SC setting LHB to be
                                                                                                                                             Figures made up as follows: BWM cancellations by Surgeon =5, at LWH cancellations as follows: Patient
                reduced by 10% by 31st March 2006 (based on end March '05             6         3           11              17         M
                                                                                                                                             DNA = 2, Patient cancellation = 8, surgeon cancellation = 1 & Hospital cancellation = 1
                figures - target 6)

                (5) % of operations cancelled (SC element)                          5.3%      3.2%        10.6%          19.8%         M     Total number of operations in July = 86, 17 cancellations
Equitable and
Timely Access (6) Appropriate use of daycase facilities (secondary care element
 to Services of LHB)                                                               83.58%    87.75%       91.83%        85.29%         M     Overall Target 75%
Efficient Use of
   Resources     (7) EFFICIENCY REQUIREMENT: Required to meet/maintain
                CHKS Daycase target rates by 31st March 2006:
                Inguinal Hernia Target 51%                                         100.00%   83.33%          -          60.00%         M

                Varicose Veins Target 61%                                          100.00%   83.33%          -                  -      M

                Bunions Target 26%                                                    -      100.00%         -                  -      M

                Arthroscopy Target 67%                                             88.80%    83.33%      100.00%       100.00%         M

                Cataract Extraction Target 97%                                     96.42%    95.00%      100.00%       100.00%         M

                D&C/Hysteroscopy Target 79%                                        100.00%      -            -                  -      M

                Laparoscopy Target 72%                                             72.72%    60.00%       80.00%                -      M
                (8) Average length of stay for Care Elderly.GP Medical - target
                                                                                    30.23     27.74        27.04          24.26        M     Care Elderly, GP Medical (SC element LHB) LHB has set internal target of 18days
                18 days
                        Average length of stay AMI                                  44.44     51.22        39.30          35.92        M     AMI (SC element LHB)
                        Average length of stay EMI                                  72.5      55.14        86.11          53.00        M     EMI (SC element LHB)

                                                                                                                                             (Self Reporting) Outline action plan complete. The 1st quarters baseline data for the new indicators is
                SaFF 27: Meet the five high level All Wales Medicines Strategy                                                               not yet available from HSW, for the LHB to be able to assess actions to be taken. This data will not be
                                                                                                                                       Q
                Group prescribing indicator targets by 31st March 2006                                                                       available until end August. . Discussions are still onging in respect of setting baseline targets for a
                                                                                                                                             number of the new 2005/06 indicators.




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POWYS LOCAL HEALTH BOARD CORPORATE BALANCED SCORECARD 2005/06 (As at July 2005)


 Strategic
                                              Goals                                    Apr   May   Mth End Q1       Jul   Freq                                                  Comments
 Objective


                SaFF 2:To deliver all identified core key actions, relevant to NHS
                Wales, of the NSF for Children, Yound People & Maternity                                                   Q3    (Self assessment Tool kit published August)
                Services by 31st March 2006
                SaFF 12: As part of Cancer Network membership, LHB to deliver
                the priorities identified within costed plan & financial assumptions
                by 31st March 2005
                                                                                                                           Q     (Self Reporting) Work underway to agree implementation plan with Regional Office by October 2005
                SaFF 12: Agree an implementation plan that identifies a set of
                proritized actions for delivery in 2006-07 by 1st October 2005


                SaFF 13: Reflecting the costed plans for CHD & financial
                planning assumptions, & through membership of the Cardiac                                                        (Self Reporting) CHD plan in place. To date the service is being developed in the North of Powys, a nurse
                                                                                                                           Q
                Network LHB to focus on the delivery of secondary prevention &                                                   appointment has been made in Brecon. Gwent & Powys await joint appointment of Cardiologist.
                secondary care priorities in '05/06 by 31st March 2006

                SaFF 16: Health communities to work together to ensure
                medical emergency admissions are reduced by 5%, against 2003-
                                                                                                                                 LHB looking to commission a 5% reduction in emergency admissions across LTA portfolio. 3 Emergency
                04 baseline, through development of needs based Chronic
                                                                                                                           Q     Admissions Commissioning Groups are being established for the North, Mid & South of Powys. LHB loking
                Disease Pathways across 5 key areas, in line with central
                                                                                                                                 to develop pathways & is currently working with GPs on emergency admission pathways.
                emerging policy & utilising the Quality Framework of the GMS
                contract by 31st March 2006

                                                                                                                                 Action plan prepared & submitted to WAG, this plan will be monitored by Regional Office on a quarterly
                SaFF 17: LHB to put in place mental health "crisis resolution &
                                                                                                                           Q     basis. Non-recurrent funds of £119,500 has been successfully received. Task & finish group will be set up
Equitable and home treatment" services by 31st March 2006                                                                        to pursue actions identified within plan
Timely Access
 to Services
 Partnership SaFF 18: Improve the therapeutic outcomes & de-stigmatise the
   Working                                                                                                                       A lead has been identified to take plan forward. Two workshops have been held to discuss issues, an
              mental health ward environment for adults of working age &
                                                                                                                           Q     action plan will be prepared to monitor progress. The LHB is likley to persue the recovery model
                older persons through the implementation of the Tidal or Re-
                                                                                                                                 identified within Adult Mental Health Stategy
                focusing model of care by 31st March 2006


                SaFF 24: Using the results of the Stroke Sentinel Audit (2004)                                             Q     Stroke Care action plan developed, implementation of pathways underway
                health communities must develop plans & care pathways
                consistent with emerging policy, incl. the establishment of stroke
                registers in 60% of GP practices by 31st March 2006                                                        Q     (PC target) 100% compliant with stroke registers all GP practices have stroke registers in place



                SaFF 25: In accordance with WHC (2002)32 joint health & social
                care assessments will be for all adult service user groups                                                       Progress is proceeding, however without appropriate information technology support there will continue
                                                                                                                           Q
                resulting in a Unified Assessment summary record &, where                                                        to be issues in meeting this target without causing unreasonable burden to staff
                appropriate, an integrated Personal care Plan by 31st March 2006


                To take forward the development of Local Care Teams & Primary                                                    Detailed LCT proposals approved by Executive Directors and EMT. Medical practices involved in the first
                Care Collaboratives to enhance multi-disciplinary team working &                                           Q     phase contacted. Meeting with PMs to take place August 2005. Implementation timetable under
                service provision in primary care                                                                                development. Information leaflet for LCT members developed. Target remains unchanged.

                                                                                                                                 Work on target for completion Autumn 2005 with final strategy being presented to October 2005 Board
                To develop & submit a Primary Care Estates Strategy in                                                           meeting. 2 stakeholder briefing sessions held mid June 2005. First stakeholder option development
                                                                                                                           Q
                accordance with WAG guidance                                                                                     workshop held 14th July 2005. Second workshop to be held 29th July 2005; this to include option
                                                                                                                                 appraisal. Target remains unchanged.

                Continued Implementation of the Diabetes NSF                                                               Q     (Self Reporting) Priorities have been identified within action plan. LHB working towards implementation




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POWYS LOCAL HEALTH BOARD CORPORATE BALANCED SCORECARD 2005/06 (As at July 2005)


 Strategic
                                             Goals                               Apr                    May      Mth End Q1             Jul               Freq                                                  Comments
 Objective

                Effective Planning Mechanisms: (Questionnaire)                                                                                             Q3    (Self Assessment Questionnaire)

                                                                                                                                                                 Original deadline of 1st October put back to 1st April 2006. LHB has set a local target to establish 3 new
                SaFF 22: To implement & comply with the new contractual                                                                                          dental practices & complete 3 PDS applications. To date 1 dental practice will open in Builth in August
                                                                                                                                                           Q
                arrangements for NHS dentistry by 1st October 2005                                                                                               '05, 1 PDS application has been apporoved in conjunction with WAG with further applications currently
                                                                                                                                                                 under consideration.

                                                                                                                                                                 All actions required of LHB achieved by target date. Further action on OOH community pharmacy
                SaFF 23: To implement the new contractual arrangements for
                                                                                                                                                           Q     services currently being undertaken to plan. Proposals for revisions currently under consideration.
                NHS Pharmacy by 1st April 2005
                                                                                                                                                                 Shropdoc to be involved weekend/bank holiday arrangements
                To progress implementation of Health & Social care Wellbeing
                                                                                                                                                           Q     (Self Reporting) Implementation action plan agreed
                Strategy

                To progress implementation of Wanless Action Plan                                                                                          Q     (Self Reporting)

                Achievement of deadlines for completion of the Annual SaFF                                                                                 I     (Self Reporting) Six monthly report will be submitted at October's EMT

                Achievement of key financial deadlines                                                                                                     M

                Effective Financial Processes:
                                                                                                                                                                 Financial monitoring returns. Table D. The % value paid this month wasxx%. Figures relate to NHS &
                Achievement of Public Sector Payment requirement                                      92.25%        93.4%             93.0%                M
                                                                                                                                                                 Non NHS invoices

                Efficient cash Management                                                                                                                  M     Financial monitoring Returns.

Equitable and
 Management Financial plans to address variance in line with operational plans                                                                             M     Financial monitoring Returns.
Timely Access
Processes that
 to Services
  support the
  delivery of  Effective referral and admission processes:
timely quality
   services    Referral / admission protocols in place                                                                                                     Q     To be reviewed & monitored following the implementation if the GP in hours hospital contract

                Effective IP/DC admission, bed management and                                                                                                    Discharge processes in place, bed mgt policies are being developed in line with the introduction of the GP
                                                                                                                                                           Q
                discharge processes:                                                                                                                             in hours hospital contract

                (2) Increased numbers of new outpatient consultations.                                           ex. Urology, &
                                                                                                                                                                 A number of specilaties in July have exceeded the set quartile these are as follows: Urology 2.67,
                Required to meet the Welsh upper quartile specialty targets by                                    Orthodontics                             M
                                                                                                                    > target                                     Orthodontics 5.78, Dermatology 1.94 & Rhuematology 5.44.
                31st March 2007. Interim targets to be agreed by RO

                Effective Outpatient Management Processes: (in respect of
                secondary care services within LHB)

                                                                                                                                                                 Figures relate to consultant clinic DNA's (New & F/ups) Specialties with the largest DNA rates are AMI,
                Low DNA rates (Target < 5%)                                      8.8%                  9.1%          9.6%         To be provided           M     EMI & Paediatrics, excluding these specialties DNA rates for each month are as follows: 7.5%, 7.9% &
                                                                                                                                                                 7.2%
                Patients booked in chronological order (PTL achieve 80%)
                                                                                                                                                                 Welsh Trust PTL's monitored by Commissioning Team. English Trusts do not complete PTL's however
                .LHB to ensure through Commissioning process patients                                                                                      Q
                                                                                                                                                                 RJ&AH are keen to adpot this process.
                booked in chronological order
                                                                                                        (40 &
                                                                                  No data available




                Inpatients (Specialty Range) (Average)                                                  53%)        40.0%                                  M     In June scores are as follows: AMI 100% - no W/L, Pain Mgt 40%
                                                                                                                                         To be provided




                                                                                                       (67%)
                                                                                                         (42-
                                                                                                                  (30-100%)                                      In June scores are as follows: ENT, Gynaecology & Opthalmology achieved > 80% , Oral Surgey 30% &
                Daycases (Specialty Range) (Average)                                                   100%)
                                                                                                                    (72%)
                                                                                                                                                           M
                                                                                                       (79%)
                                                                                                                                                                 General Surgery 40%
                                                                                                      (24-84%)     (20-90%)                                      In June Pain Mgt, Dermatology & Rheumatology achieved > 80%, lowest score was within Haematology
                Outpatients (Specialty Range) (Average)                                                 (60%)        (58%)
                                                                                                                                                           M
                                                                                                                                                                 & Urology where score was 20%




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POWYS LOCAL HEALTH BOARD CORPORATE BALANCED SCORECARD 2005/06 (As at July 2005)


 Strategic
                                               Goals                            Apr   May   Mth End Q1          Jul   Freq                                                     Comments
 Objective

                 Effective Waiting times management processes:
                                                                                                                       Q3    (Self Assessment Questionnaire)
                 (Questionnaire)
                 To ensure effective commissioning of General Medical
                                                                                                                       Q3    (Self Assessment Questionnaire)
                 Services completion Questionnaire required
                 To ensure appropriate HR systems are in place:

                 Continued implementation of EWTD,Consultant Contract &
                                                                                                                       Q     (Self Reporting)
                 Agenda for Change

                 Continued implementation of the Equality Plan                                                         I     (Self Reporting).

  Management                                                                                                                 All projects underway , wiht the majority currently on track. Some delays have been experienced in the
Processes that Achievement of milestones in Informing Healthcare Readiness                                                   rollout of equipment due to resource shortages & dependency on setting up servers etc. Access to
                                                                                                                       Q
   support the  plans                                                                                                        Learning (ECDL) project slow to take off but plans and actions now being put in place to address this.
   delivery of                                                                                                               Contact Centre issues emerging which will require resolution
 timely quality
services cont'd                                                                                                              (Self Assessment questionnaire)
                 To ensure effective Commissioning.                                                                    Q3


                 To ensure effective Delivery of General Medical Services                                              Q3    (Self Assessment questionnaire)

                                                                                                                             % GP Practices that have implemented the Revised (2005) GP Security Policy and have undergone an information
                 To ensure effective Information Governance arrangements                                               Q3
                                                                                                                             security audit by the BSC against the controls identified in the Policy

                 To ensure effective Performance Management systems                                                    Q3    (Self Assessment questionnaire)

Equitable and
Timely Access To ensure effective Clinical Governance Arrangements                                                           (Self Assessment questionnaire)
                                                                                                                       Q3

 to Services
                 To ensure effective Corporate Governance Arrangements                                                 Q3    (Self Assessment questionnaire)

Investment in
 Management
 Development
              Workforce with relevant skills                                                                           Q     (Self Reporting)
 and Training

                 Well developed leadership skills throughout the organisation
                                                                                                                       Q3    (Self Assessment questionnaire)
  Effective      (Questionnaire)
 Leadership

                 Developing learning organisation culture (Questionnaire)                                              Q3    (Self Assessment questionnaire)

Creating and Effective investment in R&D (Questionnaire)                                                               Q3    (Self Assessment questionnaire)
maintaining a
  learning    Staff encouraged to contribute to system development
organisation                                                                                                           Q3    (Self Assessment questionnaire)
                 (Questionnaire)

                 Sharing of best practice (Questionnaire)                                                              Q3    (Self Assessment questionnaire)
Universalising
best practice
                 Effective implementation of innovation (Questionnaire)                                                Q3    (Self Assessment questionnaire)

PERFORMANCE KEY:                                                                            MONITORING FREQUENCY KEY:

RED - Failing to achieve                                                                    M = Monthly
AMBER - Working to achieve                                                                  Q = Quarterly
GREEN - Achieving                                                                           I = Interim




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Description: Quality Management Office Balanced Scorecard document sample